Belinda Beresford Economic, social and humanitarian considerations should be driving the government to introduce a national strategy to reduce mother-to-child transmission of HIV, according to research presented at the Aids in Context conference last week. Opinion has been varied on why the government has shown such tardiness in introducing nationwide measures to cut the transmission of HIV from mother to child. But a paper by Nicoli Nattrass and Jolene Skordis of the University of Cape Town answered one argument that the state could not afford it by showing that it could not afford not to afford it. The study has implications for the general use of anti-retroviral therapy for people with HIV, since further analysis may find that it would be more expensive for the state not to fund such treatment than to bear the costs of HIV-positive patients’ extended and expensive collapse in health and ultimate death. There has been speculation in the private sector that some medical aids may soon find it cheaper to provide anti-retrovirals to their members than to pay for treatment for opportunistic infections. This is even more likely to be the case as the price of drugs starts to come down under international activist pressure, especially surrounding the court case between the Pharmaceutical Manufacturers’ Association and the government over drug prices.
The Nattrass and Skordis study found that not only are the costs of cutting mother-to-child transmission low, but they are lower than the cost of treating the children who would otherwise become infected. The research details that: “South Africa cannot afford to do nothing to combat mother-to-child transmission of HIV. Short of denying HIV-positive children any access to health care (which would be unconstitutional), the probable cost of one HIV-positive child in terms of basic hospital costs and ‘unrecoverable’ welfare spending is substantially greater than any of the … intervention discussed.” The paper also highlights the complex choices facing the Department of Health, and the government as a whole, in deciding how best to respond to the epidemic. Nattrass said one reason for the government’s inaction on previous studies suggesting money should be put into preventing mother-to-child transmission was “because existing studies do not frame the argument in a way that addresses the impact on the budget”. Public health interventions tend to be measured in the saving of Dalys (disability adjusted life years). A Daly is a complex weighting of age where years in the prime of life are deemed to be worth more than years of childhood or old age, but the further away any saved life years are, the less weight they carry. Dalys allow for different interventions to be ranked and many studies arguing for the cost-effectiveness of intervention to prevent vertical transmission of HIV use cost per Daly as an argument. Calculating the money that would be saved per Daly, however, doesn’t help in formulating policy, Nattrass said. Such decisions require that research be put in context. Otherwise it leaves unanswered arguments such as that advanced last year by the chief director of the Department of Health’s HIV/Aids directorate, Nono Simelela, that putting money into mother-to-child transmission would divert it from other needy areas of the health service. It was to answer this and to show that the costs of not providing money for mother-to-child transmission would ultimately drain more from other health needs that prompted Nattrass to extend her study and look at the difference between the estimated costs of providing, and not providing, anti-retroviral drugs to prevent mother-to-child transmission. She pointed out that the costs to the state of HIV-positive children go far beyond the medical: many such children live in poor families and are therefore entitled to child-support grants. This money is an investment in children and hopefully should be repaid when the child grows to become a tax-paying adult. But it is effectively a wasted investment on HIV-positive children, many of whom fail to reach their fifth birthday. Adding such welfare costs to the estimated health costs of HIV-positive children, Nattrass calculated that infected infants cost the state between R160-million and R747-million a year. The health expenditure is based on estimates of the costs involved in treating opportunistic infections and excludes expensive measures such as anti-retroviral treatment. She analyses three different methods of intervention to prevent mother-to-child transmission: giving a short-course treatment of AZT and breastfeeding; the same AZT treatment but providing formula feeding; and providing nevirapine and breastfeeding. Her research suggests that of the three the cheapest was just to provide nevirapine, which would cost an estimated R1428 a child saved from HIV, compared to more than R5 000 for the other two options. The use of nevirapine would save fewer lives than providing AZT and formula, which of the three options would save the greatest number of lives. Nattrass calculated that the state would save about R360,9-million by providing nevirapine, R347,9-million by giving the AZT and formula, and R180-million simply by giving AZT. These results again highlight another dilemma for policymakers, whether to go for the option that is most effective in terms of lives saved or to choose the programme that is most economical in pure financial terms. Cost-effectiveness is not as clear-cut as it sounds in public health terms.