The Institute of Medicine, the prestigious health arm of the National Academy of Sciences, has weighed in with a massive report on the President’s Emergency Plan for AIDS Relief (PEPFAR), the multibillion dollar US effort to confront the epidemic in the developing world. The evaluation validates PEPFAR’s enormous reach during its first 10 years and identifies concrete actions that Congress and PEPFAR should take for the program to become more sustainable moving forward.

Like other PEPFAR-watchers, I’ve spent many hours digesting the landmark 700+ page evaluation and I’m pleased to see the detailed and rigorous attention (96 pages!) that the IOM has paid to PEPFAR’s data collection and knowledge management.  I am happy that the IOMs recommendations align with those previously put forth by the Data Working Group (DWG) of PEPFAR’s Scientific Advisory Board (SAB), on which I serve. Could this consensus lead to action?

Having conducted a large-scale evaluation of this scope, the IOM is  uniquely positioned to understand both the strengths and gaps in PEPFAR’s data systems – after all, the authors can only offer “evaluation” to the extent that there is appropriate data to support their analysis and conclusions. Indeed, the IOM is up front about the implications of limited data throughout the report, particularly with respect to financial (p. 92), monitoring (p. 523) and outcome/impact (p. 64 & p. 527) data – data limitations which motivated the chapter on knowledge management, an area originally outside of the evaluation’s Congressionally-define scope (see p. 514). The DWG observed similar challenges with knowledge management and presented preliminary recommendations to Ambassador Goosby at an October 2012 SAB meeting.  It’s worth noting up front that PEPFAR has already begun to take meaningful steps toward improved financial data collection – like institutionalizing expenditure analysis into routine annual reporting.  But of course, there is more to be done.

So with an eye towards both reports, here are four recommendations where there seems to be agreement and feasible opportunities to improve PEPFAR’s collection, utilization, and dissemination of data and knowledge.

1.       Establish and maintain a PEPFAR public access knowledge portal

While PEPFAR’s current website is an invaluable resource for those interested in the USG contribution to the fight against AIDS, public accessibility of PEPFAR data and documents does not compare favorably to those of its partners and foreign counterparts (think DFID, the Global Fund, and the World Bank) – nor has it lived up to the spirit of the Obama administration’s Open Government Initiative. In fact, since 2007 the scope of PEPFAR’s annual public reporting has declined substantially – from a detailed 216 page report in 2007 to a bare-bones 5-page report for 2012 (shorter than 2007’s executive summary!).  Still, as the IOM points out, “PEPFAR has the opportunity to play a significant leadership role in making HIV/AIDS monitoring, evaluation, and research data available to other researchers, evaluators, and the public, so that these data are used for the greatest public health impact and to accelerate the pace of new knowledge creation” (p. 586).

Based on the principles that data are a public good (that allows learning by others) and that data should strengthen transparency and accountability, both the IOM and DWG recommend that PEPFAR establish and maintain a public access portal which offers PEPFAR-funded reports, publications, and financial and programmatic data. Further, to the joy of researchers everywhere, both reports echoed the importance of making data available in a timely manner for use by external evaluators and researchers to facilitate analysis at a more granular level.

2.       Strengthen and streamline HIV/AIDS program indicators

In examining PEPFAR’s data systems, the DWG found that huge quantities of data are being collected, at a high cost and burden to OGAC and implementers alike (to get an idea, see the picture below which shows the incredible complexity of the data flow process). Yet, it appears that that indicators are often of limited utility, either due to low epidemiological or programmatic relevance (i.e. inputs or “trainings”), or because the reported data is incomplete or unreliable.  Similarly, the IOM report finds that “PEPFAR’s current indicators do not capture sufficient information on its stated prioritized goals and activities and are focused primarily on inputs and outputs. As a result, the program monitoring system has limited utility for determining the effectiveness of PEPFAR’s effort” (p. 508).

Source: Slide 21

Based on these findings, both reports recommend that PEPFAR streamline its indicator list, and data collection and reporting process. This could be done by commissioning an external study on its indicators system, including a cost/benefit analysis of the value and cost of each indicator, and then using that report to identify a small set of “Tier 1” indicators that should be reported up to headquarters (as the IOM report recommends). Tier 1 indicators would stay consistent over time, be harmonized with existing global and/or national indicators, and form the basis of Congressional reporting on PEPFAR’s portfolio-wide achievements and epidemiological trends.

3.       Require each future grantee and contractor to submit a standardized, realistic, and contractually binding “Data Management Plan” that conforms to specific PEPFAR guidance.

Currently, most contractors are required to submit some sort of “performance monitoring plan” or a similar document as part of the grant proposal process. Typically, these documents outline a definition of each performance indicator; the source, method, frequency and schedule of data collection; and targets for each performance indicator. But because PEPFAR has not historically provided centralized guidance for the preparation of such documents, they have been limited in standardization, scope, enforceability, and utility beyond “indicators.” For example, such documents rarely account for the collection, archiving, and sharing of patient or facility-level data, such as on patient retention and outcomes.

Accordingly, the IOM report recommends that PEPFAR “develop systems and processes for routine, active transfer and dissemination of knowledge both within and external to PEPFAR” (p. 594). One way to do this (as the DWG recommends) is for PEPFAR to produce clear, centralized guidance for Data Management Plans, which would focus on 1) high-quality data collection and reporting for PEPFAR’s essential indicators, and 2) implementers’ internal collection and management of patient-level data for their own purposes, including the expectations for public access to such data.

