The cost of AIDS

20 The cost of AIDS Donald S. Shepard This theatre group in Zimbabwe stages ploys which inform villagers about the risk of AIDS and how lo prevent infection. Photo Panos Pictures/ R. Giling © Estimates concerning the AIDS epidemic, up to the end of 1996, were: 29 million people world- wide infected with HIV and 6.4 mjJlion deaths . About 90% of those now living with HIV/AIDS are in developing countries. To help na- tional governments and donor agen- cies to reassess how best to manage the worldwide epidemic, the World Bank and the European Commission organized a brief study of how much HIV was costing the health systems of selected developing countries. The assignment was approached through case studies in five countries spanning different levels of eco- nomjc development: Cote d' Ivoire and the United Republic of Tanzania in Africa, Thailand in Asia, and Brazil and Mexico in the Americas. The studies were national in scope except in Brazil, where the study focused only on the state of Sao Paulo, where most of the country's AIDS patients live. A collaborative effort by researchers and public health officials in each country and in the United States enabled the study to proceed simultaneously in all regions. Knowing that no single source of data would be sufficient, the study team used analyses of government budgets and reimbursements, studies from hospitals which kept careful records, comprehensive health sector analyses where available, and estimates made by informed experts. Official epidemiological listings of reported AIDS cases understate the prevalence, largely because of cases not known to health workers, sus- pected cases not completely diag- nosed and therefore not counted in official reports, and incomplete reporting of confirmed cases. The studies spanned both preventive and curative services and all three sources of funding - government, donors and private payments. In order to elicit expert opinion as systematically as possible, the team consulted experts with diverse perspectives. In Cote d'Ivoire, for example, the team and the National AIDS Control Program!11e convened a workshop with researchers, clini- cians from the tertiary and smaller hospitals, and a traditional healer who cares for AIDS patients. Workshop participants noted that World Health • SOth Year, No. 5, September-October 1997 A five-nation study of the cost of HIV /AIDS prevention and care activities confirms that the highest priorities for future expenditure are prevention and low-cost treatment. patterns and sites of care varied according to the part of the country where the patients resided, and according to their financial means to buy drugs and private care. Even among patients without health insur- ance, a person living in the country's largest city, Abidjan, was estimated to receive more services than one living in the interior because of proximity to hospitals and physi- cians. From information on the cost of each hospital day or each consul- tation, the study team calculated the total costs of care. Findings To compare costs among countries, the team first converted local curren- cies to Unjted States dollars at market exchange rates . It then con- verted these "international dollars", using 1994 purchasing power pari- ties which standardize for cross- national differences in the costs of basic commodities. The resulting annual per capita expenditures for the total population on HIV-related prevention and treatment ranged from $ 1.48 in Mexico to$ 8.69 in Sao Paulo, Brazil. The simple average across the five countries was$ 4.36. As Sao Paulo had the highest per capita GDP among all five areas ($ 5600), its high absolute expenditures per person were understandable. World Health • SOth Year, No. 5, September-October 1997 Because the state spent so much on health care overall, however, Sao Paulo actually devoted the lowest share of its health expenditures to HIV-related illness (1.4%) among all five countries. The United Republic of Tanzania, the poorest of the five, devoted 13.7% of its health expenditure to HIV. Surprisingly, this high share was a reflection not of the burden of curative care, but of impressive preventive efforts. Of Tanzania 's AIDS expenditures, 85% were di- rected to prevention, supported largely by international donor contri- butions. The share of health expendi- tures devoted to HIV I AIDS was 1.5% in Thailand, 1.8% in Mexico and 6.7% in Cote d' Ivoire. The simple average was 5.0%. Although the short-term suc- cesses of protease inhj bitors and combined drug therapies may hold promise for a few AIDS patients, the cost of their widespread use would be prohibitive. Even without these latest drugs, in the richest of the case- study areas, Sao Paulo, the lifetime treatment of an average AIDS case already costs three times the state 's per capita GDP. Adequate prevention programmes are therefore the key to stemming the growth in HIV infections. The study identified several promising ap- proaches that could and should be widely replicated. Impressive results have been reported in Mwanza, United Republic of Tanzania. Through a vigorous programme of treating sexually transmitted dis- eases, including an improved supply of drugs, as well as education and condoms for patients and contacts, HIV incidence was reduced by 42%. Under the direction of a National AIDS Committee chaired by its Prime Minister, Thailand has launched a policy of universal con- dom use in commercial sex. Sometimes the clients themselves pay for the condoms, but the govern- ment monitors the brothels to ensure that condoms are available. WHO itself has developed treatment guide- lines for managing the care of people with AIDS. By ensuring that the health workers in clinics and dispen- saries are trained and supplied with diagnostic materials and basic drugs, many opportunistic infections can be treated at reasonable cost at periph- eral health facilities. Antiviral drugs Both Brazi l and Thailand are starting to expand access to antiviral drugs , such as zidovudine (AZT). Following the finding that the drug reduces maternal-infant infections by 66%, Thailand has begun to make zidovudine available for mothers in a few hospitals. This time-limited use of zidovudine appears to be both cost-effective and affordable. In a population in which 5% of women were infected, the screening, coun- selling and treatment of infected women would add about$ 15 to the cost of an average delivery. Controlled tests of the original and simplified regimens, suitable for more widespread use, are under way in Cote d'Ivoire, South Africa, Thailand and other countries. But experience to date advises consider- able caution in using public financ- ing to provide antiviral drugs to AIDS patients other than pregnant women. The study found that the HIV epidemic is most advanced in sub- Saharan Africa, where over half the medical patients in many tertiary hospitals are HIV-infected. In Cote d'Ivoire, for example, one person in 20 is HIV-infected, and an HIV- 21 infected patient occupies one hospi- tal bed in five. Despite thi s burden, the health systems of these five countries have coped so far with the AIDS epidemic because AIDS patients receiving expensive treat- ment still represent a li mited propor- tion of the population . For the future, however, the 20 million persons in developing countries already infected with HIV present a sobering challenge. The highest priorities for future expendi- ture are those for prevention (partic- ularly ensuring that persons with many sexual partners always use condoms) and first-line treatment (diagnosis and antibiotic treatment of sexually transmitted diseases, and treatment of uncomplicated oppor- tunistic infections). Policy-makers must balance investment in anti- retroviral therapy and other sophisti- cated treatment for AIDS with the growing demands for preventing and treating other diseases. • Professor Donald S. Shepard is at the Institute for Health Policy, Heller Graduate School, Brandeis University, Waltham, MA 02254- 9110, USA AIDS counselling being given to a pregnant woman in Sao Paulo, Brazil. Photo Panos Pictures/ S Sprague ©