ARV Treatment: Special Focus
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Steve, I hope I can contribute to the discussion this way, through e-mail. I had been preparing some comments; now I find them more apposite in view of your request for a practical agenda. I think you are right; we must move ahead - but I am seriously concerned that we move ahead with full professional data. Michael Kirby, the judge from Australia, always says that one of the single most important elements in responding to the epidemic is to be "informed"; and I don;t think we are informed enough. You raise a series of questions. Here are some more things to think about if we are to inform policy makers. It seems to me that the presence of HIV in a society, community, country will tend to increase costs within the health system (public and private) (and irrespective of other costs) in three ways: 1. Increased general morbidity (particularly TB, pneumonia, gastro-enteritis, hepatitis, etc); while the system may not respond well to this increase, it will, in various ways, respond, with corresponding increases in drug bills, human resources and training expenses, primary care services, hospital admissions, houshold spending on medicines, etc. 2. HIV specific costs: costs of conventional prevention programmes; the money people spend (which seems, anecdotally, to be very high indeed here in India) searching for "cures" from all sorts of sources (including quacks, alternative systems, etc) when they are first diagnosed; counselling services; ARV therapies and others; terminal care costs. 3. Indirect health system costs associated with increased prime age adult mortality: deterioration in nutrition and child care, female health, etc, within affected families. An important element here is that the second group, the HIV specific costs, largely only apply when HIV status is known. In a country like India, where the vast majority of people (and they will be very large numbers indeed) infected with HIV and their families will probably never associate the illness and death of the person with HIV or AIDS, the greatest implications will be in the first and third ways. A health policy for HIV and AIDS would need to respond to all these situations. Consequently, it seems to me very difficult to isolate any one area for cost-benefit, cost-effectiveness, affordability or equity analyses, without analysing its position in the overall problem. ARV may seem very expensive, when considered alone; but what is its place in an overall balance sheet? There are important equity and ethical issues to be considered. I am not making a case for or against ARV here; only saying that I am not sure that we have enough data to make professonal, as opposed to political or personal, decisions. This kind of data is URGENTLY needed; this should be the future agenda.. Incidentally, you mention "willingness-to-pay" as a tool for economists to look at; have you seen the research on willingness-to-pay in David Bloom and my book; or the Chinese work on willingness-to-pay for blood that was done with ADB support? peter godwin |
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