4.       Expand the collection, application, and sharing of budget, expenditure and cost data through the Expenditure Analysis initiative

The lack of available financial data for PEPFAR has been a longstanding frustration for those who want to understand the distribution and use of PEPFAR funds (see here, for example). But it’s not just a transparency issue – there’s some evidence that even internally, PEPFAR has not historically been able to track and manage its cost-structure below the prime partner level. In recent years, PEPFAR has worked proactively to better understand and improve the cost structure and cost-effectiveness of its programs, most ambitiously through the Expenditure Analysis (EA) initiative, which released a pilot report from its first six countries in July 2012.

While EA itself was not a focus of the IOM report, the need for better financial data was repeatedly emphasized. The authors’ analysis itself was limited by data gaps in this area, for example on annual expenditures (p. 107) and PEPFAR’s prime and sub- implementing partners (p. 123). And the IOM reported implications of this limited data for program management and accountability:  “partner country governments have been frustrated by not knowing where the PEPFAR money was going. Some interviewees wondered how the government could be expected to hold implementers accountable if they did not know where the money was going” (p. 399). Accordingly, the IOM recommends that PEPFAR collect and report financial data that is more closely aligned with programmatic data and program implementation (p. 92). Further, the DWG urged PEPFAR to share the relevant (albeit anonymized) underlying EA data more widely, particularly with partners and country governments, who must understand the financial implications and cost structure of HIV/AIDS programs if they hope to assume direct responsibility for program implementation.

To be clear, this is not a comprehensive list of all IOM recommendations for knowledge management; beyond what’s discussed above, the IOM also considers issues such as PEPFAR’s evaluation policy and permitted research methodologies.  Nonetheless, these four focus areas provide perhaps the most feasible, practical, and meaningful opportunities to improve PEPFAR’s collection, utilization, and dissemination of data and knowledge, ultimately helping us to better understand the HIV/AIDS epidemic and improve our programs. I am optimistic that this apparent consensus between the IOM and the DWG will lead to real action. Let’s get started!

The objective proposed by the new PEPFAR blueprint is to reduce new infections below the number of people newly added to treatment in a given year. But this isn’t good enough, because the total number of people in low and middle income countries who are living with HIV/AIDS and dependent on the US and other donors for their daily medication would continue to grow – along with the moral entitlement to support these people on treatment.

Moving forward, I suggest that the US should figure out how to convert the moral entitlements it has already granted into credible long-term enforceable commitments which are more analogous to the commitments it makes to Social Security beneficiaries in the US.  My logic is that unless there is a lower bound to the US commitment in an individual recipient country, the recipient government will have little financial incentive to contribute its own scarce resources to AIDS treatment, because every penny it contributes might well be offset by the withdrawal of US resources.  (Even if the Obama administration means to continue funding this treatment, future administrations are entirely too free to renege.)  But just as the US must reform Social Security and Medicare to clearly establish a more sustainable upper bound for future payments, the US should clearly establish and communicate an upper bound to the US commitment to AIDS treatment in every beneficiary country.  The combination of the long-term commitments to a lower and upper bound on US contributions will change the incentive structure in recipient countries, establishing that the recipient country is responsible for the balance of the treatment need – and that the country has much to gain financially as well as through improved health of its citizens by implementing effective HIV prevention as rapidly as possible.

The recommendation in my book, “Achieving an AIDS transition,” is that, in addition to all the patients the US has started supporting, the US should commit to support a fixed percentage of the new treatment need in each recipient country, which might vary from 20% to 80% depending on the country.  The US government would have to plan how much would be required to meet each percentage point of need in each country and choose what percentage it intends to finance in every country to fit within the US’s projected future budget for AIDS treatment overseas.  But such an arrangement would assure continued US support and generate strong incentives for the country and its citizens to improve their HIV prevention efforts.

The pressure is on for the US government to cut spending.  In this environment, vague statements of administration support for meeting its moral commitments to AIDS patients in other countries provide unfair and perverse incentives to recipient government partners and provide insufficient guidance to Congressional and Administration budget cutters.  The White House should append the blueprint just released with a firm multi-year commitment to AIDS treatment specific to every recipient country.

Graph above is created from UNAIDS data accessed on December 3^rd, 2012 from the AIDSinfo database. Here is the Stata code to replicate the graph.

Background

Since January, 2011, I have served on two of the working groups of PEPFAR’s Scientific Advisory Board , those on data and key populations.    As I described in a previous post, Ambassador Goosby formally constituted this board in January, 2011 under the auspices of the Federal Advisory Committee Act and requested it to advise him and PEPFAR “concerning scientific, implementation and policy issues related to the global response to HIV/AIDS.”  [From the SAB’s charter.]  PEPFAR has recently posted the 22 presentations from the recent meeting as a downloadable 28 MB zip file.  For those who are following the progress of PEPFAR, the US’s most prominent, most frequently praised and most costly foreign assistance effort, these presentations provide a wealth of fascinating perspective, information, opinion and advise.  Because of the packed agenda, the SAB as a whole had little opportunity to review all of the material or to discuss each of the topics in the depth they deserved.  Hopefully many of the issues raised will receive a fuller discussion in the public arena, including on blogs such as this one.

