Lots of things could have talked about in global issues: does AIDS reduce economic growth?

State of epidemic:

70% of AIDs patients are in sub-Saharan Africa
almost 10% of adults age 15-49 are infected
S. Africa has increased from <1% to 20% in less than a decade
Women particularly at risk –> which then puts babies at risk
16% in South and South East asia
could be particularly bad b/c so much of world’s population lives there,
Striking regional differences

The Caribbean has high % of population affected

One lesson to draw: AIDS is NOT a “gay” disease
The experience of the US has shaped our view

Former Soviet Union
a disaster waiting to happen

Demographic impacts (draw some ties to Black Death)

Population growth reduced, will soon be shrinking populations
Has reduced life expectancy by 10 years in many places in Sub saharan africa, by 8-9 in some Caribbean nations, and 3 years in S./SE Asia

Increased Child mortality
Many, many orphans due to epidemic, great loss of adult population
will necessitate child labor
No/ far less schooling for these children
The “big” impact has yet to happen

Lifetime risk is much, much greater than prevalence rate: in Zambia w/ a 20% prevalence rate, an individual has a lifetime risk of dying from AIDS of 60%

Black death killed b/t 1/3 and ½ of Europe’s population- horrific impact
AIDS will be far worse, b/c the disease is different-
Black death killed w/in 3 days, HIV stays hidden for years (sometimes) which could increase transmission
People could have children in that time period, leaving orphans

Plus, patients are debilitated often for years
Lowered productivity
Increased social expenditures (count family caregivers, not just gov. $)
What to do?

Successful campaigns to reduce transmission in Thailand - have greatly increased condom use, especially in brothels

Treatments (in the Industrialized world)

HAART therapies have had initial great success, however, mortality rates have stopped dropping, probably due to drug resistance
But, has reduced MTCT- still get some in mothers w/ no antenatal care or who didn’t know were HIV+

Have increased quality of life
has gone from an acute disease to more like a chronic disease
Becomes more expensive (high expenses for longer period of time)

Still big problems w/ undiagnosed individuals

Transmission has NOT continued to decrease, and risky behavior has increased in some populations
Is becoming concentrated more and more in vulnerable (already stigmatized, poor, w/ bad access to health care) groups

Behavioral data
What can it help w/?
Deciding which types of prevention efforts to fund
What services should be provided
Will help figure out budgets, and predict budget needs for those services
Reduce inefficiency

Where the estimates of HIV/AIDS prevalence come from and why they might be biased
Many from antenatal clinics:
Selection bias in who goes to the clinics (higher educated, )
Only pregnant women, who are by definition sexually active
But, also, only fertile women, AIDS reduces fertility
Studies to check on this have found that sometimes over, sometimes under, sometimes right on, so an okay measure

What to do? Or, how I learned to stop worrying and love cost-effectiveness analysis

We have talked about how budgets are limited

We have talked about how services are distributed

Take percentages:

Is it moral/ethical to put a price on a human life??
Are some people worth more than others?

People do put prices on own lives every time they engage in risky behavior, from not eating vegetables to more extreme behavior. Just a matter of degree, but we are constantly making judgements that pleasure today is worth taking a few days/weeks/months off life at end of it.

Conviser asked, is cost-effectiveness the enemy of quality? I would argue it’s the DEFINITION of quality

Can make the argument that it is unethical NOT to use this analysis

What is cost - effectiveness?

Measure, in a ratio of (Cost of programs - medical and other costs saved i.e. work productivity) divided by Health Benefits i.e. years of life saved, quality of life saved, etc...

Disability adjusted life year-DALY (so can evaluate AIDS tx. W/ diabetes tx etc...)

Cost effectiveness will vary depending on:

the population prevalence of the disease (might want to target “at risk” populations),
the effectiveness of the treatment or prevention,
the severity of the disease
higher potential DALYs for children than for elderly- is agism okay?
lower DALYs for interventions among the disabled- could de facto discriminate against this group
problems studies not uniform, there are some guidelines (i.e. what costs do you include/exclude?)
Arbitrary cut-off on what is/isn’t cost effective
for Sub saharan africa, generally $50 per DALY, for US, $75,000
Do you count costs from other diseases (live long enough to get heart disease- should that reduce cost effectiveness?) (No)
Sometimes interventions/treatments are not cost effective from one particular institution’s point of view (insurance company, say), but are SOCIALLY desirable, key is to correctly assess costs/benefits from social perspective
Importance;
Some counter intuitive results:
Prevention programs may work best when HIV prevalence is low (too late when already high)
Targeting high risk groups w/ stigma not necessarily a good idea (like social security, since everyone gets it, it’s not viewed as a bad thing to do, a popular program among the elderly, even though we use it to give more money to the poor)
Anti-retroviral tx (in industrialized nations) reduce viral loads, which reduces probability of transmission from each encounter- however, risky behavior increased among those populations, totally swamping any preventive effects
Conclusions Not the only thing we need to consider, is simply a tool, but analysis can be informative (see above examples). Need to be aware of limitations. Also, intervention that works in one culture may not translate to another culture. But, especially given limited budgets of countries with high HIV/AIDS incidence, is very important to make sure spend the money efficiently in order to do the most good.