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In Response
Submit responseWe thank Ms. Sedio, Dr. Johnson, and Dr. Montaner for their thoughtful comments. Ms. Sedio points out the importance of HIV prevention as a cornerstone of long-term response to the epidemic. We agree with Ms. Sedio, but would highlight 2 important caveats. First, our analysis does not suggest that PEPFAR failed on prevention. As Drs. Johnson and Montaner suggest, a relative reduction in deaths with parallel prevalence trends imply some reduction in incidence.
Second, while we are in favor of HIV prevention, it is not clear to us which prevention efforts are effective and sustainable. Measuring incidence directly would greatly help in evaluation of prevention programs and decisions of resource- allocation. Drs. Montaner, Lima, and Williams tested the hypothesis that PEPFAR activities were associated with decreased HIV incidence and find a lower median percent decrease in incidence in the focus countries. This is a first-pass analysis which calls into question whether PEPFAR was associated with a decrease in HIV incidence. We agree with their call to define the relative contribution of interventions on the course of the epidemic, especially as the specter of declining resources looms over PEPFAR.
Finally, Dr. Johnson points to an evaluation of PEPFAR done by the US Census Bureau, which we were not aware of when we performed our work. We applaud the US Census Bureau for estimating PEPFAR’s impact of health outcomes in terms of years-of-life-gained (YLG). We can transform our estimates to YLG by estimating the number of deaths averted each year assuming a 10% reduction in mortality associated with PEPFAR, and calculating the YLG given the number of deaths averted each year. Thus, we estimate that PEPFAR was associated with approximately 260,000 deaths averted in 2004, 284,000 in 2005, 313,000 in 2006, and 344,000 in 2007. Adding up the YLG (260,000 x 4 + 284,000 x 3 + 313,000 x 2 + 344,000 x 1), we arrive at an estimate of 2.9 million YLG from 2004 to 2007, which is in good agreement with the US Census Bureau’s estimates.
Conflict of Interest:
None declared
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The Doctor Drain and HIV in Africa
Submit responseHats off to Drs Bendavid and Bhattacharya for their work assessing the United States’ spending to address the global HIV epidemic. Wrestling with these statistics is an extremely important part this sort of massive global initiative. It is I think a victory to estimate 1.2 million lives saved, which echoes the victory on the ground in those countries of sub- Saharan Africa where these interventions are making such an amazing impact.
I would like to point out a piece of bitter irony in this story. Table 1 shows the focus countries and the control countries. Why are the “control” countries not adopting the available intervention; why are they not taking the offered resources to help their populations? There are of course many reasons. But one probable reason can be found by researching the WHO statistics from these countries: not enough doctors.
Let’s look at Losotho for example. A country horribly caught in the midst of the AIDS epidemic, the WHO estimates up to 29% of its population is HIV positive, and over one in 10 die from HIV! Despite its high literacy rate and resources, in 2003 there were only 89 doctors for its nearly 2 million residents. Certainly not enough physicians to help organize the program needed for PEPFAR funding.
What does this have to do with the United States? One must try to find out where the doctors went. They left to work in South Africa. As did the doctors from Liberia, and many other African Nations. And where did this vast need for doctors in South Africa come from? From the mass exodus of doctors to Canada, New Zealand, and the United States. Doctors who took slots in primary care residencies. Doctors who filled empty psychologist shoes.
It takes a number of very motivated, organized, and educated physicians for a country to be on the receiving end of the PEPFAR funding. This is as it should be, and has likely contributed to the successful programs in place today. But, paradoxically, the United States is helping to destroy the physician base needed to fight the medical battles in Africa by relying so heavily on foreign-trained medical graduates to feed its own seemingly insatiable medical appetite. To overcome this problem, the US must reign in the importation of doctors from other countries. It is not enough to send money and drugs overseas, while the doctors come over here. The responsible thing is to put caps and limits on residency programs, liscencing agencies, and boards, to limit the doctor exodus from where they are most needed.
Notably, this is a time of flux for the United States medical system. There is much debate regarding how to fund, staff, and manage the care of the American patients of the future. We must build into our planning the idea that we must not rely so much on physicians trained overseas. We must take responsibility ourselves for our primary care and our rural health needs. None of the ideas for reform that I have seen include the need to limit the number of foreign medical graduates coming into the country. The reforms coming, involving more money for the medical system, will likely make this problem worse without a concerted effort to address this issue.
Conflict of Interest:
None declared
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About methodology
Submit responseCongratulations to the researchers. This article shows an interesting contribution in measuring HIV effects of PEPFAR. This is an outstanding example of how to do this. I want to know if the positive finding regarding number of HIV-related deaths is strong enough; i am afraid that we are talking about a falacy due to a weak methodology. It is of note whether HIV-related mortality has any change through the study period. One might ask if there is bias?