The Data Working Group

Since January, 2011, I have served on two of the working groups, the ones on data and on key populations.  While I have long had an interest in improving the global response to the epidemic in key populations (an interest that was inspired by my early collaboration on an article with Peter Piot here and ungated here), my interest in data has only been instrumental.   I have appreciated data not for their own sake but only as a means to an analytical end.  But serving on the Data Working Group has opened my eyes to both the opportunities and the challenges that PEPFAR faces in the arena of data collection, management and disclosure.  In a series of meetings and conference calls over the past two years with other members of the DWG and with US government staff of PEPFAR and other agencies, I have learned that PEPFAR and its contractors are spending a great deal of money, perhaps $500 million per year or even more, collecting and managing data, but neither the intended beneficiaries (the AIDS patients and vulnerable populations of recipient countries) nor the US taxpayer is benefitting as much as they could from this effort.

In our group deliberations, the members of the DWG based our recommendations on a set of “principles of data collection and management”:

1. Data should strengthen US government program management
2. Data are a public good (i.e. the consumption of data is neither “excludable” nor “rivalrous” and therefore its production and distribution require government support)
3. Data should further transparency and accountability of government programs
4. Data should be standardized for comparability through a common data “platform”
5. Data based analyses of the progress or problems of a US government program should be replicable by members of the public, who can also be a source of independent ideas (“Crowd sourcing”)

How do you, the readers of this blog, feel about these principles?

The DWG’s Recommendations to PEPFAAR

Proceeding from these principles, the Data Working Group arrived at a set of four recommendations which we delivered to Ambassador Goosby (the US’s Global AIDS Coordinator) in the form of a presentation that I presented at the recent October meeting.  These were that PEPFAR should:

1. Establish and maintain a PEPFAR public access knowledge portal
2. Strengthen, streamline and publicly disclose PEPFAR’s collection and management of key program indicators
3. Establish, collect and publicly disclose activity-based budget, expenditure and cost data
4. Require each future grantee and contractor to submit a “Data Management Plan”

Since PEPFAR already has a website and collects indicators, the first two of these recommendations may seem anodyne.  However, those who have attempted to retrieve more detailed quantitative information from the PEPFAR website already know how frustrating such an effort has been.  PEPFAR does well on collecting its mandated indicators, but lags behind other US agencies both in the scope of its reports to Congress and in its  ranking on the 2012 Aid Transparency Index.  PEPFAR’s indicators also need to be strengthened (e.g. to better capture the retention as well as the enrollment of AIDS patients) and also streamlined (to minimize the collection and reporting of unusable indicators).  See the full presentation for more details on both the strengths and the weaknesses of PEPFAR’s current efforts.

Recommendation 3, the collection and disclosure of activity-based budget and expenditure data, may be the most surprising recommendation to the average US taxpayer, who wants to be sure US foreign assistance is wisely spent.  The taxpayer might well ask, “Aren’t the budget, expenditure and cost of PEPFAR funded activities already fully disclosed?”   Unfortunately long before PEPFAR was created the US government ceded to its contractors the “right” to declare their detailed activity-based budgets and expenditure reports to be, get this, “trade secrets”, which the contractors can refuse to divulge to the public.  These data that would intuitively seem to be the property of the citizens of any democratic country, are hidden behind so many layers of protection that sometimes even PEPFAR staff cannot access them.  See this enlightening blog post by Till Bruckner who attempted to extract such information from US aid contractors using a Freedom of Information Act request.

The good news is that PEPFAR has taken aggressive steps to better understand the cost-effectiveness of its programs, but has not yet disclosed the underlying data to the public.  The DWG recommended that PEPFAR build on its recent progress in this area by:

1. Regularly repeating its surveys of the activity-linked unit cost of anti-retroviral treatment and disclose the properly anonymized underlying data
2. Expanding its activity-linked unit cost analysis to other PEPFAR supported HIV/AIDS services
3. Releasing the properly anonymized activity-linked budget, expenditure and  cost data at the unit of observation, which is the partner or program
4. Disclosing the anonymized activity-linked financial data on PEPFAR’s open web portal, freely browsable by the public

Recommendation 4 will be the most controversial in the PEPFAR research community.  Researchers have many reasons, both good and bad, for preferring not to share their data.  The good reasons are to protect the privacy of their patients or subjects and to respect the sovereignty of host countries (although one must ask whether the host countries preferences for data control should trump those of the American taxpayer and the global community in every case).  The bad reasons have to do with researchers’ ambitions to squeeze out all of the possible publications from the data before releasing them for use by other researchrs.  (As a researcher I have not been immune to this temptation.)  Unfortunately, the two sets of reasons can become easily confounded, since a researcher wishing to retain private use of data over a longer time can often persuade the host country government to request the data not be shared.

Although I empathize with the researchers’ desire to have privileged access to data they have collected, at least for a while, as an economist I am aware that private incentives will always be slanted against optimal public disclosure of data.  In this fourth recommendation, we on the DWG advise PEPFAR to represent the public interest as a counterweight to the various private interests of host countries and researchers and support the principle that publicly funded data should eventually enter the public domain and that US government contractors must establish an approved timetable for archiving their properly anonymized data for public use.

An opportunity for some quick progress.

Assembled in a blog post by CGD’s Lawrence MacDonald, four colleagues and I propose that those in the Obama administration with attention to spare from the task of avoiding the fiscal cliff could make a few immediate, low cost or free changes that would substantially improve US policy support for poverty reduction in poor countries for years to come.  Building on what I’ve learned on PEPFAR’s SAB, my contribution to this list is to suggest that Ambassador Goosby and his staff move forward quickly towards greater public disclosure of existing data (DWG Recommendation #1) and towards mandating the Data Management Plans for contractors (DWG Recommendation #4).  Looking forward to 2013, we can all hope and expect that further improvements in PEPFAR’s collection, management and disclosure of key program data will support continued improvement in the quality, efficiency and accountability of PEPFAR’s efforts against the AIDS epidemic.

