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Fighting a Concentrated Epidemic: MARPs in Vietnam

June 2, 2011

Fighting a concentrated epidemic: MARPs in Vietnam

 

William McGreevey

 

Department of International Health, Georgetown University

 

mcg1938 at gmail.com

 

Vietnam has a concentrated epidemic focused in injecting drug users (IDU), more than a quarter of whom are HIV+, and other most-at-risk populations (MARPs) including sex workers, where HIV prevalence is just under five percent. There is significant crossover of risk behavior, for example, rising trends in drug use behavior among sex workers. The most recent Government of Viet Nam report to UNGASS notes that the epidemic may have begun to stabilize in many locations among these populations but is rising in others such as in the northwest (Dien Bien and Son La). In 2009 national adult HIV prevalence was (aged 15-49) was 0.43 percent. HIV prevalence tends to be positively correlated with population density, which will increase substantially in Vietnam, with an estimated 43 percent of its population in the urban areas by 2030.

Over the past 10 years Viet Nam has strengthened the policy and legal environment governing HIV. Significant developments include the National Strategy on HIV/AIDS Prevention and Control (2004-2010) and the Law on HIV/AIDS Prevention and Control passed in 2006. Other more recent innovations include the amendment to the law on drug control which permits the use of harm reduction. While there have been significant advances in programs and interventions for MARPS groups, policy and legal gaps and tensions remain. Under the 2003 Ordinance on Prostitution Prevention and Control, anyone selling sex is subject to administrative detention; similarly the Ordinance on Administrative Violations and Decree 94 of the new law on drugs contain provisions to detain drug users in compulsory settings and limit access to HIV and harm reduction services.[1]  How and in what measure do interventions focused on most-at-risk populations yield benefits adequate to repay program costs?

 

Lives saved and future care and treatment averted by keeping IDU, sex workers and MSM free of HIV can add up to benefits that substantially exceed program costs over coming years. The value of lives saved can be estimated using methods developed and tested by respected health economists in the USA and other countries. Likely and ?Çÿcounterfactual´ scenarios can identify cost savings as well as life enhancement results. Paragraphs below describe these methods and offer a preliminary vision of how a program of analysis could unfold.

Vietnam, like other countries in rapid transition, does not commit enough resources to the fight against AIDS.[2] A comprehensive response to financing needs for HIV/AIDS will require just a quarter of one percent of GDP and a small share of total health spending in Vietnam (see Table 1). Resource mobilization is financially feasible but politically difficult.

Table 1:        Prospective AIDS spending requirements, 5 CRT countries, spending per person, per PLHIV, as percentage of GDP and percentage of health spending, 2030/31

Full Coverage Spend, US$ millions
(1)

AIDS Spend/
P
erson
(2)

AIDS Spend/
PLHIV
(3)

AIDS Spend percent of GDP
(4)

AIDS Spend percent Health Spend
(5)

China

$9,945

$6.68

$14,208

0.07

0.16

India

$5,770

$4.07

$ 2,404

0.17

0.36

Indonesia

$2,202

$7.71

$8,155

0.36

1.77

Thailand

$328

$4.65

$538

0.09

0.26

Viet Nam

$491

$4.62

$1,692

0.25

0.44

Source: Futures Institute projections of financing requirements under scenario of full coverage. AIDS spend/PLHIV assumes same number of PLHIV as estimated for 2007 in UNAIDS Report on the global AIDS epidemic 2008, Table 1, p. 219.

Money alone will not be enough to contain the epidemic. Politics (political will) and policy space could, in the years between now and 2031, matter more than money and fiscal space. Demonstrating the benefits of investing in prevention and harm reduction among IDUs, sex workers and MSM may help tilt the balance of political will in favor of these actions in Vietnam.

Harm reduction could be the cornerstone of a national program, implemented in several cases of Government-donor cooperation. To justify expanded Government commitment, future analysis needs to demonstrate and identify evidence of the returns on investment in HIV prevention. There are two major approaches now being employed in the health economics field:

  1. Calculation of program costs vs. the value of statistical lives saved and disability-adjusted life-years saved, employing approaches developed by W. Kip Viscusi, William Nordhaus, and David Cutler. A quick cost-benefit analysis (CBA) indicates that cost per IDU is about $80 annually. If, as with the Stover and others Science article, proposed targeted spending could prevent half the infections that they project would otherwise occur, a lives-saved approach can probably show a ratio of benefits to costs in the range of 5 to 8 and hence likely to be a sound investment;
  2. Cost-utility analysis that can demonstrate cost per infection averted by means of alternative combinations of prevention, care and treatment services, accompanied by estimation of costs saved as fewer persons ever becoming HIV+ lead to lower costs of ART and hence cost-savings from the interventions employed.

