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Marlink, Richarda,b; Forsythe, Stevenc,d; Bertozzi, Stefano Me; Muirhead, Debbief,g; Holmes, Marionettea,h; Sturchio, Jeffreyi(Editorial Steering Committee)

doi: 10.1097/01.aids.0000327616.99675.09

From the aHarvard School of Public Health, Boston, Massachusetts, USA

bElizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA

cInstituto Nacional de Salud Publica, Cuernavaca, Mexico

dFutures Institute, Glastonbury, Connecticut, USA

eCenter for Evaluation Research and Surveys, National Institute of Public Health (INSP), Cuernavaca, Mexico

fAurum Institute for Health Research, South Africa

gHealth Policy Unit, London School of Hygiene and Tropical Medicine, USA

hSpelman College, Atlanta, Georgio, USA

iThe Merck Company Foundation, Whitehouse Station, New Jersey, USA.

Correspondence to Richard Marlink, Harvard School of Public Health, Boston, MA, USA. Tel: +1 617 432 4114; fax: +1 617 432 4545; e-mail:

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In the more than 25 years since the advent of the HIV/AIDS pandemic, the commitment of international agencies, national governments, the private sector, people living with HIV/AIDS and donors have contributed to dramatic changes in the global response. Trends in HIV prevalence have stabilized in some developing countries, greater coverage of key prevention interventions such as the prevention of mother-to-child transmission have, at times, been achieved, and access to treatment has increased fivefold between 2003 and 2006 [1]. In addition to increased prevention and treatment provision, successful strides have also occurred in the mobilization of global financial resources for HIV/AIDS. According to estimates of the Joint United Nations Programme on HIV/AIDS (UNAIDS), global HIV/AIDS spending rose from approximately US$300 million in 1996 to approximately US$10 billion in 2007, a more than 30-fold increase [1]. The impact of HIV/AIDS has, however, increased as the epidemic matures and, with new infections estimated at 2.5 million per year, expanded prevention efforts are still sorely needed. Even with the unprecedented level of funding now available, an additional US$8.1 billion is still required if universal access to prevention, treatment and care is to be provided to all those infected with HIV [2]. Questions have thus shifted towards how to combine or maximize outcomes from HIV/AIDS treatment and prevention strategies efficiently. To this end, the papers in this supplement explore the question: how do we best utilize the increased funding available?

Decisions about how to allocate scarce resources when faced with such serious and competing demands can be guided by the tools of economic analyses. In 1988, Over et al. [3] published one of the first studies on the economic impact of HIV/AIDS, which analysed the direct and indirect costs of AIDS in Tanzania and Zaire. Ten years later, a special supplement of the journal AIDS published an article by Forsythe and Rau [4] entitled ‘Evolution of socioeconomic impact assessments of HIV/AIDS’. This article summarized the accomplishments and failures of economists working in the field of HIV/AIDS during the first decade of analysis (1988–1997), and concluded that ‘[e]xisting economic impact assessments in the field of HIV/AIDS will need to be replaced by more targeted economic research intended to encourage the development of appropriate workplace policies, mitigate the impact of HIV/AIDS on families, and address critical treatment issues.’

The recent increase in HIV/AIDS-related research across disciplines, including economics, demonstrates international efforts by researchers to contribute to the development of a more successful response to the epidemic. Regrettably, economic analyses have had limited impact on the effectiveness and efficiency of HIV/AIDS programmes. To influence policy more effectively, recommendations drawn from economic analyses must be presented in ways that are easily applied by decision makers and communities managing the challenges of HIV/AIDS prevention, care and support. This special issue of AIDS presents a mix of recent economic analyses and commentary on how best to distill economic insights to improve HIV/AIDS policies and programmes.

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The 2006 Conference– HIV/AIDS interventions in resource-scarce settings: using economic analyses to help guide policy and action

In September 2006, economists, public health researchers and health scientists met with policymakers from national ministries of health, international agencies and donor organizations to discuss how results from economic analyses can better inform decision making. This conference ‘HIV/AIDS interventions in resource-scarce settings: using cost benefit and cost effectiveness analyses to help guide policy and action’ was organized by the Harvard School of Public Health with the goal of changing the existing paradigm of economic evaluation research from a mostly academic exercise to a pragmatic tool that can be used effectively by policymakers and planners in developing countries.

The conference facilitated an open discussion and debate among policymakers and researchers to identify best practices and devise economic analyses to enhance HIV/AIDS-related resource allocation. Discussions centered on analytical tools that economists regularly employ, such as cost-benefit and cost-effectiveness analysis, economic impact analysis and macroeconomic modelling, which can be used to guide local and global policymakers in decisions such as what, where and how to scale up and the consequences of scaling up various HIV/AIDS interventions. Conference panellists, which included representatives from the World Health Organization (WHO), the Botswana Ministry of Health, the World Bank, the Bill and Melinda Gates Foundation, the Elizabeth Glaser Pediatric AIDS Foundation and UNAIDS offered particularly insightful perspectives on the potential impact of economic evaluation and analyses. The following sections highlight a few of the conference discussions between health economic researchers and international HIV/AIDS policymakers on the keys to and constraints of using economic evaluation to inform HIV/AIDS policy and programming decisions in developing countries [5].

