Dr. John Blandford discusses the economics of treatment as prevention
John Blandford, PhD is a keynote speaker at NCHIV 2012. He currently heads up the Health Economics, Systems and Integration branch in the Division of Global HIV/AIDS of the US Centers for Disease Control and Prevention (CDC). Trained as an economist, he has worked extensively with healthcare professionals and epidemiologists to gain an understanding of the economic benefits and value of various HIV-related programs, especially from a public health perspective. His work at the CDC also supports sustainable scale-up and maintenance of global HIV programs under the US President’s Emergency Plan for AIDS Relief (PEPFAR). We spoke with Dr. Blandford about his ideas on the value of treatment as prevention.
Could you please give an overview of the benefits, economically or otherwise, of providing antiretroviral therapy (ART)?
Well, if we look at PEPFAR, it was originally started as an emergency response, focused on prevention and on providing care and treatment for the direct benefit of individuals. But as the programme continued, we found evidence of other benefits to society. By treating parents, fewer children were orphaned. By keeping patients healthy, there were benefits to productivity, employment and household wealth. Also, it was found that treatment reduces the incidence of transmitting infection, through lowering the amount of virus in a person’s body fluids, known as the ‘viral load’. This was clearly shown in the HPTN 052 study, which showed a 96% reduction in sexual transmission of HIV to an uninfected partner. We better understand now the broader benefits of providing treatment to those who need it.
How does treatment as prevention compare to other prevention strategies?
It’s important that providing antiretroviral treatment to individuals is considered as one component of the combination prevention package. We also need to focus on other high-impact prevention methods including voluntary medical male circumcision, condom use, and prevention of mother-to-child transmission. Used together, they have a great effect in reducing the incidence of HIV transmission and impacting the HIV epidemic.
Can you explain how the recent financial crisis has impacted PEPFAR and the provision of ART?
PEPFAR is fortunate to have strong support across political parties and that has helped to maintain a reasonable level of funding. In the context of the global financial crisis, PEPFAR resources and international resources have flattened. This means that we need to keep finding innovative was of giving people access to the high-impact programmes. How do we leverage the resources most effectively?
Since PEPFAR was started, we’ve seen the efficiency of programmes has increase substantially. The early investments in health systems and human resources are showing longer-term benefits. Where PEPFAR was spending nearly $1100 per patient per year for treatment when PEPFAR started, it now costs PEPFAR around $335.
As the focus has turned from an emergency response to long-term, there has been increased attention on country ownership of national programmes. In some countries, such as South Africa, national governments are now driving program scale-up and providing substantial resources to support treatment programmes, to save lives and lower long-term costs. At the same time, it should be recognized that some low-income countries with severe epidemics are probably going to need extended external support.
So what we see is that treatment provides considerable benefits to the patient and society, and that the cost of treatment has dropped dramatically. This suggests that treatment improves cost-effectiveness and is perhaps cost saving.
What other challenges are there when considering treatment as prevention?
Adherence is a central issue. In order to fully realize the health and prevention benefits of treatment, patients need to have access to treatment, take it, and adhere to it. We need to continue to find ways to make it easier for patients to access and adhere to therapy. We also need to do this in a way that recognizes the real health systems and human resources constraints in developing country settings. So from a public health approach we need to look at innovative ways to deliver therapy and provide the necessary resources, such as staff and accessible care facilities.
An example of an innovative pilot programme is one initiated by Doctors Without Borders in Mozambique. There they have found a way to deliver therapy by forming community groups of 5-6 patients. From the group, one person makes the trip to the clinic each month to pick up therapy for all group members. They also provide each other with adherence and social support. Group members visit the clinic on a rotational basis, so that each person visits at least every 6 months, lightening the burden both on the patients as well as on the clinic and pharmacy staff that support them.
What do you think needs to be done to make sure treatment as prevention has the most impact?
Given what we know of the benefits of providing antiretroviral therapy, I feel that it’s the responsibility of public health professionals to efficiently deliver HIV treatment and other high-impact programmes, in order to reach as many people as possible with the available resources. With further realistic gains in program efficiency and the strategic allocation of resources, scaling-up access to antiretroviral therapy can be achieved. And together with other prevention methods, it can alter the course of the epidemic.