Yesterday was an exciting day for me. In a debate at the World Bank timed to coincide with the International AIDS Conference a colleague and I took an unpopular position against two development celebrities in front of a potentially hostile audience and changed some minds. The proposition was:

“Continued AIDS investment by donors and governments is a sound investment, even in a resource constrained environment”

This was the line-up:

- Richard Horton | Editor, The Lancet (moderator)
- Charles Holmes | Chief Medical Officer and Director of Research & Science, Office of the U.S. Global AIDS Coordinator (debate introduction)
- Jeffrey Sachs | Economist and Director, The Earth Institute, Columbia University (panelist FOR the motion)
- Michel Sidibé | Executive Director, UNAIDS (panelist FOR the motion)
- Roger England | Chair, Health Systems Workshop, Grenada (panelist AGAINST the motion)
- Mead Over | Senior Fellow, Center for Global Development (panelist AGAINST the motion)

For those who missed it, the LiveBlog Twitter roll, as well as a video of the event, is here:

Mead Over addresses his colleagues at the
World Bank debate. (Photo Credit: Matt
Schneider/CGD)

Here’s my take:

Roger England and I seemed to fare OK. We benefited, I think, from Richard Horton’s well-informed and high-spirited introductions and interventions and especially from his decision to depart from past practice by asking for a show of hands at the beginning of the debate and at the end. The waving hands revealed to all just how lop-sided the support for the proposition was and probably gained a bit of sympathy for Roger and me. To the surprise, I think of the moderator and all four of us debaters, a sizable minority of people changed their views from supporting the proposition at the beginning to opposing it at the end, a fact that would not have been apparent without Richard’s poll.

Why were Roger and I able to change more peoples’ minds? The audience seemed to be moved by Michel Sidibé’s argument that AIDS spending had engendered and subsequently fueled global social progress and tempted by Jeff Sach’s assertion that resources can be cajoled or wrested from the rich to meet all possible health needs. But neither of them adduced evidence to support the proposition at hand. In fact, both argued, Michel implicitly and Jeff explicitly, that the proposition be discarded so that the debate could be held on different premises and with different metrics.

I suspect that many in the audience, especially those who at the outset were less firmly committed to the proposition, were a bit put off by Jeff and Michel’s decision not to play by the rules. This left an opening for Roger and me, which we had luckily prepared for: An evidence based argument. If Michel and Jeff had bombarded the audience with impressive statistics, like ART’s 96% prevention rate of HIV-negative partners from the HPTH 052 trial or the Granich et al finding that AIDS could be eliminated in South Africa within “only” 40 years by a $100 billon test-and-treat program, the proponents would have held onto, and perhaps gained, adherents. We could have fired back our own statistics, which in many ways would dominate a logical argument. But given an equal number of competing and impressive-sounding statistics on both sides, it’s possible that the philosophical positions adopted by Michel and Jeff would have tipped the undecided more towards their side. However, by sticking to their “high road” and leaving out the numbers and specifics, I believe that Michel and Jeff left themselves open to our guerilla offensive – and lost credibility.

In adopting the negative side of this debate, I was forced to put aside my skeptical persona and deliver the best impressive statistics I could with as much authority as I could muster. It was fun. But in this blog space I now have time to go back over some of the arguments that were advanced on both sides and compare their “truthiness” to what I believe can actually be said based on a more contemplative and nuanced overview of the evidence. While I can’t predict how I will come out a few blogs from now on whether “HIV/AIDS spending is a sound investment, even in a resource constrained environment,” I can tell you one thing: I will be less certain of my position than I appeared in the debate.

And, hey, call me a class warrior, but I do kind of like Jeff’s idea of a financial transaction tax on movements of cash from the Cayman Islands to Mitt Romney’s Boston checking account – earmarked of course for global health spending.

The debate comes at an interesting time in the history of the effort to control the epidemic.  UNAIDS has just published their updated report on the epidemic in which they point with pride to treatment achievements but concede that the impact of global HIV policy on the rate of new infections is hard to discern.  The following graph from their report illustrates the problem.

Source: UNAIDS, Together we will end AIDS, 2012, p. 37

In 2001 the World Bank under then president Jim Wolfensohn committed to spend heavily to combat HIV/AIDS, eventually spending two billion dollars. In recent years, however, bank spending on the epidemic has fallen sharply, primarily because the Bank’s clients have not wanted to borrow for it. This was rational because countries could obtain virtually unlimited grant money for AIDS from the US Government’s PEPFAR program or from the Bank’s multilateral competitor in health, the Global Fund for AIDS, TB and Malaria.  But with donor funding leveling off—and the number of people needing treatment continuing to climb—the question arises whether the bank’s clients and the bank management and staff will consider HIV/AIDS is a sufficiently sound investment to be financed by World Bank credits and loans.

The recent arrival of a new World Bank president, Jim Kim (who will be speaking just ahead of the debate) makes this an especially propitious time to consider whether HIV/AIDS spending is indeed a sound investment. As the head of WHO’s campaign to expand AIDS treatment, the “3 by 5 initiative”, Kim invested a substantial portion of his career in the push to expand AIDS treatment. To what extent will his experience shape his views about whether or not spending on AIDS is a good investment?

