We need to fight Aids and poverty

The Mail & Guardian has given significant coverage to recent research on the costs of an Aids prevention and treatment programme. Two distinct research projects were involved: demographic modelling of the impact of such a programme by the University of Cape Town’s (UCT) Centre for Actuarial Research (Care); and an economic costing exercise based on the demographic projections. I supervised the economic study (which was co-authored with Nathan Geffen and Chris Raubenheimer).

In reporting on this research, the mistaken impression has been created that I was “commissioned” to do it by the Treatment Action Campaign (TAC). This is not true: I acted solely in my capacity as a university academic and received no payment — either for my time, or to cover costs.

UCT student Sean Muller, writing in last week’s comment section (The best medicine for the people, March 14), linked the supposed commissioning of my work to an accusation of “clear bias” against me. He implied that we had been mandated to come to our conclusions. This offensive ad hominem argument is without foundation. Our research was objective, followed academic standards and used the best available local and international information.

The same cannot be said for Muller, who made a series of factual errors in his article. For example, he criticised our main cost estimate for leaving out viral load tests (in favour of CD4 tests only) on the grounds that this violated World Health Organisation (WHO) guidelines. If he had actually read the paper rather than engaging in an irresponsible commentary on a short seminar presentation (by one of my co-authors), he would know that viral load tests are optional under WHO guidelines — and that we went on to cost them anyway in a separate exercise.

If anything, we overestimated costs in order to be sure that the intervention would not cost more. For instance, we used market prices for anti-retrovirals (when the government could negotiate bulk discounts) and we assumed that 90% of those needing treatment would eventually receive it (when in practice the number is likely to be lower). 

We estimate that the direct costs of Aids treatment would peak in 2015 at R18,2-billion. Once the costs of voluntary counselling and testing, mother-to-child-transmission prevention, and treating sexually transmitted infections are included, the total cost of the intervention (including infrastructure costs) rises to R20,3-billion in 2015.

This means that the direct costs of a full-scale programme will cost about 1,7% of the gross national product (GNP) at the height of the pandemic. If the “savings” to the state are factored in (that is, lower expenditure on opportunistic infections, fewer orphans) then the net cost to the government will be at least a third lower than the direct cost estimate. Interested readers (including, I hope, Muller) can access the paper on www.uct.ac.za/depts/cssr/papers/wp28.pdf.

Is this affordable? According to the WHO’s Commission on Macro-economics and Health, “it is feasible, on average, for low- and middle-income countries to increase budgetary outlays for health by 1% of GNP by 2007 and 2% of GNP by 2015”. Our cost projections are within this envelope. It is not macroeconomic madness to suggest that we should introduce a full menu of prevention and treatment programmes. The resources are there. The issue is now one of political judgement and will.

The article by Muller argued that anti-retrovirals should be limited to rape victims, medical personnel and those rich enough to afford them — and that spare resources should otherwise be allocated to poverty reduction. The emphasis on poverty reduction has merit: poor people are more vulnerable to HIV infection, and people with Aids live longer when they are better nourished.

But this is an argument for fighting Aids and poverty — not for fighting poverty instead of treating Aids. It is an argument for providing food parcels to poor people on anti-retrovirals (as happens in the Western Cape) — not an argument for providing food parcels only. There is no reason why treating Aids should come at the cost of social security. It could, for example, be funded out of defence budget cuts, public sector wage restraint or higher taxes. And, if the government negotiated bulk discounts on anti-retrovirals and applied for assistance from the Global Fund to Fight Aids, Tuberculosis and Malaria, then significant pressure could be taken off the government budget.

As any economist knows, there are always trade-offs. Money spent on Aids treatment ultimately means less money spent elsewhere. This is why an open and informed social debate is necessary on the subject. That means examining our social values as well as financial costs.

Speaking now as a concerned citizen, I believe that the Aids pandemic challenges society in a unique way. It poses the fundamental question of how we deal with the right to life of millions of people who cannot afford treatment. Do we turn our backs on those dying undignified and painful deaths and create a society shot through by stigmatisation and hopelessness — or do we do the civilised thing, and help them?

But there are other, more instrumental, arguments for financing Aids treatment. People on anti-retroviral therapy have lower viral loads (and are therefore less infectious), and if life-prolonging treatment is available, more people are likely to get tested and counselled about safe sex (as is happening in the Western Cape). Aids treatment thus helps reduce the number of new HIV infections.

This is why Care’s demographic projections of the impact of Aids treatment show an increase in average life expectancy of more than double the increase in life expectancy for HIV-positive people. The benefits to society thus far outweigh the benefits to individuals on anti-retroviral therapy.

This positive social outcome, as noted in Muller’s article, depends on people changing their sexual behaviour. The evidence is uneven on this score, but the vast majority of studies indicate that there is a reduction in risk-behaviour following counselling — which is why Care built this into its model.

There is, unfortunately, also evidence that a small (but still worrying) number of people in South Africa are spreading Aids deliberately, or say they would spread Aids deliberately, if they became HIV positive. This so-called “empathetic void” can only worsen if we condemn HIV-positive people to the scrap-heap of history, and offer them no comfort, dignity and hope. It is all the more reason to create a caring, rather than stigmatising, social response to people living with Aids.

Nicoli Nattrass is professor in the school of economics at the University of Cape Town

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