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Evidence base for resource allocation in HIV/AIDS

The urgency of implementation and rapid expansion to meet universal access goals currently competes with the need for more research and data. For example, although large amounts of resources were involved, decisions regarding the implementation of the US President's Emergency Plan for AIDS Relief (PEPFAR) programme were made quickly. Policymakers at the conference cited the lack of cost and cost-effectiveness data as an impediment to developing and establishing evidence-based public health policies. Researchers agreed. Dr Stefano Bertozzi, founding director of the Center for Evaluation Research and Surveys at Mexico's National Institute of Public Health, mourned the lack of data-driven decision making in national and international HIV/AIDS responses.

‘Twenty-five years into the epidemic, we are far past the time– if that time ever existed– when the urgent need to respond trumps the need to respond intelligently and efficiently…. I really am, and continue to be, amazed by how much money we spend and with such little knowledge.’

Rigorous prospective evaluations have rarely been incorporated into the scaling up of HIV/AIDS programmes, but there are signs that this tide is starting to turn. Participants from the Bill and Melinda Gates Foundation, for example, highlighted the forthcoming launch of the International Initiative for Impact Evaluation (3ie), and Dr Piot noted the investment of UNAIDS, the World Bank, and the US Centers for Disease Control and Prevention in both global monitoring and evaluation and in building the capacity of countries to conduct local monitoring and evaluation.

Although additional global cost-effectiveness data are needed, country-specific economic evaluations that incorporate local data are also lacking. Policymakers stated, for example, that costing data available from a neighboring country is not sufficient to guide financial planning in their own country; only economic evaluations using local data will provide planners with the evidence-based research to make strategic and judicious decisions. At the country level, however, local data about local situations must use methods that are understood by policymakers. The conference group discussed the importance of collecting data alongside the roll-out of country interventions as natural experiments to add to a region's body of knowledge. This method would be an efficient means of ensuring the collection of realistic information to inform both local planning and global discussions on resource allocation for HIV/AIDS.

Although policymakers and researchers agreed that there is a need for more data, opinions differed concerning the reasons why more data do not exist and what the research implementation process should be until the necessary data are available to guide policymakers towards a sustainable provision of universal treatment and care.

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Economic evaluation as a useful policy tool

Economic evaluation data are still needed to determine what combination of intervention, prevention, mitigation, care and subpopulation targeting will have the largest impact for the available budget. Better use of economic evaluation has also been strongly advocated as a tool for decision making by various international agencies, including the World Bank, WHO and UNAIDS. Joy Phumaphi, former Assistant Director-General for Family and Community Health at WHO and now a vice president at the World Bank, compared trying to implement a programme without cost-effectiveness analysis, assessment and evaluation as ‘trying to do math without a plus or minus sign’. Dr Peter Piot, Executive Director of UNAIDS, reiterated the need for cost-effectiveness analysis with the following response to researchers:

‘Our goal is to maximize the impact of the existing money… and maximize the impact to make sure the money is going where it's supposed to be… and ensure that we have a comprehensive approach where science and intervention and technology on the one hand and the social change agenda on the other are coming together.’

Challenges in methodology and technical language barriers between researchers and policymakers have, however, long prevented the full use of economic evaluation to guide HIV/AIDS policy decisions. Communication can be improved when analysts, policymakers and implementers work closely together from the inception of an HIV/AIDS intervention throughout the stages of scale-up.

Policy panelists recommended that the most effective method for economists to present results from economic evaluation to policy planners is to use the most accessible language possible. They cautioned that ‘rigorous academic studies are necessary and serve as references, but it can be very difficult to follow a discussion that is made impenetrable with technical vocabulary and acronyms’. Cost-effectiveness analyses should, moreover, present information that local decision makers use. For example, local planners are interested in how many infections are averted by a particular HIV prevention programme rather than in quality-adjusted life years gained, as is frequently used within cost-effectiveness analyses to evaluate HIV prevention.

Policymakers emphasized that economic evaluation, and specifically cost-effectiveness analysis, is not the only tool needed to guide the implementation of evidence-based strategies. Although research often focuses on informing policy development, researchers should emphasize what is often the most challenging part of the process: carrying out new policy. Policy representatives presented economists with possibilities of a new discipline, called ‘the science of implementation’, which would integrate cost-effectiveness analysis, decision analysis, ethnography and rapid-cycle operations research.