Conflict of Interest:
None declared
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Response to Bendavid and Bhattacharya
Submit responseThe recent analysis by Bendavid and Bhattachrya is an interesting and innovative approach to looking at the impact of The President’s Emergency Plan for AIDS Relief (PEPFAR) in focus countries. We would like to provide some additional information on the scope of PEPFAR activities and further elaborate on some conclusions and interpretations discussed in the paper.
Since 2007, the U.S. government (USG; the Census Bureau) has evaluated PEPFAR through estimations of years-of life-gained (YLG), not deaths averted, based on the recommendation by the UNAIDS (1). The Census Bureau estimates an impact of 3.2 million cumulative YLG from 2004-2009 in PEPFAR countries (2).
The authors’ conclusion that no difference in the relative change in prevalence exists between focus and non-focus countries is a bit misleading. While they find that PEPFAR has had an impact on mortality, they do not account for this in their analysis of prevalence, with the exception of a brief comment in the discussion. In fact, for a given level of incidence, a reduction in mortality due to people on anti- retrovirals should result in an increase in prevalence (or less of a decrease) in focus countries; therefore, the finding of a decrease in mortality and a stable prevalence suggests a possible decrease in incidence in the PEPFAR focus countries.
The authors tried to adjust their models for other sources of HIV funding using the amount of funding from the Global Fund. However, this does not adequately account for overall per capita HIV funding from all other sources including PEPFAR, other parts of the USG, and other donors that have put considerable resources directly into some of the “non-focus” countries. These contributions may diminish or mask the perceived impact of PEPFAR spending in focus countries in comparison to non-focus countries.
We appreciate the efforts by the authors to better understand and quantify the impact of PEPFAR. The fact that the authors claimed that no evaluations have been done to date suggests that the USG should be more proactive in disseminating and publicizing the evaluations that have in fact been done, especially in the peer-reviewed scientific literature. We also encourage others to develop methods for measuring the success of PEPFAR and other efforts to mitigate the impact of the HIV epidemic worldwide.
References:
1. UNAIDS. (2007). Methods for estimation of ART’s impact on deaths averted/delayed; and Developments in EPP 2007, Report of the meeting of the UNAIDS Reference Group on Estimates, Modelling and Projections, Baltimore, USA, July 13, 2007. http://www.epidem.org/Publications/Baltimore2007_13July.pdf
2. Office of the U.S. Global AIDS Coordinator. (2009). PEPFAR 2009 Annual Report to Congress. Washington, D.C. http://www.pepfar.gov/documents/organization/113827.pdf
Conflict of Interest:
None declared
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The President’s Emergency Plan for AIDS Relief in Africa-An evaluation of outcomes
Submit responseTo the Editor
Bendavid and Bhattacharya1 recently reported on the positive effects on HIV-related prevalence and AIDS mortality associated with the implementation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in a select number of Sub-Saharan African countries since its implementation in 2003. The authors compared trends in HIV prevalence (reported as number of people living with HIV infection) and AIDS mortality (reported as number of deaths) before and after the initiation of PEPFAR activities in 12 focus countries and 29 control counties with a generalized HIV epidemic in 1997-2002 and 2004-2007. Based on four years of PEPFAR activity, AIDS mortality during 2004-2007 decreased the most in focus countries compared to control countries (10.5% lower, p-value=0.001), prevalence trends did not differ between groups (1.7% lower, p-value=0.124).
Based on these results we hypothesized that PEPFAR activities would have also been associated with decrease HIV incidence in focus countries. In order to test this hypothesis we obtained raw prevalence and (AIDS and Non-AIDS) mortality data for adults and children during 1997-2006 from UNAIDS2 and the U.S. Census Bureau3. We obtained population estimates during 1997-2006 from the U.S. Census Bureau4. We used the formula below to estimate HIV incidence in each of the 41 countries from 1997 to 2006.
In brief, t0 is the beginning of the time interval and t1 the end of the time interval, for t0, t1 = 1997,…, 2007; with t0 <t1. The estimated number of new infections, based on (1), is presented in Table 1. Noted that by using formula (1) we were only able to estimate HIV "incidence (t0t1)=Prevalence (t1)- Prevalence (t0)+AIDS Deaths (t0t1)+Non-AIDS Deaths (t0t1)," during 1997-2006.