Each method has its advocates and uses; our objective must be to find results that can convince policy makers in Vietnam of the soundness of effective spending for HIV/AIDS interventions. Procedures and methods for these calculations could be developed in future stages of work on this topic.

ANNEX: Estimating the value of a statistical life

 Health economists focus on the cost-effectiveness of health investments by estimating the cost per disability life-year (DALY) that can be saved with investments in prevention, care and treatment of a wide range of health services. Analysts using CBA will require that DALYs be translated into benefits in monetary terms. They can multiply DALYs by a country´s average per capita income expressed either at current exchange rates or by using common measures of purchasing power parity exchange rates expressed in international dollars. David Cutler pushed the benefits estimate even higher because GDP understates the value of additional lives; his analysis suggests that an additional year of life gained by health interventions is worth approximately 2.5 times the value of per capita income and product (Cutler 2004). Cost-benefit analysis (CBA) could consider the fuller range of non-health benefits that may derive from health improvements, e.g., greater productivity, more foreign direct investment, and increased international trade for private-sector producers;

Viscusi shows convincingly that a life saved in the USA is often compensated in the US legal system at a value of $3 million to $7 million. Cohen´s work shows that spending on HIV/AIDS interventions of an amount less than $250,000 per DALY saved is cost-effective, whereas Holtgrave, Pinkerton and their co-authors focus on $50,000 per DALY saved as a good buy in US health care services focusing on HIV/AIDS (Holtgrave and others, 1997, 2002, Pinkerton and others, 2000). These analyses, in both developed and less-developed country settings, demonstrated the potential gains from applying economic analysis in the health sector can be substantial.

David Cutler drew on the earlier work of Viscusi (1993), Viscusi and Aldy (2004), and Nordhaus (2002) to show that health interventions in the USA since 1960 brought far greater value in lives and life-years saved than they cost in terms of health spending. He shows, for example, that improvements in cardiovascular disease treatment alone saved more money and lives than the aggregated spending on all health care in the last half century.[3] In later work with Grant Miller, the authors calculated the life-saving benefits of extending water and waste sanitation capacity to the billions not now served and demonstrate via a counterfactual calculation that benefits would far exceed costs. (Cutler was the principal advisor to the Obama Administration during the run-up to passage of health reform legislation recently.)

By 2005, there was already broad though not universal agreement among health economists that lives and life-years saved are sound measures of benefits to be derived from health investments (Cf. Berman 1998. Their views are summarized in Priorities in health (Jamison and others 2006, and Disease control priorities (DCP2, ed., Jamison and others, 2006 and www.dcp2.org). Guidance provided there is also of direct utility for analysis of projects that the Vietnamese Government and its donors will consider.

Priorities in health, Chapter 3, sets out some key terms and their definitions summarized here:

  • Units for cost-effectiveness ratios: Calculate cost-effectiveness in terms of US dollars per DALY (disability-adjusted life-year), where DALYs are calculated using disability weights provided by WHO and a 3 percent discount rate;
  • No differentiation by age: Saving of an infant life counts for more than saving the life of an older person because of the difference in expected years of life; a year of life saved is equal at all ages;
  • Basis for calculating years of life: Use regional life expectancy;
  • Currency units: Convert local currencies to US dollars at current exchange rates or via International dollars at purchasing power parity;
  • Costs: Count the costs of producing an intervention but not the costs of consuming it on the part of patients and their families (Jamison and others, 2006, 41).

