March 31, 1996
In an attempt to
'compress' the discussion on the 1997 conference theme, several
postings have been sent together.
Prescott, World Bank
I wish to endorse
and emphasise the significance of Chris Green's comment
highlighting the low probability that universal early detection of HIV might
induce significant health improvements in a typical developing country context.
Based upon my
recent research for the Thai MOPH on the affordability and cost-effectiveness
of case management options for HIV/AIDS (in collaboration with Dr Jos
Perriens, UNAIDS), I would assert that:
(a) no known
chemotherapy regime involving treatment of opportunistic infections and
antiretrovirals at any stage of HIV/AIDS offers an expected value of extended
survival beyond about 1.25 years compared to no treatment;
(b) the likely
out-of-pocket cost of any recognised treatment regime would be
unaffordable by the private sector -- defined as exceeding the percapita nonfood
household consumption expenditure -- by all except the top three deciles of
the income distribution. This assumes that antiretrovirals are fully
and that users are charged only 1/3 of the unit cost of chemotherapy for
opportunistic infections, as well as only 1/3 of the cost of delivery of
associated inpatient and outpatient hospital services. Note that under these
generous subsidy assumptions, universal coverage of the projected caseload in
Thailand is unaffordable by the public sector under existing budgetary
priorities. Thus both government and household budget constraints impose a major
limitation on the case management response even in the economic environment of
Thailand, which is significantly better off than any other heavily affected
Asian population, including Indonesia to which Chris refers.
of clinical and economic reality does preclude any large scale case
management response to early detection, which constitutes one potential branch
of its expected benefit.
The other major
branch of expected benefit of early detection lies in the presumed
behavioral response in preventing transmission by people living with HIV. Being
uninformed about this literature, I wonder if there is significant
empirical evidence of the likely magnitude and epidemiological effect of this
behavioral response in typical Asian, as distinct from US, settings?
I would conclude
that focusing the proposed theme of the conference on early detection
alone could be unduly limiting. Instead I would suggest that a broader theme
highlighting the key words of "Affordability and effectiveness" would be of deeper
to a previous message by Clive Wing],
Your two cents
worth is indeed worth a lot more. Lets hope conference organisers listen to what
people such as yourself have to say. Chaing Mai was a travesty in the way that it
skirted around the difficult issues. What amazes me is
that no one seems to question whether such conferences are actually of any
use. We continue to go to great extremes and expense to bring together people in
the vague hope that somehow it will be all be better and that government,
communities (both medical and non medical) will work together.
is not the outcome and many people leave feeling dissillusioned. Perhaps it is time
that we started to question both the purpose and format of such conferences -
if we are going to bring people together then I can't see the point of giving
people ten minutes to give a presentation with virtually no time for questions or
discussion. We need dialogue, particularly between the different sectors,
we need to get honest about what's working and what isn't and we need to
overcome the domination of the bio-medical which stops these conferences from
taking off and developing some sort of identity more representative of what's happening in the real world.
Surely its crazy
to continue to have conferences in the developing world with such a huge focus
on medical treatments when so few people will have access to those treatments.
Alternative therapies and lifestyle issues must be an integral part of such
Just looking at
who has been responding to the request for conference themes is interesting in
itself. Unfortunately its very difficult for us westerners to shut our big
mouths and keep out it but we can at least encourage the organisers to canvas widely
and hope that they don't just rely on those of us who have access to the
Well, just my two
W. Green, Jakarta, Indonesia
Thanks to Prof.
Frerichs for bringing up the topic of home testing kits, a subject which
doesn't appear to have generated much correspondence or information, at
least over the last several months. I agree that we
cannot overlook the benefits of such testing methods, although as others
may have noted from my earlier post, I do have concerns over the cost of
treatment following diagnosis.
However, there is
one major concern which we have discussed among ourselves which does not
appear to have generated any wider discussion, and this is the fact that
these tests use saliva and urine.
As we try to
preach acceptance and support of those infected by HIV, we constantly
emphasize that there is no risk of transmission from casual or social contact.
Some religious leaders have tried to make mileage out of the risks of kissing
and this sometimes generates undue fear, particularly among young people. We
are constantly battling the fear of transmission from toilets, from
swimming pools, from coughs and sneezes, from sharing eating utensils and of
course from kissing. I think we are making progress with this, but we all
fear that once it becomes known that the virus can be identified in
saliva with what will be seen as a relatively unsophisticated test kit, the
automatic assumption will be that the disease can be contracted from
saliva (and urine).
As I say, I have
not seen this concern addressed yet. Have I missed something? Does
anyone have ideas on how we can overcome this real concern?
In asking for potential themes for the coming AIDS
meeting, Dr. Evelyn
Gacad has stimulated some interesting discussion. It seems that those of
us who responded most quickly, put forward themes that reflect our own
views of the epidemic, including me. Being an epidemiologists, I suggested
a theme that has a strong epidemiological component. Others of you who
are social scientists, put forward suggestions that more broadly reflect
the social and cultural dimensions of the epidemic. Subsequently, testing
and the cost and consequences of testing became element of discussion,
encouraged by the debate over the proposed theme. The flow of correspondences
intensified, so the site editor wisely decided to summarize the various
messages into a "jumbo" message, sent out on Sunday, March 31 to all.
