Kaiser Daily HIV/AIDS Report Summarizes Study, Opinion Pieces Published in NEJM

The New England Journal of Medicine in its Sept. 14 issue published a study and two opinion pieces related to HIV/AIDS. Summaries appear below.

Study

"Cost-Effectiveness of HIV Treatment in Resource-Poor Settings -- The Case of Cote d'Ivoire": Sue Goldie of the Harvard School of Public Health and colleagues used a computer simulation -- which incorporated HIV viral load, CD4+ T cell counts and predictors of HIV progression -- to assess the cost-effectiveness of various HIV treatment strategies in a group of HIV-positive adults in Cote d'Ivoire. The researchers compared long-term economic and clinical outcomes related to not using any treatment, using only antiretroviral therapy, using only prophylaxis therapy and using a combination of antiretroviral and prophylaxis therapies. The study finds that the cost per life year gained for prophylaxis alone is $240; the cost per life year gained for antiretroviral therapy combined with prophylaxis but without CD4+ T cell testing is $620; and the cost per life year gained for antiretroviral therapy combined with prophylaxis and CD4+ T cell testing is $1,180. In addition, the study finds that when antiretroviral and prophylaxis therapies are initiated based on clinical criteria and CD4+ T cell testing, life expectancy rose from 10.7 months -- when antiretroviral therapy and prophylaxis was initiated only on the basis of clinical criteria -- to 45.9 months. The study also finds that life expectancy increased by 30% when second-line antiretroviral therapy was used after first-line therapy failed. The researchers concluded that a strategy that includes prophylaxis and antiretroviral therapies, with the use of "clinical criteria alone or in combination with CD4+ T cell testing to guide the timing of treatment, is an economically attractive health investment in settings with limited resources" (Goldie et al., NEJM, 9/14).

Opinion Pieces

• Susan Okie: "In a world with many celebrities but few heroes, Bill Gates has attained heroic status by committing much of his enormous fortune to the advancement of global equity," Okie, a contributing editor of NEJM, writes in an opinion piece. According to some people, "the example set by Bill and Melinda Gates has been as important as the money they've donated," Okie writes, adding that "[b]y calling attention to global inequities, they have attracted funding from others and made it fashionable for the rich or famous to become involved in solving global problems." For example, Warren Buffet in June announced a large donation to the Bill & Melinda Gates Foundation, a move that likely will "amplif[y]" the foundation's impact on global health, according to Okie. However, the estimated cost associated with "solving" health problems in developing countries is "far higher than even the most optimistic projections for giving by Gates," Okie writes, adding that in order to meet the world's health goals, "international aid would have to increase by a factor of three to seven." While the Gates Foundation has "several notable health-related achievements to date," it is "still evolving, and its leaders acknowledge having made mistakes," Okie writes, adding that perhaps the "greatest influence" the foundation has "derives from its assumption that intractable problems can be solved, given enough money and international cooperation" (Okie, NEJM, 9/14).
  

• Robert Steinbrook: The "time to deliver" theme of the XVI International AIDS Conference in Toronto "suggested both ongoing urgency and frustration at the pace of the response" to the HIV/AIDS pandemic, Steinbrook, a correspondent for NEJM, writes in an NEJM opinion piece. Although highly active antiretroviral therapy, which became available a decade ago, has "streamlined" HIV/AIDS treatment, "the average cost of first-line regimens remains hig[h], and second-line regimens may cost $1,500 or more per year," Steinbrook writes. He adds that HIV/AIDS treatment provision in many countries is "compromised by profound shortages of skilled health workers and dysfunctional and inefficient health systems." According to Steinbrook, HIV/AIDS "prevention and treatment are inextricably linked; it is not possible to deliver one without the other." Several new HIV prevention methods -- including some that are "controversial," such as male circumcision and pre-exposure prophylaxis -- are being evaluated, Steinbrook writes. "By August 2008, when the XVII International AIDS Conference is held in Mexico City, it will be clear whether the world is continuing to lose ground to the AIDS pandemic or finally getting ahead of it," Steinbrook concludes (Steinbrook, NEJM, 9/14).