International AIDS Conference and the AIDS Transition--Mead Over and Jenny Ottenhoff

Next week the International AIDS Conference will be held in the United States for the first time in 20 years.  CGD senior fellow Mead Over, one of the world’s leading experts on the economics of the epidemic, and policy outreach associate Jenny Ottenhoff join me this week to discuss the state of the epidemic, budget austerity, and the US role in the global response.

First I ask Jenny how it happens that the United States—the primary funder in the global fight against HIV/AIDS – has not hosted the conference for two decades.

“There was a travel ban in the United States on people who were HIV/AIDS positive, but Obama overturned that ban upon taking office in 2009,” explains Jenny. “That paved the way for the AIDS conference to return this year.”

Ironically, opening the way for the biennial conference to be held in Washington may lend increased visibility to AIDS advocates, many of whom are disappointed that U.S. funding appears to have peaked and is likely to be held flat or even decline in the years ahead. Past conferences have sometimes included dramatic demonstrations by groups such as ActUp.

The theme of this year’s conference is “Turning the Tide Together” and US secretary of state Hillary Clinton urged the United States and other countries last November to use new scientific discoveries to create an “AIDS-free generation.”  But she offered no clues about where the money would come from to finance that inspirational and potentially costly vision.

Mead pointed out in a recent CGD book, Achieving an AIDS Transition: Preventing Infections to Sustain Treatment, that although the United States and other funders have been successful in getting millions of HIV-positive people on treatment, the number of people infected with HIV has continued to grow, outstripping available funds for treatment. To achieve an AIDS transition—the point at which the number of people with HIV begins to decline—will require much greater emphasis on prevention, he says.

Mead’s insistence on the central role of prevention is familiar to me. In 1997 I edited Mead’s first book on the topic, Confronting AIDS: Public Priorities in a Global Epidemic. I ask Mead about the legacy of that book, written jointly with Martha Ainsworth, when all three of us were working at the World Bank.

“Martha and I like to think of this book as the first and maybe only book that applies economics to the AIDS epidemic,” says Mead. “We argued that HIV prevention should be a priority for governments and donors because it was relatively inexpensive compared to treatment, and also because every case prevented would have a multiplier effect and prevent many more cases. So there was a public goods argument to be made to do HIV prevention.”

Unfortunately, measuring cases averted—and making evident the huge impact of prevention on the lives of people who did NOT become infected—turned out to be extremely difficult.  The subsequent availability of relatively inexpensive anti-retroviral (ARV) medicines and the dramatic, life-saving impact of these medicines on people who would otherwise have died from AIDS, made spending on treatment much more appealing than investment in prevention.

That distinction is blurring, as recent studies have shown clearly that early treatment can substantially reduce the spread of the virus. Many advocates are urging “treatment as prevention.” Mead welcomes this news, but notes that treatment as prevention alone  may not be sufficient.

“We have to use all the tools at our command -- not only treatment, which is also very effective at prevention -- but also behavioral interventions, to bring the rate of new infections below the rate at which AIDS people are dying. Only if deaths from AIDS are held low and the number of new infections is even smaller than the rate at which the people are dying from AIDS, will we achieve an AIDS transition so that the total number of people living with and dying from AIDS begin to decline.”

One important step, Mead believes, is to greatly improve the measurement of “infections averted” by closely monitoring the number of new infections and then rewarding reductions below an established trend, for example, with additional resources for care and treatment. Mead calls these approaches to the allocation of AIDS funding “incentive compatible.” He notes that no country currently allocates AIDS funding on this basis.

“In the current environment, the more sick people there are, the more money the country is likely to get, which creates perverse incentives,” he says.

I end by asking Jenny and Mead what the best possible outcome of the international AIDS conference would be.

“I hope the conference will drive more innovative discussions on how we can address the epidemic in the ways that Mead has just discussed, with innovative financing to achieving an AIDS transition; maybe paying for results using approaches such as Cash on Delivery Aid (CODAid),” says Jenny. “There’s a lot of space to come up with more streamlined and innovative ways to deliver the technologies that are available today.”

Mead hopes that concern that AIDS funding is uncertain will help to increase interest in new measures to make the global response to the epidemic more efficient and effective. To that end, CGD will be hosting a two-day meeting of the  International AIDS Economic Network (IAEN) during the run-up to the main conference. Mead is a founding member of the IAEN and I helped to establish its online presence after the release of Confronting AIDS.

But despite the efforts of the IAEN, health economists’ suggestions for responding to the epidemic have received relatively little attention compared to the views of AIDS advocates and physicians, who have tended to put much greater stress on treatment. As a result, prevention has often been neglected and millions of people who might otherwise have remained healthy have become infected, grown sick and died.

Mead’s arguments in favor of greatly increasing the effectiveness of AIDS spending—and his insistence that spending on AIDS should be weighed against other, possibly more cost-effective global health measures, such as childhood vaccines and anti-diarrheal campaigns—has not always been well received by AIDS advocates.

He will have another opportunity to make this case—albeit in front of a difficult audience—in a public debate sponsored by the World Bank and USAID next Monday, July 23.  The proposition: “Continued AIDS investments by donors and governments is a sound investment, even in a resource-constrained environment.” Speaking in favor of the motion will be Jeffrey Sachs, director of the Earth Institute at Columbia University and Michel Sidibé, executive director of UNAIDS. Joining Mead in speaking against the motion will be Roger England, chair of the Health Systems Workshop, an independent center of expertise in the health sector focusing on lower and middle-income countries based in Grenada.

If you have iTunes, you can subscribe to get new episodes delivered straight to your computer every week. My thanks to Alexandra Gordon for her production assistance on the Wonkcast recording and for assistance in drafting this blog post.