HIV incidence between 1997 and 2006 by country is shown in Figure 1a (http://cfenet.ubc.ca/files/PEPFAR.pdf) for control and 1b (http://cfenet.ubc.ca/files/PEPFAR.pdf) for focus countries, respectively. A general trend towards a lower HIV incidence rates is apparent with notable exceptions, including Lesotho, Sudan, Swaziland and Togo among the control countries and Kenya, Mozambique, Namibia and Zambia among the focus countries. Overall, 28% (8 out of 29) of the control and 50% (6 out of 12) of the focus countries experienced a decrease in incidence during 2003-2006. Finally, the median percent change in HIV incidence rate between 2003 and 2006 was 1.76 (interquartile range (IQR): -0.20 to 3.35) for control countries and 0.96 (IQR: -2.41 to 23.56) for the focus countries.
Several authors (5, 6) have recently postulated that expanded antiretroviral therapy coverage may play a significant role in curbing the spread of HIV globally. Our incidence estimates for focus and control countries are compatible with the postulated beneficial effect of treatment on the prevention of HIV transmission. However, caution should be exerted when using this ecological approach to evaluating these results given that (1) the selection of focus and control countries was not random and (2) that PEPFAR comprises a number of activities not limited to the roll out of antiretroviral therapy (3) PEPFAR is part of a complex national response. Therefore, given the breadth of PEPFAR supported activities and the complex nature of the country-level response, further research and careful prospective monitoring of the relative contribution of interventions such as expanded ART to the growth of the HIV epidemic is needed. Given the current economic situation, scientific evidence regarding the relative impact of public health interventions is critical to inform public policy in the attempt to control the spread of HIV.
References
1. Bendavid E, Bhattacharya J. The President’s Emergency Plan for AIDS Relief in Africa-An evaluation of outcomes. Ann Intern Med 2009; 60520-117.
2. UNAIDS. 2008 Report on the global AIDS epidemic. Accessed at http://www.unaids.org/en/KnowledgeCentre/HIVData/Epidemiology/latestEpiData.asp on 15 April 2009.
3. U.S. Census Bureau, International Data Base. Table 008 Vital Rates and Events. Accessed at http://www.census.gov/ipc/www/idb/tables.html on 15 April 2009.
4. U.S. Census Bureau, International Data Base. Table 001 Total Midyear Population. Accessed at http://www.census.gov/ipc/www/idb/tables.html on 15 April 2009.
5. Montaner JS, Hogg R, Wood E, et al. The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. Lancet. 2006; 368:531-6.
6. Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009; 373: 48–57.
Conflict of Interest:
Dr. Montaner has received financial support from government agencies in USA and Canada and pharmaceutical companies working in the area of HIV/AIDS. Dr. Lima and Dr. Williams report no conflict of interest.
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PEPFAR Must Focus on HIV Prevention and Women
Submit responseTo The Editor:
We applaud Drs. Bendavid and Bhattacharya for undertaking a much- needed quantitative evaluation of effectiveness of the President’s Emergency Plan for AIDS Relief (PEPFAR), the largest international health initiative ever dedicated to a single disease.
While it is important to recognize PEPFAR’s success in decreasing AIDS-related deaths by more than 10 percent and providing anti-retrovirals to more than 2 million people (1), it is no less important that the authors conclude PEPFAR has had no success in lowering HIV prevalence among adults. In 2007, UNAIDS estimates there were 2.7 million new HIV infections, that is five new infections for every two people on treatment(2).
As a woman living with HIV in one the hardest-hit countries, Botswana, I urge the world to recognize that a meaningful, sustainable response to the pandemic must focus on HIV prevention and on women, particularly young women. Most people living with HIV/AIDS—more than 22 of 33.2 million—live in sub-Saharan Africa and, among adults, 61 percent are women (2). In my region, three young women are infected for every young man, ages 15-24 (3).
To be most effective, PEPFAR-supported prevention programs need to ensure that all individuals have access to the full range of information and services to protect themselves from HIV throughout their lives, including female and male condoms. It also requires the integration of family planning and other HIV services, widespread access to comprehensive sexuality education, and the protection of all people’s human rights to live free of stigma, discrimination, and violence. PEPFAR recipients must be free to work with all communities at risk of contracting HIV, including sex workers.
It is our moral obligation and fiscal responsibility to use PEPFAR funding to prevent as many infections as possible. Large sums of money spent unwisely will not save lives and will create an ever growing need for increased resources in the future.
References
1. The President’s emergency plan for AIDS relief. http://www.pepfar.gov/about/c19785.htm
2. UNAIDS, 2007 AIDS epidemic update. report on the global AIDS epidemic: executive summary. Geneva: UNAIDS, 2007.
3. UNICEF, 2008 The State of the World’s Children: Table 4 HIV/AIDS. New York: UNICEF, 2008.
Conflict of Interest:
None declared