Antiretroviral treatment (ART): Things to look out for

Antiretroviral treatment (ART) is one of the more well-publicized ways to help people in the developing world. The (RED) campaign puts it front and center, and the Gates Foundation places heavy emphasis on it as well. It seems at first glance like a fairly straightforward, if expensive, intervention: directly treat HIV-positive people with proven drugs to extend their lifespan and improve quality of life.

But the Copenhagen Consensus disease experts (also lead authors on the Disease Control Priorities report) make the case for caution (from pg 40 – emphasis mine):

• Poor implementation (low adherence, development of resistance, interruptions in drug supplies) is likely to lead to very limited health gains, even for individuals on therapy. (This outcome is unlike that of a weak immunization program in which health gains still exist in the fraction of the population that is immunized.) Poorly implemented antiretroviral drug delivery programs could divert substantial resources from prevention or from other high-payoff activities in the health sector. Even worse, they could lead to a false sense of complacency in affected populations: evidence from some countries suggests that treatment availability has led to riskier sexual behavior and increased HIV transmission. The injunction to “do no harm” holds particular salience.
• Unless systematic efforts are made to acquire hard knowledge about which approaches work and which do not, the likelihood exists that unsuccessful implementation efforts will be continued without the appropriate reallocation of resources to successful approaches. Learning what works will require major variations in approach and careful evaluation of effects. Failing to learn will lead to large numbers of needless deaths. Most efforts to scale up antiretroviral therapy unconscionably fail to commit the substantial resources required for evaluation of effects. Such evaluations are essential if ineffective programs are to be halted or effective ones are to receive more resources.
• Many programs rely exclusively on the cheapest possible drugs, thereby risking problems with toxicity, adherence, and drug resistance. From the outset a broader range of drug regimens needs to be tested.

An ART program needs to use the right drugs, ensure compliance, be there for the long haul, and deal with side effects (both medical and behavioral). None of these are a given, with the (RED) campaign’s beneficiaries or anyone else, until you see the evidence that the programs are working.

And ART costs can be in the range of $600 per patient treated per year. Compare with vaccinations, which are estimated as saving lives for as little as$200 apiece, have a strong track record of success, and in many ways introduce less potential for complications.

Comments

• Kris Zyp on December 12, 2011 at 6:48 pm said:

I am curious if the recent (more recent than this post anyway) studies demonstrating that ART can reduce HIV transmission by 73-96% would significantly alter the cost effectiveness estimates of these types of programs?

• Hi Kris, it’s a good question; we haven’t looked into this, and may do so relatively soon.

For most of our history we’ve relied on cost-effectiveness analysis done by other groups, and recently we’ve determined that we ought to be doing our own. So far we’ve done this analysis only for our top charities (which were identified as promising based partly on their choice of intervention); in the coming year we may be revisiting the question of what the most promising health interventions are, based on our own estimates rather than estimates from others (which may be out-of-date and/or flawed in non-transparent ways).

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