Bringing HIV Programming Home: the Efficiency Possibilities of Country Ownership
June 16, 2011
Bringing HIV programming home: the efficiency possibilities of country ownership
Gettysburg College, Gettysburg PA, USA
This IAEN series of papers is about effectiveness and efficiency of HIV/AIDS programming. Earlier contributions have made a persuasive case that effectiveness is context-specific, and that the pursuit of efficiency, too, may depend on who are the key players providing and allocating resources. Shrinking donations and country ownership could introduce some instability in the path of HIV prevention and treatment programs in low- and middle-income countries. But they also can stimulate a more aggressive search for efficiency in programming.
AIDS did not arise in isolation. The worst HIV epidemics are found in countries with multiple endemic diseases and inadequate health systems. In the early days of AIDS epidemics, national governments often raised the protest that their populations faced multiple health risks and the emphasis on HIV/AIDS was not proportionate to the burden of disease. While that approach was too conservative, given the enormity of the HIV epidemic, especially in southern Africa, it does point to some important opportunities for increased service delivery with greater efficiency.
Integrated health programs can enhance efficiency by taking advantage of economies of scale and of scope. They are also better suited to address diseases and other health problems, such as malnutrition, that have significant and multiple interactions. Vertical programs isolate funds for narrowly defined uses, missing the opportunities for positive externalities in health spending. Donor-driven programs tend to be vertical and reflect health priorities from the viewpoint of donors. Vertical programs make less sense with a shift in emphasis to country ownership, and that goes for HIV/AIDS as much as for any other health issue.
National ministries of health already address a wide range of health problems. There is the potential for better integration of diverse services when they are housed under one ?Çÿroof.´ With country ownership comes the opportunity to address the long-standing health problems of their populations with greater efficiency because of the possibilities for integrating multiple services that require similar facilities, equipment, and staff. HIV/AIDS programming can find a home in the ministry of health and in local clinics and hospitals, along with other pressing health concerns, many of which interact with HIV.
Integrating health services to improve efficiency has a biological evidence base, as well. Diseases can act synergistically, increasing susceptibility and contagiousness. Moreover, one of the ongoing problems with the AIDS pandemic is addressing co-infections, including TB, STIs, and hepatitis. Countries with good access to ART, such as Botswana, are finding that many women under treatment still die, but from cervical cancer. Comprehensive women´s and men´s health programs are needed to protect people living with HIV. Other co-infections endemic in tropical and sub-tropical poor populations also complicate both prevention and treatment.
Malaria increases HIV replication and viral load as much as ten-fold, doubling sexual and vertical transmission for several weeks after febrile episodes, which may recur several times in a year . Moreover, treating malaria reduces HIV viral load . Preventing HIV in malaria-endemic populations requires that we also prevent and treat malaria.
Another example of a common disease that interacts with HIV is urinary schistosomiasis, which affects almost 200 million people in sub-Saharan Africa. Women with genital lesions of schistosomiasis are three times as likely to be infected with HIV as women in the same villages without genital schistosomal lesions . Treatment for schistosomiasis costs 7 US cents.
Effective treatment of HIV will also require an integrated approach. People infected with schistosomiasis often cannot tolerate antiretroviral therapy because a heavy parasite load impairs liver function. Moreover, trials have shown that CD4 counts can be increased in HIV-infected persons co-infected with ascaris (round worms)  by giving them deworming medication that costs about 2 US cents. It is likely that other intestinal helminthes have a similar impact on CD4 counts and viral load. Thus, it may be possible to postpone first-line antiretroviral therapy in these persons for a considerable length of time, protecting their health, increasing their productivity, and preserving first- and second-line therapies.
Just as TB treatment precedes ART, deworming should be part of the ART protocol. Trying to roll out ART without treating widespread, easily curable conditions like worms wastes lives and squanders first-line therapy. Deworming is safe, effective and easily dosed; it generates positive externalities (treating one person may reduce others´ risk of infection); and it might also prevent the failure of first-line ART ?Çô at a cost of as little as 2 US cents per person. The cost of moving to second-line therapy will far exceed the cost of treating coinfections. It is important to move as many people to early initiation of ART as possible. But we know that in poor populations many people will never have access to ART and many others will be sick too long before they start. If we can keep people healthy longer with simple, cheap treatment for highly endemic conditions, like worms, we will save more lives more efficiently. Even women who survive with ART treatment will die unless a more comprehensive protocol, like early screening for HPV and cervical cancer, becomes the standard.
It is possible to shift the entire distribution of risk of HIV acquisition and transmission in poor populations by focusing more on co-infections. When HIV/AIDS is isolated from other health concerns, that creates a bias against spending what are really trivial amounts to change the risk of transmission of HIV and the risk of treatment failure. Such investments are not a diversion of funds from HIV prevention and treatment; they are necessary complements. And they can best be implemented when HIV is part of a whole health approach.
Trying to solve one health problem at a time is doing things the hard (and expensive) way. It throws away the many opportunities to solve multiple problems simultaneously, and using lower-cost, higher-impact, readily available options.
Standard HIV-prevention policies, and thus cost-effectiveness analyses evaluating those interventions, have overlooked complementary investments for treating coinfections. Treatment for TB, schistosomiasis, malaria, malnutrition and helminthes is relatively inexpensive, highly effective, and essential for improving immune status in HIV-negative persons and decreasing viral load in HIV-infected persons.
To make a difference in the epidemic, it is not enough to accept programming as it is and try to deliver it more efficiently. Economists should be asking more fundamental questions about the causes of poor health in poor populations, including what is the constellation of factors in each country determining the spread of HIV there and leading to death following AIDS. The vast majority of HIV-prevention funding targets sexual behavior. Certainly sexual behavior influences individual risk, in any country. But the empirical evidence is clear that sexual behavior does not explain differences in population risk [5-8]. So far, cost-effectiveness studies of HIV-prevention interventions have generally produced Type III errors — they determine efficient solutions to the wrong problems.
It´s not much help to determine that an expensive campaign to change sexual behavior is cost-effective in changing sexual behavior (or maybe just effective in delivering the message, outcome unknown) if the larger reason that HIV spreads so rapidly in poor populations has little to do with sexual behavior. In that case, cost-effectiveness analysis gives us very precise, even correct answers to the wrong question.
Consequently, AIDS resources for prevention and treatment are squandered on the wrong prevention programs and on less effective treatment. With country ownership, ministries and NGOs need to own the right programs, and those programs will address broad health concerns of the population, including HIV. Effectiveness requires that HIV interventions address population risk, and that is a biological problem that derives from the health environment, not a behavioral problem. Efficiency requires that we stop chasing after one virus, one person at a time. We can do more with less, and we can do it better by focusing on health in integrated systems.