 

Even without pricing a DALY, the analyst can calculate the cost per DALY gained. Comparisons with results emerging from CEA approaches would usefully complement and could potentially reassure health project analysts that a proposed project does or does not meet standard criteria for assessing health project investments. In summary:

  1. Cost-effectiveness analysis, basically the cost per DALY, would help promote a focus on the most cost-effective health sector interventions;
  2. Cost-benefit analysis (CBA) could consider the fuller range of non-health benefits that may derive from health improvements, e.g., greater productivity, more foreign direct investment, and increased international trade for private-sector producers;
  3. Vietnamese HIV/AIDS managers could weigh these risks along with its estimates of economic rate of return and the cost-effectiveness of health interventions in reaching its decisions.

Selected References

Aral, S.O. and M. Over, K.K. Holmes, L. Manhart, N. Padian, and S. Bertozzi. 2004. Sexually Transmitted Infections. Disease Control Priorities in Developing Countries 2005. Pre-publication.

Barnum, Howard. 2001. Economic evaluation of health projects. In Belli, P., and others, Economic analysis of investment operations. Analytical tools and practical applications. Pp. 99-119.

Becker, Gary. 1975. Human capital: A theoretical and empirical analysis with special reference to education. Chicago: University of Chicago Press, Second edition.

Belli, Pedro, Jock R. Anderson, Howard N. Barnum, John A. Dixon, and Jee-Peng Tan, editors. 2001. Economic analysis of investment operations. Analytical tools and practical applications. Wash DC: World Bank, WBI Development Studies. 264 p.

Bongaarts, John, and Mead Over. 2010. Global HIV/AIDS policy in transition. Science 328, 11 Jun 2010, 1359-60.

Centers for Disease Control. 1999. Ten great public health achievements — United States, 1900-1999, MMWR Morb Mortal Wkly Rep. 48:241-43.

Cohen, D.A. et al. 2004. Comparing cost-effectiveness of HIV prevention interventions. Journal of Acquired Immune Deficiency Syndrome 37: 1404-1414.

Cohen, D.A., S. Wu, and T. A. Farley. 2005. Cost-Effective Allocation of Government Funds to Prevent HIV Infection. Health Affairs. 24:4 p. 915-926.

Cutler, David. 2004. Your money or your life: Strong medicine for America´s healthcare system. New York: OUP.

Eckstein, Otto. 1958. Water resource development. The economics of project evaluation. Cambridge MA: Harvard University Press. 300 p.

Frederick, Shane, George Loewenstein, and Ted O´Donoghue. 2002. Time discounting and time preference, a critical review. Journal of economic literature XL, June, 351-401.

Gottret, Pablo, and George Schieber. 2006. Health financing revisited, a practitioner?ÇÖs guide. Wash DC: World Bank.

Gramlich, Edward. 1997. A Guide to Benefit-Cost Analysis. Second Ed. Waveland Press.

Jamison, Dean T, and others, Editors. 2006. Priorities in health. Wash DC: World Bank.

Nordhaus, William. 2002. The health of nations: The Contribution of Improved Health to Living Standards. Unpublished, NBER and Yale University Economics Department. 31 p.

Stover, J., and others. 2006. The global impact of scaling up HIV/AIDS prevention programs in low- and middle-income countries. ScienceExpress, 2 February and 10 March 2006.

Tan-Torres Edejer, T. et al (ed.). 2003. Making Choices in Health: WHO Guide to Cost-Effectiveness Analysis. Geneva: World Health Organization.

Tengs, T.O. and T. H. Lin. 2002. A Meta-Analysis of Utility Estimates for HIV/AIDS. Medical Decision Making. 22 p. 475-481.

Viscusi, W. Kip. 1993. The Value of Risks to Life and Health. Journal of Economic Literature 31, 4, 1912-1946.

Viscusi, W. Kip, and Joseph Aldy. 2003. The value of a statistical life: a critical review of market estimates throughout the world. The journal of risk and uncertainty 27, 1, 5-76.

World Bank. 1993. World development report: Investing in health. Wash DC: World Bank.

 



[1] Government of Vietnam: Fourth UNGASS report 2010

[2]               No country in Asia meets the Independent Commission on Aids in Asia (ICAA) criterion of spending a half to a dollar per person per year on HIV/AIDS. Nor do these countries focus their efforts on the interventions that yield the greatest reductions in new infections and the most beneficial actions to extend lives and avoid premature deaths.

[3] See Cutler, David. 2004. Your money or your life: Strong medicine for America´s healthcare system. New York: OUP, pp. 47-75.

 

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