The AIDS community seems to sense that there is a lot riding on today’s debate.  The debate organizers have filled the program with introductory remarks by speakers who can be expected to support the proposition.  And there is indeed much good news about AIDS treatment spending, some of which I have personally contributed.  So my friends have been asking me: Why did you accept the Bank’s invitation?  Do you really believe that HIV/AIDS spending is NOT a sound investment?

Although I have been working on the economics of HIV/AIDS for 25 years (since I helped a WHO team design the first HIV/AIDS plans in Kenya and Nigeria), my motivation for this work has not been to increase HIV/AIDS spending.  Rather I try to to search out, analyze and present the theory and evidence that would guide the appropriate prioritization of that spending.  Sometimes the evidence leads me to the view that an intervention should have a low priority, sometimes a high one.  As new evidence becomes available, I try to adjust my recommendations accordingly.

It’s in the spirit of this ongoing inquiry that I accepted to speak against the proposition that AIDS is a sound investment, even in a resource constrained environment. Do I “believe” the negative view?  Tune in to see if Roger and I can sway your views even a little.  And then check this space tomorrow for my thoughts on tonight’s proceedings.

I present her comments here and invite readers to add their own thoughts in the comment section below (where I also reserve the right to rebut!)

Excerpt of e-mail from Laurie Garrett

Overall I would make a couple of suggestions:

1) Prevalence does NOT equal incidence. Here in the USA, with all the technology and money we have, the CDC officially declared the annual INCIDENCE of new HIV infections to be 40,000, every year from 1983-2007. This was ludicrous. In 1983 the CDC could be forgiven a back-of-the-envelope guess because we didn’t even have a valid HIV test. But by 2000 — long after the SF Dept of Health invented the “de-tuned assay” for incidence measurement, it was unforgiveable. Either the hundreds of millions of $$’s spent annually on HIV prevention were an utter failure, allowing 40,000 new cases annually, or nobody knew what they were doing. In 2008 the CDC finally started creating valid ways to measure incidence, and discovered their data was off by 40%: There were some 60,000 new cases/year in 2005-7. Moreover, the incidence was overwhelmingly African American and gay. For the first time in more than 2 decades the USA was applying a reasonable toolkit to prevention of HIV. Folks at Hopkins estimated the newly discovered incidence amounted to a $250 million/year increase in treatment costs, alone. That is why the Obama Admin has put so much prevention energy into DC and Baltimore, where things are exploding and incidence now surpasses Uganda.

2) If you are going to hold GOVERNMENTS accountable in a COD approach for HIV prevention, you had better have a toolkit better than the ones we have used in the USA. Even now, post-2008 I am not sure the USA could meet your COD standards.

3) Confusing prevalence and incidence is forgivable in general conversation, but not as a basis for cutting off funding to a nation. As the numbers of people surviving HIV thanks to ARVs grows worldwide prevalence is an increasingly irrelevant and misleading number. [Mead is proposing to estimate incidence by first subtracting prevalence in a baseline serosurvey from prevalence in a follow-up serosurvey and then using a model to correct for mortality and ARVs. However,] creating a valid serosurvey on a national basis for annual incidence assessment is a daunting, expensive, scientifically extremely difficult task. In our UNAIDS effort we determined that it would be impossible in a country without head-of-state and legislative full support: the logistic, political and ethical dilemmas are so large that only top-of-government mandates can make the effort doable. Do you think that is possible in Swaziland? Perhaps even more relevant, in Uganda where Museveni has a stake in downplaying incidence, due to his advocacy in ABCs?

4) The actual HIV Transition is a moving target. As mortality declines with ongoing roll-out of ARVs the magic point for incidence targets also gets harder to attain. Here in the USA our HIV-related mortality is now so low that corresponding incidence would probably have to drop from the current 60,000/year to less than 10,000 (maybe even 5,000) to come close to the transition. (At the mortality peak in the USA in 1995-6 we experienced about 17:100,000 deaths annually due to AIDS. For the last 8 years we’ve held at 8:100,000. In July a multi-country survey found that death rates in the US and Western Europe were rising among elderly HIV+ individuals, but had dropped significantly for most people on ARVs. A summary stated: “The authors calculated an 88 percent reduction in excess mortality in 2000-2001 compared with the period prior to 1996. This was very close to the 87 percent reduction seen in 1997-2001. In 2004-2006, the excess mortality was 94 percent lower than pre-1996 levels.”) Imagine what it would take for us to achieve that! For a generalized epidemic like Kwazulu-Natal the first few years of effort would require an incidence target FAR easier to attain, but if treatment rollout achieves Mead’s 80% uptake target mortality should plummet so dramatically that the incidence target gets down to the less than 3%/annual level — a very hard threshold to pass in such an epidemic.

I think US’s $100 million spent on understanding combination HIV prevention– which is matched by almost as much investment from the Bill and Melinda Gates Foundation and other partners– is money well spent to show whether combination prevention can work. But here’s the rub, the prospect of eventually having an AIDS-free generation depends crucially on the outcome of these rigorous multi-year research projects that are just now being launched. And none of the current PEPFAR funded trials will be able to untangle the separate contributions of the several prevention interventions being combined (to do so would require more “arms” for each study, which would increase costs almost commensurately). The fact is, we don’t yet know whether any of them will succeed in lowering rates of new infection in the community as a whole. But we do know their costs will be exorbitant.