Cost-effectiveness analysis can play a role in the implementation process by identifying areas where the most absorptive capacity for financial investment exists. Members of the conference policy panel discussion suggested that cost-effectiveness analysis can help to identify the most efficient means of implementing a programme given the stage of the epidemic, the political background, and the capacity of that particular health system, especially when complemented by management research on implementation bottlenecks and qualitative research on social, cultural and political barriers to programme roll-out.

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Focus areas for future economic analysis

At this stage in the AIDS epidemic, decision makers recognize the significance and importance of addressing questions both locally and globally. Several participants expressed concern about the disparity between the priorities of policymakers at local, national, and global levels. Decisions made at the global level to meet the Millennium Development Goals, for example, may not be relevant to local policymakers. Likewise, the most pressing questions for policymakers at the local and national level are specific to their communities and constituents and may not be a high priority for academics in high-income countries competing for research funds from their governments. The focus should thus be on building the capacity of researchers in the developing world to address the issues that are most pressing in their respective countries. Partnerships and alliances must be created between national and international research institutions and local and national governments. The role of researchers in developing countries must be integrated into the local capacity-building processes. Intellectual capital on conducting and interpreting economic analysis should be transferred to local health economists. This process should be executed simultaneously with the implementation of improved monitoring systems and rigorous prospective evaluations of programme impact.

Panel members commended the audience of social scientists on their rigorous evaluation of treatment programmes and for providing empirical evidence to inform earlier debates on the need for adult antiretroviral therapy. Across global, national, and local levels, however, the call was sounded for more and better evaluations and cost-effectiveness analyses. These concerns were echoed in a recent review of cost-effectiveness analysis of HIV/AIDS prevention and treatment programmes [6]. Further work is required to examine the relative efficiency of prevention interventions in different settings.

In conclusion, this special supplement of AIDS provides insights on what economists in the field of HIV/AIDS have achieved in the second decade of HIV economic analyses (1998–2007) by presenting papers contributed by academic and policymaker conference participants. Economic analyses were presented from countries as diverse as India, Nigeria, Thailand, South Africa, Mexico and Botswana. This special supplement should also be viewed as a challenge to economists working in the field of HIV/AIDS. As this third decade of economic analyses concerning the epidemic begins, economists must design studies with clear policy objectives in mind. Local data should be used to address local questions. Microeconomic impact studies should employ sound methodologies and macroeconomic impact assessments must provide clear policy direction, rather than simply restating concerns about potential impacts. Treatment studies must provide policymakers with answers about the affordability, effectiveness and sustainability of particular treatment strategies. At the same time, the rigorousness of economic analysis must continue to improve. We must learn more about the impact of HIV/AIDS on families and their children, including the effectiveness of strategies designed to mitigate the impact of AIDS on orphans. Economists, by the end of the next decade, should have a much better idea of how to implement the results of cost-effectiveness analysis in resource-limited settings.

The 2006 Harvard Conference took place at a pivotal point in the fight against HIV/AIDS. Policymakers reflected on the past 25 years and offered recommendations for the future. In a conference speech, Dr Peter Piot communicated the goals of UNAIDS for the next 25 years and how economic analyses could play a key role. Given the global increase in resource investment to fight HIV/AIDS, Dr Piot emphasized the need to show that economists can ensure that the HIV/AIDS community is ‘making the money work’. Economic analysis can assist in ensuring that funds are allocated to where they are needed and can have the greatest impact in a given setting. Communication between economists, governments, businesses, and people living with HIV/AIDS must continue in order to increase the positive present momentum.

Conflicts of interest: None.

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1. UNAIDS. Annual report: Making the money work. Geneva, Switzerland: UNAIDS; 2007.
2. UNAIDS. Financial resources required to achieve universal access to HIV prevention, treatment, care and support. Geneva, Switzerland: UNAIDS; 2007.
3. Over M, Bertozzi SM, Chin J, N'Galy B, Nyamuryekunge K. The direct and indirect cost of HIV infection in developing countries: the cases of Zaire and Tanzania. In: The global impact of AIDS. New York: Alan R. Liss; 1988.
4. Forsythe S, Rau B. Evolution of socioeconomic impact assessments of HIV/AIDS. AIDS 1998; 12(Suppl. 2):S47–S55.
5. HIV/AIDS interventiond in developing countires: using cost benefit and cost effectiveness analysis to help guide policy and action. Boston: Se 13-15, 2006. Available at: Accessed: July 2008.
6. Bertozzi S, Padian NS, Wegbreit J, DeMaria LM, Feldman B. HIV/AIDS prevention and treatment. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, editors. Disease control priorities in developing countries, 2nd ed. New York: Oxford University Press; 2006. pp. 331–369.
© 2008 Lippincott Williams & Wilkins, Inc.