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

Overview and Key Questions

Governments in many developing countries are under mounting pressure to pay for anti-retroviral (ARV) therapy for the growing number of people living with HIV/AIDS. Because few developing countries could do this without dramatically restructuring or increasing government expenditures, it has been suggested that an international fund be established to provide the necessary financing. However, even assuming that such a fund could be organized, the question of public priorities remains.

Should public funding of ARV therapy be a higher or lower priority than other health interventions (for example, preventing HIV transmission, treating or preventing such diseases as TB and malaria, or treating and preventing childhood diseases)? And what priority should ARV therapy be given relative to the many public concerns that fall outside of the health sector, including poverty reduction, education, infrastructure, and local and global environmental problems?

One way to begin untangling these issues is with a discussion of cost. In "Cost And Financing Aspects Of Providing Anti-Retroviral Therapy" Katherine Floyd and Charles Gilks conclude that in most developing countries, ARVs are at present neither affordable nor cost-effective. For example, providing triple combination therapy to all people with HIV in sub-Saharan Africa could consume between 9% and 67% of total GDP.

Nicholas Prescott reaches similar conclusions in his article "Setting Priorities for Government Involvement with Antiretrovirals." He also points out issues that governments should consider in funding ARV therapy, including trade-offs with other needs in the health sector and with broader development objectives. And he argues that when counting the number of life years saved per dollar spent on publicly funded ARV therapy, one should not include health benefits for people who would have otherwise received their care from the private sector.

Chapter 4 of Confronting AIDS: Public Priorities in a Global Epidemic (World Bank, Martha Ainsworth and Mead Over, co-authors) provides a detailed discussion of the impact of HIV/AIDS on the health sector, mostly from a public economics perspective. It points out that providing increased public funding for health care and/or providing special subsidies for the treatment of HIV/AIDS may have unintended consequences that exacerbate the impact of the epidemic on the health sector, making if more difficult for everybody to obtain care. Furthermore, it argues that larger public subsidies for ARV than for other serious adult illnesses, such as cancer and heart disease, are difficult to justify as (1) reducing the infectiousness of treated individuals, (2) insurance against catastrophic health events or (3) "merit" goods for the poor. As an alternative, the chapter calls for increased efforts to eliminate barriers to access of other, less expensive types of treatment that have the potential to greatly ease the suffering and extend the lives of people in developing countries with HIV/AIDS.

Joe Thomas's article from AIDS Analysis Asia takes a very different approach, arguing that equity and human rights considerations require a global initiative to provide people in developing countries with access to sophisticated treatments for HIV/AIDS. He urges a UNAIDS-directed Global AIDS Related Biotechnology Transfer Protocol to make ARV and other advanced treatments for HIV/AIDS available to people in developing countries. His article concludes: "The political commitment of many northern governments and agencies will remain the key question in facilitating a global AIDS related biomedical technology transfer initiative. Many of those governments wish to portray themselves as being in the vanguard of promoting human rights in developing countries. However, it may not be easy for some of them to acknowledge that that their trade policies are at the same time becoming a source of violations of human rights of persons with AIDS in developing countries."

Joseph Brunet-Jailly's provocative article, AIDS and Health Strategy Options: the Case of Côte d'Ivoire, discusses how efforts to provide international public funding for ARV are developing in one country hard hit by the epidemic. He asserts that "the technical and economic context in which the ARV initiative is being implemented makes it fundamentally inequitable" since the poorest patients receive very little publicly-financed care, while "the Government provides very generous subsidies for the tertiary level, which in practice serves the richest patients." He concludes that public funding of ARV treatment, supported in part by UNAIDS, seems set to follow a similar pattern, but predicts that "it will be favorably received because it will make the international organizations feel good, because it will allow the country to receive assistance, and because the country's population is used to having an unjust health system."

These readings, and other material posted on the site, offer a wealth of information and ideas about the provision of ARV treatment in developing countries. Questions of whether and how governments and the international community should fund such treatments are urgent. At the end of 1997, UNAIDS estimated that 30 million people are living with HIV/AIDS. The vast majority live in developing countries and are cannot afford the ARV therapy that in many cases could greatly prolong their lives. We hope that through this on-line discussion people concerned with these issues throughout the world will be able to identify responses that that are cost-effective and compassionate, and fair to all people, whether or not they are living with HIV/AIDS.

What do you think? In the on-line conference, participants were asked to share their views on the questions below:

Key Questions for Discussion

1) The papers by Katherine Floyd and Charles Gilks, and by Nicholas Prescott, present a variety of estimates of the cost of providing ARV therapy in developing countries. Both conclude that ARV's are currently not affordable or cost-effective in developing countries. Do you agree? [View Responses]

2) Chapter 4 in Confronting AIDS finds that even low cost medicines that can extend the lives and improve the health of people with HIV/AIDS, which are easily purchased in industrial countries, are currently unavailable in much of the developing world. These include medications to treat symptoms, such as headaches and diarrhea, and to treat opportunistic infections, such as tuberculosis. Would easing access to these lower-cost treatment options be a sensible alternative to public funding of ARV?  [View Responses]

3) Joe Thomas argues that providing ARV treatment is a question of equity and human rights--and that the international community has an obligation to do this. Are the equity and ethical issues different for HIV/AIDS than for other life-threatening diseases that are difficult and expensive to treat? [View Responses]

4) Can public funding of ARV therapy be equitably distributed in a situation such as that described by Joseph Brunet-Jailly in Côte d'Ivoire? What advice should be given to donors and developing country policy makers in such a situation concerning international assistance for HIV/AIDS in general and ARV therapy in particular?

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