ARV Treatment: Special Focus
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Unfortunately I have not had sufficient time to follow and participate in the discussion thus far. I have been coordinating the National HIV/AIDS Economic Research Initiative in Canada for the past 3 years and several research projects in both the care and prevention areas have been synthesized into a final report. I have also completed and published a study on the Economic Burden of HIV/AIDS in Canada (Co-Author Greg Williams). This study examined both the economic and epidemiological dimensions of the disease (i.e. the Scott Holmberg component model was adapted and replicated) as well as estimating Canada's national investment in HIV prevention through two national strategies (over a 10 year period). The discounted lifetime direct costs for one HIV/AIDS episode was estimated to be $153,000 (CAN). Indirect costs were estimated to be $600,000 (CAN). One of the key findings from our study was the shifting and changing epidemic. HIV in Canada is feeding on young and marginalized people. Indeed, social and economic marginalization has become a key determinant. Although not totally correct, there is an analogous situation in North America to that in the developing world. The key ethical and equity issue is that of distributive justice. The familiar emergency 911 slogan "Hard to find is hard to help" captures the main challenge in delivering both care and prevention services to these populations in need. For us, it also embodies the key ethical issue concerning distributive justice. Economists must begin to examine key ethical issues in order to provide a more holistic policy framework. Allan Williams from the U.K. has said it best: "The maximization of health is as the job of clinicians, who are little interested in costs or equity, the minimization of costs is seen as the job of managers, who are little interested in health or equity, and concern about equity is nobody's job in particualar and therefore remains the interest of only spectators...at present we economists talk alot about equity/efficeincy trade-offs, but we then get on with efficiency calculus and leave equituy to others to worry about. The two key ethical concepts to be considered are the utilitarian notion of maximizing benefit and justice or the fair distribution of resources. In combination, both concepts point towards the need to pursue greater aggregate benefit provided that we act justly in pursuit of that goal. A fair distribution of benefit is dependent on the access to and availability of care and prevention services. Availability and accessibility are indeed intertwined. Availability relates to macro-allocative decisions concerning which programs will be funded. Accessibility plays out more at the micro level concerning the geography and placement of the programs. In Canada, we have available services that marginalized individuals do not access. For example, under 66% of IDUs in Vancouver have accessed the insured drug benefit program. There are two types of equity: Vertical equity (unequal funding for unequal needs) and Horizontal equity (equal funding for equal needs). Said another way, not all needs deserve equal consideration, but equal needs should be considered equally. Hence, the greatest and most urgent needs should be given priority. The overall goal: to justly maximize the aggregate benefit available from scarce and limited resources. Well, I think I have framed the ethical jargon. Having read the discussions thus far, I must admit that I do not have answers for the developing world. I think that the transition economy countries could benefit from the recommendations we have made concerning better epidemic control. We have also conducted as study entitled, In search of Best Practice: A Comparision of Five OECD Countries. Unfortunately, I feel somewhat helpless in finding answers to improving access to care (drugs) and prevention in developing countries. In terms of the drugs, compliance will be a very difficult issue to contend with. We have this problem now in Canada with street-involved/homeless people. Some of the drugs need to be taken with food (a problem for many in the developing world), others without and at specific times - Some report that the drugs run their lives. Perhaps the drug companies might be given the incentive to develop the all-in-one pill once-a-day given the large market in the developing world and the expanding one consisting of the poor and homeless in north america. The big question and the one that seems to have been discussed quite extensively is, who's going to pay and how are we going to allocate resources between caring and preventing? Sorry for the pontification. I hope to hear from others |
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