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Solutions to consider on Worlds AIDS Day: Send more girls to school and circumcise boys

AP Photo / Jerome Delay
An herbal concoction made in South Africa intended for people with HIV. A recent analysis finds the continent is decades away from being HIV-free.
Published Last updated This article is more than 2 years old.

On World AIDS Day, we hear considerable rhetoric about the importance of stepping up the fight against HIV. But the reality is that donor fatigue and tougher economic conditions have caused external HIV/AIDS funding for Africa to stagnate.

This puts at risk recent dramatic progress, including a dramatic expansion of treatment (although universal treatment remains out of reach), and promising reductions in mother-to-child transmission.

It also makes it even more important that we do the most good with the money that is spent. This is the subject of a new book I edited, RethinkHIV: Smarter ways to invest in ending HIV in Sub-Saharan Africa.

A collaboration between the Rush Foundation and the Copenhagen Consensus Center, the project is the first comprehensive attempt to use cost-benefit analysis to help identify the best interventions to fight HIV across sub-Saharan Africa. The research is conducted by top HIV economists, along with epidemiologists and demographers.

Why bring cost-benefit analysis to the challenge of HIV/AIDS in Africa?

First, because this is a challenge that is far from beaten. In 2011, Sub-Saharan Africa was home to an estimated 23.5 million people living with HIV, or 69% of the global HIV burden. Nine out of 10 children who acquired HIV, and nine out of 10 pregnant women living with HIV, were in Africa.

And second, because billions of dollars have been spent confronting this challenge with too little focus on establishing efficacy. There is a dearth of analysis of program efficacy and, in the worst cases, money has been wasted on approaches such as abstinence promotion, with no reliable evidence of benefits.

The research in RethinkHIV makes it clear that there is no silver bullet to the epidemic. Dean Jamison, of the University of Washington, and Robert Hecht, of the Results for Development Institute, perform the first cost-benefit analysis on HIV and AIDS vaccine research, and find it likely that, on current progress, we remain decades away from the advances that could really mean an HIV-free generation in Africa.

But their analysis also shows that a relatively small amount of additional funds devoted to vaccine research could have a substantial impact in bringing the breakthroughs forward. For every dollar spent on extra vaccine funding, the benefits in avoided HIV infections and deaths could run beyond $11— and that is not including the broader benefits to humanity from more knowledge on vaccines.

Charlotte Watts, Michelle Remme and Anna Vassall of the London School of Hygiene and Tropical Medicine highlight the importance of moving beyond addressing HIV and AIDS within a “health silo.” HIV long ago ceased being a mere public health concern, particularly in countries with severe, generalized epidemics, where it is an acute drain on resources. They argue that our response to the disease needs to fit this reality. Donors and governments can no longer afford to overlook investments that would combat HIV and other development and health problems at the same time.

Watts, Remme and Vassall explore investment in girls’ schooling as a policy with clear HIV benefits–girls who remain in school engage in sex later–as well as health and development benefits. For every dollar spent, we could end up doing more than $7 of good, though the HIV benefit alone is rather small. Alcohol taxes also have multiple benefits, including on HIV: less excessive drinking means less unsafe sex. Efforts to reduce gender-based violence are another policy that should be recognized for its effects on HIV.

RethinkHIV highlights many cost-beneficial, powerful ways to step up the fight against HIV. One of those is adult male circumcision, increasingly being recognized as a tool to reduce heterosexual, female-to-male sexual transmission. Economists show that the reduction in HIV illness and death, put into economic terms, is worth more than $13 to society for every dollar spent by decision-makers. And they argue that infant male circumcision, which is cheaper and has fewer complications, should also be seen as part of a longer-term response to the HIV epidemics.

The debate on priorities is a vital one. Of course, we should question the economists’ models and estimates, and cost-benefit analysis should not be the only driver of policy decisions. But the stakes are far too high for us not to ask the question: How can we do the most good with each dollar spent?

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