ARV Treatment: Special Focus
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Anti-Retroviral (ARV) Treatment in Developing Countries:
Questions of Economics, Equity and Ethics

Final Summary

A final overview of the on-line conference held May 4, 1998 through May 28, 1998

by Steven Forsythe, Conference Moderator

The organizers would like to thank all the participants who made this on-line conference a successful and thought-provoking experience. The positive feedback from participants has clarified the continued need for discussions on such specific and timely topics. There have been nearly 90 postings during this conference, and participation by people from more than 30 different countries. This on-line conference was successful in initiating a critical discussion regarding the issue of economics and 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 recommended by participants and may be addressed in future on-line conferences include:

Lessons Learned:

Below the moderator has summarised the lessons that have apparently been learned through this experience.

  1. First, there is currently a lack of consideration being given to issues of public economics and its implications for treatment.
  2. Next, it was learned that in many countries, policymakers remain in the dark in regards to the current and future prevalence of HIV. Numerous contributors noted that 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. Some of this lack of modelling is in the process of being address by UNAIDS, WHO and USAID (as well as a number of other research institutions) that are trying to improve models to estimate future HIV prevalence. However, these models will depend on accurate HIV surveillance and behavioral data. It is anticipated that future mathematical models will 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 decision making 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 little of this economic research is currently being initiated, at least in developing countries.
  4. The discussion has raised the issue of targeting potential recipients of 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 and Cote d’Ivoire, 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 implying that saving the child is more cost-effective or of greater political importance than prolonging the life of the mother or the father through longer-term treatment.
  5. It was 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.
  6. Furthermore, some data indicate 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).
  7. Alternatives to HAART have not been carefully assessed. This includes a review of monotherapy, dual-therapy, cyclical and pulse therapy for adults, and the provision of AZT to women during pregnancy. There is currently no data comparing ARVs and non-ARV alternatives, such as drugs to treat opportunistic diseases.
  8. Economic research has tended to focus on the cost-effectiveness of ARVs currently, but has not developed models that would assist in evaluating the potential cost-effectiveness of ARVs in the future, when the prices are likely to be substantially less than current prices.
  9. Most economic research has not adequately taken into consideration issues of equity. 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 in other articles 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. The moderator has therefore proposed an agenda based on our lessons learned so far. It should be emphasized again that this agenda is only focusing on economic research, 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 take place while taking into consideration changes in financing mechanisms and the organization of the health system. Economists need to develop and refine a set of tools that governments can use to decide whether to subsidize new expensive experimental treatments like ARVs for AIDS, chemotherapy for cancer, organ transplants, etc. A further discussion of the public economics of offering different types of therapy would be useful and should be pursued.
  2. In addition to public economics, there is a need to further define what is meant by "equity" as it applies to the access to care for ARVs. Where equity and effectiveness are in conflict, it is critical to determine how trade-offs will be addressed.
  3. 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, cyclical 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.
  4. For developing countries, 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.
  5. 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. In addition, the impact assessments should also assess the positive and negative impacts that access to ARVs will have on access and quality of the entire health care system.

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