ARV Treatment: Special Focus
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The first week of this session has been quite busy and useful. I’d like to thank all those who contributed, and encourage you to continue. I’d also like to encourage others to begin posting their thoughts and opinions on these issues. We hope that each of you will provide your input into what is being discussed. Let me try to summarize some of the discussion that occurred during the first week. If I misquote anyone, please correct my errors by posting to this thread. If you have more to add, please do so under this summary of the first week. One of the first postings came from Mead Over at the World Bank, who recommended that we begin by discussing the justification for the purchase of ARVs with public funds. <[message]> Mead correctly pointed out that there are a number of very important needs in developing countries that are not adequately being met, and that giving preference to the purchase of ARVs may take away from investment in more cost-effective public investments. Targeted HIV prevention programs and home-based care might be a better investment for developing country policymakers. Mead also noted that public funding for ARVs is likely to divert resources from self-financed purchases of ARVs. In other words, the wealthy who could have paid for these drugs, are likely to receive them for free if they are offered by the public sector. This conclusion appears to have been validated by the excellent contribution from Stefen Flessa from Tanzania, who noted that Tanzania’s purchase of ARVs would consume the country’s entire health budget. With needs for other basic health needs, it was argued that it would certainly be impossible for Tanzania to address the demand for ARVs through the public sector. <[message]> We also received two postings from John Stover and Alan Johnston about the practical realities of African health care systems. John notes that despite the economic constraints in Africa, many very expensive forms of treatment are currently made available. For reasons of prestige or politics, many African countries have developed elite health care facilities designed to provide excellent care (including heart and brain surgery and cancer research). <[message]> Alan noted that it was not so easy to separate between public and private goods. He commented that even in cases where treatment is provided solely through the private sector, the reality is that public health resources continue to be utilized. <[message]> While neither John or Alan argued that ARVs should be provided publicly, they did accurately note that there are, and will continue to be, increasing political demands for African countries to provide ARVs. The arguments for and against providing ARVs appear to be quite different in Latin America. While we were launching this web site, a letter to the editor was published in JAMA (April 22/29, 1998) which made a number of fascinating arguments regarding access to ARVs <>. The letter concluded that despite the overwhelming costs of providing ARVs, the purchase of these drugs in most countries was not likely to “break the bank”. Only in countries where prevalence is already high or income is quite low, such as in Haiti, Guyana, Honduras and Suriname, would the public purchase of these drugs exceed 1% of GDP. On average, the purchase of ARVs would consume only 0.08% of GNP in the Americas, or US$6 per capita. Jorge Saavedra provided an extremely useful contribution, making a convincing argument that the ARV issues in Latin America are significantly different from those in Africa. It was noted that the provision of ARVs in Mexico would consume only 0.02% of GDP, an amount which is significant but not prohibitive. Dr. Saavedra concluded that in Latin America, “we should not try to compete inside the scarce Health Budget, but to compete against other clearly inefficient public budgets” (such as defense budgets). <[message]> A contribution from Hilda Abreu revealed that the purchase of ARVs had been carried out with relative success in Uruguay. However, it was noted that there is a lack of convincing economic data surrounding this issue in the country, and that help is needed to look at the economic issues in greater detail. <[message]> Other useful comments by Ralph Frerichs raised the issue of the need for counselling and testing in order to determine how best to address the epidemic. [message] Neil Soderlund was one of the first contributors to raise the issue of ARVs for the prevention of vertical transmission. [message] Eugene Boostrom emphasized his concern that political pressures could cause governments to pursue politically expedient rather than carefully thought-out health policies. [message] Finally, Waranya Teokul questioned for whom we were looking at cost-effectiveness (for the individual or the nation as a whole. [message] Thanks again for the many contributions by all these people during the week. In order to start off the second week, I’d like to pose a number of additional issues/questions. |
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