I will be responding to several issues raised in the March 31 set of
messages, but do so with some hesitation. Mr. Nicholas Bates correctly
notes that our exchange of ideas has not included many health professionals
from the countries of Southeast Asia. I especially likely the honesty of
his pointed refrain, "Unfortunately its very difficult for us Westerners
to shut our big mouths and keep out [of] it, but we can at least encourage
the organizers to canvas widely and hope that they don't just rely on those
of us who have access to the internet." I am sure that Dr. Gacad and her
colleagues will heed his advise and "canvas widely." In the mean time,
I will try to have my say one more time, and then "shut my big mouth" (or
at least my email responses).
With that said, I would like to leave the theme issue (the Philippine
group now has many suggestions) and respond to the messages of Nicholas
Prescott of the World Bank and Chris Green of Jakarta. I had not realized
that Mr. Prescott was commissioned by the Ministry of Public Health (MOPH)
in Thailand to study the cost-effectiveness of the case-management decisions
they would have to face if HIV was more easily detected. This is clearly
an important area, and I would like very much to receive a copy of this
interesting report. I was intrigued by Mr. Prescott's introductory statement
that seemed to say that early detection would likely not improve the health
situation in a developing country setting (or at least, the probability
of doing so is "very low"). Since few developing countries have been willing
to commit to early detection (other than Cuba, of course), I am not sure
what was the basis for his strong statement. Perhaps he could expand on
his concerns and offer some supporting documentation.
In his detailed comments, Mr. Prescott appears to focus primarily on
the high cost and marginal benefits of anti-retroviral and anti-opportunistic
infection drugs. He does not address the benefits of avoiding further viral
transmission to spouse or offspring. Nor does he address the potential
benefits to HIV infected persons of avoiding opportunistic infections that
may hasten death. Both of these benefits come with early detection. For
the end of 1994, GPA/WHO had estimated there were 700,000 HIV infected
adults in Thailand (see UNAIDS web site for details). If these infected
persons are not detected, those who are married will likely transmit the
disease to their spouse and some of their children. The infectivity of
the HIV subtype E appears to be much greater than subtype B which we find
in the US or Europe. Thus within a few years of marriage (with 100-120
coital events per year), the virus will probably move from the infected
to the susceptible spouse.
If we accept Prescott's contention that case-management is too expensive
to justify early detection, then Thailand will soon face one million HIV
infected persons, followed by two and three million.
There is no long-term logic in avoiding case-detection, or at least
attempting case-management. Such a short-term cost-savings strategy will
result in long-term misery and death, and in high medical expenses as AIDS
patients continue to accumulate. Of course efficiency experts will always
find ways to reduce the cost of treating AIDS patients, and possibly compromising
the quality of their care. What I am suggesting is that we move beyond
helping AIDS patients, and find ways to reduce the transmission of HIV
so that there will be fewer with this deadly disease. My sense is that
early detection is one of the few strategies that has not yet been evaluated,
and one that holds considerable promise if people can be encouraged to
address the problem in an open, caring, and responsible manner. If we accept
the excessive worrying about the immediate expense of case-management,
we will stop even the smallest demand for experimentation.
Only if we do an objective evaluation in a field setting, will we know
if Mr. Prescott's concerns are valid, or if they are based on unwarranted
fear and pessimism, understandably brought on by this difficult epidemic.
My final comment is directed at the question Chris W. Green raised concerning
the use of saliva-based tests. He suggests that having a saliva HIV test
will confuse people into believing that there is risk of transmission from
casual or social contact, with saliva being the transmitting medium.
I agree that some will likely believe that this is so. They will not
understand the distinction between having HIV antibodies in saliva versus
having infectious HIV in saliva. But isn't this what our public health
education efforts are all about? If we have a good test that is easy to
use and can quickly identify those who are likely to be infected, does
this not justify the extra burden of educating the public?
If the need for early detection is accepted by various governments,
then public health officials have at least four educational messages that
will need to be delivered. The first is that HIV is a virus that is transmitted
from one person to another by intimate sexual contact, contaminated blood,
or from infected mother to child (i.e., HIV is a virus). The second is
that HIV infected persons should be viewed the same as persons with hypertension,
diabetes, cancer, heart disease or other life-shortening conditions (i.e.,
HIV is a chronic disease and not a sin). The third is that HIV transmission
can be stopped with simple barriers if we know who is infected (i.e., HIV
is not easily transmitted). The fourth is that simple tests that look for
HIV antibodies can identify who is likely to be infected (i.e., all potential
or current sexual partners should be tested).
Few developing countries, other than Cuba, can afford periodic widespread
testing. Thus if testing is to become common in poorer settings, the public
must share in the cost, as is typically done with other products in the
If our goal is to have people buy and conduct tests of self- and sexual-partners,
we cannot impose excessive constraints on them. This is why I favor the
sale of HIV indicators, or simple saliva- or fingerstick-based tests that
people can buy for use in the privacy of the home, with limited government
interference. I believe in three notions that others out there may support
people have a right to know their own health status,
neither governments nor other organizations should take this right away
from them with bans on home testing or other more subtle restrictions,
governments should be responsible for setting standards for HIV tests and
monitoring the quality over time.
This form of responsible regulation imposes and maintains standards necessary
to avoid product fraud or deceit, but does not restrict use.
If others out there agree, than it is time that we start a demonstration
project to evaluate the potential benefits and harms of an early detection