What is lacking in the Secretary’s vision of an AIDS free generation is the intermediate goal of an “AIDS transition” that I describe in my new book (which will be launched at CGD on November 16). The objective suggested by Secretary Clinton of reducing the number of new infections to match the number of new people placed on treatment is sadly not sufficient, as the people living on AIDS treatment are dependent on daily medication and require expensive lifetime support. Instead, the number of new infections must fall below the number of AIDS deaths, while ART is sustained and expanded. A country that accomplishes this objective will have achieved what I call the “AIDS transition”.

So how can the U.S. promote the AIDS transition? A solid, clearly defined multi-year US commitment is the fair and incentive-compatible framework upon which the US can plan its own future engagement and the recipient government can grapple with a well-defined unmet need. As Secretary Clinton pointed out, the US has for the first time made a multi-year commitment to the Global Fund for AIDS, TB and Malaria. This is commendable, but recipient African countries are extraordinarily vulnerable to the ups and downs of volatile foreign assistance disbursements and need reliable commitments even more than does the Global Fund. To each country where the US has already granted virtual “entitlements” to AIDS treatment, the administration should promise that it will sustain financing for those thousands of patients and expand treatment to X percent of those will need each year until the AIDS transition is reached. By specifying concretely the value of X, which is likely to be well below 100%, the US will be guaranteeing the minimum rate of treatment expansion, a minimum on which other donors and the recipient government can build.

How should the specific percentage for expansion of treatment be decided upon for a given country? The US should use the recent trends in new infections and the cost of treatment to estimate how much will be required to finance the given percentage of new patients until the AIDs transition is reached. Then with an eye on its overall budget, the US should only promise to treat the percentage of need that it is willing to finance from now until the projected AIDS transition, a decade or more in the future. The US and the recipient government will then share the savings if costs go down even faster. And the US can also promise that evidence of a faster-than-anticipated decline in new infections over the next few years will be rewarded with an increase in the US-funded rate of treatment expansion.

I’m glad that Secretary Clinton has taken the stage to proudly champion the US’ leadership role in AIDS. The fact that the US government has been able to continue to expand the numbers it supports on ART despite a flat budget for PEPFAR since 2008 is a tribute to the Obama administration’s leadership and to hard work by Ambassador Goosby and the PEPFAR staff. To effectively lead into the future, the US should clearly articulate its willingness to keep on expanding treatment, but not without limit. The promise of an AIDS free generation does indeed lie before us. In today’s budget environment, the only feasible path to that promise lies through the AIDS transition.

This seems a surprising list in several ways.  First, economists tend to give priority to government interventions which attempt to correct market failures, such as those caused by “externalities” (i.e. spillover effects) or “asymmetric information”.   Neither the authors nor the panelists analyze the two interventions which target populations where spillover effects and asymmetric information enhance the benefit cost ratio of interventions:  High risk groups and couple counseling.

Spillover effects: In situations where the behavior of identifiable subsets of the population make a disproportionate contribution to the HIV epidemic, a targeted intervention can have a much higher social benefit-cost ratio than an untargeted one.  While the heterogeneity of sexual behavior is evident both within and across African countries and has been known since the 1976 paper of Anderson and May to accelerate a sexually transmitted epidemic, the only assessment paper that recognized this heterogeneity is that by me and Geoff Garnett on ART.  In particular, the assessment paper on sexual transmission, authored by Jere Behrman and Hans-Peter Kohler, ignored the heterogeneity of behavior and therefore omits analysis of the potential benefit-cost ratio of interventions targeted at most at-risk populations (MARPs).
Asymmetric information:  As pointed out in Susan Allen’s comment on my Friday post, Behrman and Kohler’s analysis of “large scale testing and counseling” omits any consideration of targeting HIV testing to couples, an option that reduces the asymmetry of information regarding HIV status and therefore should have a higher benefit-cost ratio than would the individual testing on which the authors focus.

Another surprising feature of the Copenhagen Consensus list is its inclusion of an intervention which was never analyzed by any of the assessment papers and only mentioned as an additional or supplemental idea by one of the discussants: infant male circumcision.   It displaces the circumcision of adult men, which the panelists ranked in 7th place, and deprived of any of the $10 billion budget.   What happened?  How and why did the panel become so “creative”?

Here is the information that the assessment paper authors gave the panel on adult male circumcision (AMC) and on the intervention to which they allotted the largest budget share, ART.  At the discount rate of 3% and the value of a life-year of $5,000, these two interventions would have the following benefit-cost ratios:

So despite the fact that the authors considered adult male circumcision to yield from 12 and 20 times more benefit per dollar of investment cost, the panel of distinguished economists decided, on the basis of this analysis, that antiretroviral therapy ranked in fifth place among all the interventions, two places above the seventh place ranking of adult male circumcision.  Since the panelists allocated their entire hypothetical $10 billion to the first 5 interventions, they provided no incremental funding, even hypothetically, for adult male circumcision.  This decision is remarkably obtuse given the evidence on this intervention and the fact that this most promising intervention needs support to be scaled up in African countries today.

Part of the problem was that the authors of the assessment paper analyzing AMC, Jere Behrman and Hans-Peter Kohler, chose to use the 30% effectiveness assumption for their main results instead of the 60% result found in the randomized trials.  This is a very conservative assumption.  Given that male circumcision has been consistently and rigorously shown to prevent 60% of infections in the trials, field effectiveness could only be degraded down to 30% if either of two offsetting behavioral effects is extremely powerful:  (a) Selection Bias: willingness to accept circumcision is much higher among men who would have otherwise protected themselves by condom use or having fewer partners or (b) Disinhibition: willingness to accept circumcision is much higher among men who, once circumcised, engage in many times more risky sex than they would have without the circumcision.  The first effect posits that prudent well-informed men will disproportionately seek AMC, while the second posits that circumcision converts such prudent men into reckless thrill seekers.  If the sexual behavior of African men were this sensitive to the risk of HIV infection, they would have ceased their risky behavior long ago, when awareness of the danger of risky sex became widespread in African societies.

