ARV Treatment: Special Focus
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Greetings from Liverpool, I would like to again thank you for your participation in this on-line conference. The positive feedback from you has made us very aware of the need for discussions on such specific and timely topics. We have had nearly 90 postings during this conference, and have had participation by people from about 30 different countries. My personal assessment of this on-line conference was that it was successful in initiating a critical discussion regarding these issues. The only item I would have liked to see that was not included was greater discussion of an agenda for future work regarding economic research in this field. However, hopefully these discussions will continue in the future. Many participants appeared to be concerned that we were too narrowly focused on the economic aspects of this issue. The criticism is reasonable, although the original intention of this discussion group was to focus on the economics of specific issues. I don’t think anyone would propose a research agenda that was exclusively economic. However, I do think it is reasonable to carefully consider the economic issues that we are trying to address, so that they can be incorporated into the larger array of issues (medical, ethical, epidemiologic, etc.) that must be addressed in regards to ARVs. The discussions appeared to produce consensus that there should be additional on-line discussion groups of this sort. The organisers have agreed to focus on the issue of the cost-effectiveness of prevention interventions during the next session. Other suggestions for topics that were suggested by participants and may be addressed in future on-line conferences include: - Political economy of setting priorities and choosing approaches - AIDS and other development projects - Role of the private sector in response to AIDS - Modelling the HIV/AIDS epidemic - What can be done to reduce the price of ARVs - Discussion of decision analysis methods - Drug pricing and pharmaceutical patents Summary of On-line Discussion I would like this summary to represent the views of the majority of those who have participated in this on-line conference. Therefore I am sending this out to the registrants and asking for any input before finalising this as a summary of this conference. Below I’ve tried to summarise the lessons that have apparently been learned through this experience. Please email me (forsythe@liverpool.ac.uk) if you have others. Lessons Learned: 1. First, we have learned that we need to determine if there are tenable arguments for the public sector to provide ARVs. A further discussion of the public economics of offering ARVs is useful and should be pursued. 2. Next, we have learned that in many countries, we remain in the dark in regards to the current and future prevalence of HIV. Numerous contributors noted that our estimates of people living with HIV and AIDS could be severely over or under-estimated, which in turn would significantly affect the estimates of costs for providing ARVs. It was noted in Tanzania that modelling exercises performed as early as 1988 have turned out to be relatively accurate predictors of the epidemic. Conversely, modelling in Latin America has raised a number of issues about the validity of such exercises. Therefore it can be argued that more accurate mathematical modelling would help countries to better prepare for the future epidemic. 3. This discussion has exposed the lack of data regarding the potential costs and benefits of ARVs in either developed or developing countries. This lack of data has contributed to the poorly-informed decisionmaking regarding the public purchase of these drugs. Economic research is needed to address this issue, as it is likely to affect the way in which policymakers perceive the costs and benefits of these drugs. Unfortunately it appears that none of this economic research is currently being initiated. 4. The discussion has raised the issue of ways to prioritise access to ARVs. When resources are available on only a limited scale, there needs to be a decision regarding the best ways of selecting those who are eligible for care. It was noted, for example, that in Thailand access to ARVs are offered based on the assumed compliance of the patient (which is likely to be associated to their socio-economic status). In countries where ARVs are only available from the private sector, a decision is implicitly being made to have these drugs available only to the wealthiest members of that society. Other countries offer ARVs only to pregnant women, thereby concluding that saving the child is more cost-effective than prolonging the life of the mother or the father through longer-term treatment. 5. We have learned that there is no single answer to the question, “Are ARVs cost-effective for developing countries?”. The paper by Katherine Floyd and Charles Gilks made a convincing argument that ARVs are not cost-effective in most developing countries. This conclusion was reinforced by contributors from Tanzania and Vietnam (and at least partially confirmed with data from Colombia). However, data from Costa Rica, Mexico, and other initial analyses from countries in Latin America indicated that ARVs might be cost-effective in wealthier developing countries (especially in Latin America). Furthermore, some data indicates that the use of a short-course AZT regimen with pregnant women could be a cost-effective means of limiting transmission of HIV to children. As was pointed out, however, in countries with a low HIV prevalence, AZT would probably not be cost-effective (although targeting AZT programmes to areas of a country where prevalence is higher might improve the cost-effectiveness of such an option). 6. Alternatives to HAART need to be carefully analysed. This includes a review of monotherapy, dual-therapy, or pulse therapy for adults, and the provision of AZT to women during pregnancy. Economists should also consider analysing the cost-effectiveness of non-ARV alternatives, such as home-based care. 7. Economic research must consider not only the cost-effectiveness of ARVs currently, but also their potential cost-effectiveness in the future, when the prices are likely to be substantially less than current prices. 8. Future economic research needs to consider equity, not just effectiveness. The paper by Professor Brunet-Jailly from Cote D’Ivoire illustrates this issue. It is argued that the well-intentioned desire to create better health care contributed to greater inequities in places like Cote D’Ivoire, and that the provision of ARVs in the future will only further confound this problem. However, it was also argued that the provision of ARVs in developed countries, and the denial of these drugs in developing countries, is itself inequitable. Future Economic Research Agenda Finally, the issue that was not discussed in great detail was the idea of developing a research agenda for the economic aspects of ARVs. As the moderator, I’d like to propose such an agenda based on our lessons learned so far. I would like to emphasise again that I’m only focusing on the economic research here, and that obviously there would be a larger research agenda that would need to be developed. Also this agenda narrowly focuses on the issue of ARVs, even though this should be considered within the wider concept of all care for people living with HIV and AIDS. 1. In general, it appears that there needs to be further economic consideration given to the rationale for spending public funds on ARVs in developing countries. Such an economic analysis should consider the context of health sector reform that countries are currently going through, as well as addressing the equity and effectiveness issues that have been discussed during this conference. 2. Next, for the poorest developing countries where ARVs are currently not available, it appears that a medical and economic research agenda should focus on therapy that would be less expensive than HAART. This could include monotherapy, dual therapy and pulse therapy. In addition, such countries need to consider the possible cost-effectiveness of offering AZT to pregnant women to limit vertical transmission. 3. For the wealthier developing countries where ARVs are currently not available, consideration should be considered as to the willingness and ability of PWAs to pay for such therapy. Economic methodologies such as contingent valuation could be incorporated to assess how much and for how long PWAs can pay for therapy. There should also be an attempt to identify those who are able to pay for such care, so that any public provision of ARVs could be focused specifically on the poor who are unable to pay for such drugs. In addition, these countries should assess the cost-effectiveness of offering a short-course of AZT for the limitation of vertical transmission. 4. For the wealthier developing countries where ARVs are currently available, there should be economic impact assessments to monitor how these drugs are affecting the economic productivity and health care utilisation of those who have access. As I mentioned before, if you have any comments on the summary or this proposed economic research agenda, please pass them on to me. Thanks again to you for your participation and hard work. Steven Forsythe HIV/AIDS Work Programme Liverpool School of Tropical Medicine forsythe@liverpool.ac.uk |
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