Economic aspects of the HIV/AIDS epidemic refer to utilisation of inpatient and outpatient
care, drugs and the costs associated. Economic impact assessment is done for the purpose
of cost-effectiveness analysis, where health-care inputs are related to health gains (i.e.
prevented transmissions, delayed AIDS cases and gained life years).
- Highly active anti-retroviral treatment (HAART)
appeared to be as an important topic for cost-effectiveness. Increasing use of HAART has
been associated with a reduction of inpatient costs.
- Many studies report major increases in the
utilisation and costs of drugs after the introduction of protease inhibitors.
- More people with HIV/AIDS are receiving
anti-retroviral therapy. In France, persons on treatment increased from 60 to 90%.
- Major problems concerning affordability are
reported for developing countries. In India, a study reports that only 2.8% of patients
can afford combination therapy.
Bridging session : Implications of
therapies for developing countries
- Given scarce resources, countries have to make
choices. If brutal choices are not made now, in the future they will be even more brutal.
- For many countries, in addition to the fight
against AIDS, governments have many other developmental objectives. They are confronted
with diseases such as malaria, tuberculosis, other STDs, and increasingly chronic
diseases. Choices have also to be made between different areas of development.
- According to the World Bank, treating one patient
with AIDS is as expensive as giving 10 children primary health education. The list of
competing alternatives is almost endless, for example, basic access to water and food,
access to primary health care and essential drugs, rehabilitation after internal wars and
- In many regions of the world, opportunistic
infections treatments, anti-retroviral drugs, and palliative care treatments are not
- In order to implement any program, there needs to
be a stable health services infrastructure, which is lacking in many countries but it is
possible to establish a network of services. In Brazil, 58,000 persons take
anti-retroviral therapy now. The costs increased from $ 37/mo in 1996 to an estimated $
600/mo in 1999.
- Unfortunately many countries set other priorities.
- Pharmaceutical companies can make a contribution,
by lowering the prices :
- The differences in prices are shameful. In Mexico,
AZT costs less than $0,50 while it is almost $7 in Brazil. Intravenous AZT costs $6 in
Brazil and almost $50 in Mexico. The costs of triple therapy in different Latin America
countries range from $7,000 in Costa Rica to $16,000 in Uruguay.
- Pharmaceutical companies have mission statements.
But words are not enough, where action is needed. Pharmaceutical companies should no
longer focus on shareholder-value. Stakeholder-value is tomorrows management
International Funding and Policy
- The case of Thailand showed how the Asian
financial crisis is affecting their National Program and their ability to face the AIDS
crisis. The Canadian representative spoke about participating to support international
- Bernard Kouchner, the French health minister,
reiterated an important announcement. France is taking the leadership in an effort to
create an international partnership with other industrialised countries to help fund
antiretroviral medication for poor countries. This proposal has been taken to the European
Parliament and to the G 8.
- Callisto Madavo from the World Bank gave a
comprehensive explanation on why AIDS was a development issue. He offered suggestions of
what African governments could do to implement more effective policies in the fight
against AIDS. He also urged the World to help in the solution.
- Dr Jonathan Mann presented a very compelling
presentation on how prevention continues to be the most important tool against the AIDS
epidemic. He argued that the two most powerful prevention agendas today were finding an
effective vaccine and creative social change, based on human rights.
Gender and Power
Participants agreed on the importance of analysing the way socially constructed male and
female roles are affecting the spread of AIDS.
- Gender roles are not biologically determined but
- Gender is the set of norms, prescriptions and
cultural representations that a society dictates for male and female behaviour. This
varies in different societies, social classes and regions of the world, but in general
determines differences of what is expected of men and women and tends to establish both
stereotypes for each sex and double moral standards. This is the basis on which much of
the inequality between men and women is established.
The projects presented in this
session were a very vivid example of how these theoretical principals play out in
Coping strategies: Individuals,
families and organisations
Home care is often promoted as an alternative,
particularly in developing countries; but the home is not necessarily the safest place for
PWAs. Discrimination also often happens at home. Individuals and their families must
receive support in order to create the environment needed by PWAs to improve their quality
of life. Organisations develop programs that are often articulated around the following
- Training and counselling for individuals and their
families (including children);
- Information and discussion on stressful situations
in the family;
- Sex after diagnosis;
- Care for dependants, children in particular.
Promotion of community coping
strategies should NOT mean a simple shift of burden to families and communities. Women can
easily be overburdened. They must be empowered in their different roles. PWAs are also
potential care givers and agents of change, and their involvement is crucial for the
success of coping strategies.
- Recommendations included the need to establish
clear standards for program evaluation, more consistent publication guidelines, and more
studies of this type.
- Interventions aimed at enhancing evaluation skills
in NGOs can improve the delivery of programs.
- One study compared behavioural with biological
indicators of sexual risk. The results suggest that, while self-reported behavioural
change may predict risk reduction, it usually does not if measured by objective measures.
Another study, focusing on studies of sero-discordant heterosexual couples, underscored
the need for more careful exploration of risks and behaviours, and raised doubts on
whether all the necessary questions on risky behaviours are in fact being asked in current
HIV Transmission: Infant Feeding
Although vertical transmission through breast milk
was identified in 1985, there have been many complex issues surrounding the recommendation
of artificial feeding.
- For HIV-positive mothers, information on
artificial breast-feeding is essential since it can prevent the childs infection.
Each woman should have a possibility of informed choice. For artificial feeding to be
effective mothers need clean water, the knowledge on the how to sterilise utensils and
prepare the formula.
- The widespread use of artificial feeding by
HIV-negative mothers and women unaware of their status can increase malnutrition and
mortality. Infant mortality is 16 times more likely with artificial feeding than if a
child is breast-fed.
The artificial feeding business
- Emphasis on replacement feeding as a medicinal
- Procuring the formula centrally to control
- Arrange for generic packaging so as not to promote
For successful artificial feeding
there is a need for education on alternatives such as cow and goats milk, expressing
breast milk and boiling it and, if available, the use of an HIV-negative wet nurse. Making
the change from the emotional rewarding act of breast feeding to artificial feeding often
is an enormous burden for the mother to carry. Comprehensive education, emotional support
and access to different options are needed.
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