But the panel of distinguished economists apparently thought Behrman and Kohler were not being conservative enough.  At the meeting on Wednesday reported in USA Today, two of the panelists explained why they had downgraded AMC.  They justified their decision partly by the selection and disinhibition arguments, but also partly based on the undocumented assertion that adult African men would simply find male circumcision unacceptable.   Apparently in reaction to the cognitive dissonance produced by these unsupported beliefs and the authoritative estimate that the benefit-cost ratio of AMC is 60 to one, the panelists creatively introduced an 18th intervention to be added to the list they had been given: neonatal circumcision.  Arguing that neonatal circumcision would be immune to the selection and disinhibition problems and would be more acceptable to African populations, they made this one of their top five interventions.

Now neonatal circumcision is not a bad idea.  It can be expected to cost about the same as adult male circumcision and to eventually achieve, after a lag of 15 years, the optimistic benefits of adult male circumcision.  Since the costs are incurred today, but the benefits accrue 15 years later, the benefit cost ratio must be discounted by multiplying it by (1/(1.03)^15 = .64, which yields a benefit cost ratio of about 77 to one, down from 120 to one.  However, during the fifteen years we wait until the children reach maturity, the epidemic will continue to spread to a larger and larger proportion of the population.

So if neonatal circumcision crowds out adult circumcision before adult circumcision has been widely scaled-up, that would be a bad thing indeed.

Which brings me to a more general criticism of the Copenhagen Consensus’ application of benefit-cost analysis to HIV/AIDS.  Epidemics are highly non-linear.  They are characterized by a parameter called Ro, the “reproductive rate”, which is described so compellingly by Kate Winslet in the super new movie, Contagion.  If Ro is above unity, the epidemic grows until it saturates the population.  If it is below unity, the epidemic gradually disappears.  The challenge then is to find the combination of interventions, which, when working together, will bring the value of Ro down below unity.  That solution might well be a combination of ART, male circumcision, behavior change and an eventual vaccine.  The Copenhagen Consensus process, by requiring each author to analyze only one of the 17 interventions at a time, makes it difficult or impossible to find the combination of interventions which can reduce Ro below 1.0.  Thus, when applied to the control of an epidemic, the Copenhagen Consensus should modify its process to require each author to evaluate a different combination of interventions, instead of a single one.  With this approach, the Copenhagen Consensus process might have had a better chance to produce sensible results for HIV/AIDS.

(1) commissioning “Assessment Papers” on competing ways to spend a hypothetical additional $10 billion on HIV/AIDS in Africa over five years;

(2) commissioning “Perspective Papers” by discussants who critique the Assessment Papers and suggest alternatives;

(3) commissioning a “Nobel Laureate Expert Panel” to judge the competitors and rank the alternatives from most to least advantageous for the developing world populations they are intended to help.

Together with Geoff Garnett, formally of Imperial College, London and now at the Bill & Melinda Gates Foundation, I am the author of one of the six competing assessment papers in this competitive endeavor.  On Monday and Tuesday Bjorn Lomberg, Director of the Copenhagen Consensus Centre, and Marina Galanti, co-founder of the Rush Foundation will be chairing sessions at which the Nobel Laureate Expert Panel will hear all six of the authorial teams argue our analyses of our respective assigned interventions.

The six competing interventions are;

1. Prevention of sexual infections
2. Prevention of non-sexual transmission
3. Vaccine research
4. Social policy
5. Health systems strengthening
6. AIDS treatment

Geof Garnett and I are the authors of the Assessment Paper on AIDS treatment.  I am honored to be included with such a distinguished set of authors, whose names you can find on the project the RethinkHIV website.  The papers should be posted in draft form on Monday.

The rules of the exercise have been:

1. Compute the benefit-cost ratio of spending $10 billion over five years on our assigned intervention in sub-Saharan Africa
2. Show the sensitivity of the benefit-cost ratio to two alternative values of a life-year, $1,000 and $5,000, and two alternative discount rates, 3% and 5%.
3. Compare the increased $10 billion of spending to a plausible counterfactual, which might be a continuation of the current trend in program expansion.
4. Use the $10 billion five-year budget to select a trajectory for policy for coming decades from among the trajectories that would cost $10 billion in the first five years, and then evaluate the benefit-cost ratio of that trajectory.  (For a very long-period event, like the HIV epidemic or a climate intervention, it would be nonsensical to restrict a benefit-cost analysis to the benefits that occur within five years.  Most of the benefits of today’s AIDS treatment or HIV prevention will be reaped more than five years from now.)

Though I have given countless presentations in my life, I am somewhat intimidated about this one.  I’m used to the prospect that a discussant can sometimes ask pointed and challenging questions, but never since my thesis defense (an embarrassingly long time ago) have I been in the position of being grilled by a panel, and this panel consists of extremely distinguished members of my own discipline.

My discomfiture is partly that neither Geoff nor I, if we had to choose how to spend an additional $10 billion on AIDS in Africa, would spend every penny of it on AIDS treatment.  And we are pretty sure that the other five authorial teams would feel the same way about their interventions.  The stated goal of the Rush Foundation is to ”fund disruptive ideas in the fight against HIV in sub-Saharan Africa”.  Currently the most disruptive idea is “combination prevention,” an approach to combatting HIV/AIDS that combines in creative ways AIDS treatment, various medical and behavioral HIV prevention ideas and social policy in an attempt to benefit from synergy among them and create a winning mix.  (See the information here, here, here and here.)   By constraining the authors of the Assessment Papers to analyze interventions in isolation from one another, we may have been constrained from offering the most “disruptive” or beneficial ideas.

In defense of the Copenhagen Consensus approach, we are asked to analyze our interventions in a context where all the things currently funded continue to be scaled up at plausible current rates of expansion.  So when Geoff and I estimate a benefit-cost ratio for AIDS treatment, the rules permit us to suppose that the incremental $10 billion on treatment will be in addition to the trend levels of behavioral prevention and vaccine research, etc…   Furthermore, while the Assessment Paper authors were constrained, the Perspective Paper authors could propose more disruptive approaches, including combination prevention.  And of course the overarching panel of experts is free to be as creative and disruptive as they wish.

Watch this space for a report from inside the closed meetings.  In the meantime, please feel free to offer your own assessment.  How would you spend an additional $10 billion over five years on AIDS in sub-Saharan Africa?

This dramatic evidence that ART lowers the infectivity of HIV supports the hypothesis of a beneficial biological external effect of ART.  But is the evidence surprising and powerful enough to be a “game changer” as Michel Sidibe, the director of UNAIDS declared, or “to end, or at least diminish, a bitter feud within the AIDS world over how much funding should go to treatment versus prevention,” as the Wall Street Journal has suggested?

It has long been known that ART can have both biological and behavioral effects on prevention.  A simple typology of these effects classifies them as either beneficial (because they slow transmission) or adverse (because they speed transmission).  (See the table from our 2004 book reproduced at the bottom of this blog.)

So the new experimental finding adds support to the upper left quadrant of this table positing a beneficial biological effect and thus to the proposition that I blogged in 2008 here and here that these beneficial externalities of treatment might justify a greater  allocation of resources towards treatment, as compared to a pure cost-effectiveness analysis that ignores such effects.  In the majority of African countries that have not yet managed to treat a large proportion of those with more advanced AIDS disease, the push to use ART for prevention increases the tension between the ethical mandate to treat the sickest patients first and the stronger efficiency argument for allocating limited treatment resources to those who are not yet sick.

But it takes more than this confirmatory experimental trial to argue that prevention resources should be re-allocated towards treatment.  Modeling shows that even if people start treatment when their CD4 count is 500, as they did in this trial, and then faithfully adhere to their daily dose for their entire lives, the future burden of the epidemic continues to rise until 2046.  The two panels of the following figure project the future of the epidemic in Sub-Saharan Africa through 2050, incorporating the trial result that the infectiousness of treated persons is reduced by 96 %.  These calculations also assume optimistically that financing will be found to enroll every HIV-infected person whose CD4 count is below 500, that circumcision roles out to 80 % of adult males by 2025 and that a 60% effective vaccine begins to roll out to all adults in 2025.  Panel a of the figure shows that without enhanced behavioral prevention the number of Africans living with HIV/AIDS continues to increase until 2046, reaching a peak of 38 million before the AIDS transition occurs.  And so does the cost of treatment, rising from its current level of around $6 billion to above $60 billion by 2050.

Figure.  Simulations of the future African HIV/AIDS epidemic if treatment reduces infectivity by 96% and reaches everyone with a CD4 count below 500.  Both scenarios assumed male circumcision reaches 80% by 2025 and a 60% effective vaccine begins to roll out in 2025.  Panel a) assumes risk behavior is unchanged from current levels, while panel b) assumes a 50 % reduction in risk behavior.

(Source: Projections from the AIDSCost model.   If you own a copy of Stata version 10 or later, you can produce the above projections by typing “findit AIDSCost” from inside Stata, installing the program, getting the data file and executing the following command for panel a:
“aidsproj using aidscgd2010.dta, uptake(.99) takeoff(2010) horizon(2050) cd4(500) maxep(0) gp(.96) weo regions(SSA) graph grcombine”   For panel b: Same command replacing maxep(0) with maxep(0.5).  )

These projections assume constant cost per patient-year of both 1^st and 2^nd-line treatment, which seems reasonable since current pressures on unit costs are in both directions.  Perhaps the unit cost of treatment will fall as pharmaceutical firms recognize the profit potential of 35 million customers at a low price as compared to 5 million at a high price.  But no matter how inexpensive the individual drugs, the number of people taking them daily would still rise by a factor of seven, creating an ever larger dependency of recipient countries on the donors and pharmaceutical firms providing the drugs.

In contrast panel b shows a scenario combining 99% uptake at a CD4 level of 500 with effective behavioral prevention which reduces infections from high risk behavior by 50 %.  Adding only this behavioral change moves forward the date of the AIDS transition by 16 years, to 2030, so that by 2050 the number of Africans living with HIV/AIDS has declined to 24 million and annual treatment expenditures will be about 25 % less than without this behavioral change.

With these considerations in mind, behavioral HIV prevention still deserves the highest priority.  The potential savings in AIDS treatment cost from even small behavioral changes accumulate to extraordinarily large benefits over the next 40 years and effective prevention shields the African countries and their citizens from an important part of the looming burden of this disease.

Source: Based on Table 3.3 on page 46 in Over et al., HIV/AIDS Treatment and Prevention in India: Modeling the Cost and Consequences (2004) available from Google Books here.