Priorities

Georgetown University Expert Panel

RethinkHIV commissioned research papers from teams of top health economists, epidemiologists, and demographers, ranking competing HIV/AIDS interventions based upon benefit-cost metrics to help policy-makers and donors prioritize investments with the highest pay-offs in a world of limited resources.

A panel of economic experts, comprising five of the world’s most distinguished economists, was invited to consider the eighteen new research papers. The members of the Expert Panel were:

  • Professor Ernest Aryeetey, Vice Chancellor, University of Ghana;
  • Professor Paul Collier, Director, Centre for the Study of African Economies, Oxford University;
  • Professor Edward Prescott, Arizona State University (Nobel laureate);
  • Professor Thomas Schelling, University of Maryland (Nobel laureate); 
  • Professor Vernon L. Smith, Chapman University (Nobel laureate)

The Expert Panel was tasked with answering the question:

If we successfully raised an additional US$10 billion over the next 5 years to combat HIV/AIDS in sub-Saharan Africa, how could it best be spent?

        

Six Assessment Papers, commissioned from acknowledged authorities in each area of HIV/AIDS research, set out 18 proposals for the Expert Panel’s consideration. Over the course of 2011, the panel examined these proposals in detail. They gathered at Georgetown University with all the researchers and discussed each paper with its authors.

Papers were commissioned from three sets of researchers for each topic, in order to ensure that a range of expert views were presented. Based on the costs and benefits of the solutions, the panel ranked the proposals, in descending order of desirability, as follows: 

The Ranking by the Expert Panel

  1. Accelerate AIDS vaccine development by scaling up funding for innovative vaccine research by 10 per cent or $100 million per year
  2. Introduce and scale-up medical infant male circumcision to reach  50 per cent coverage
  3. Prevent mother-to-child transmission by scaling up Option A treatment of pregnant women and breast feeding infants to 90 per cent coverage in all countries
  4. Make blood transfusions safe by achieving 100 per cent coverage of quality-assured HIV testing of donated blood
  5. Scale-up antiretroviral treatment starting with the most sick and most infectious patients first
  6. Make 95 per cent of medical injections safe by providing adequate supply of auto-disposable syringes and training of health staff in medical equipment disposal
  7. Scale-up male circumcision for young adults in high HIV prevalence countries
  8. One-time innovative information campaign using mass media and peer group counseling in high HIV prevalence countries
  9. Large-scale home- and clinic-based HIV testing and counseling focusing on young adults in high HIV prevalence countries
  10. Create incentive for less risky sexual behavior by offering conditional cash transfers for all girls from impoverished families to keep girls in secondary school
  11. Reduce risky injecting drug user behavior in Kenya, South Africa and Tanzania by increasing coverage rate to 60 per cent for outreach, information and education campaigns, needle and syringe exchange programs and opioid substitution therapy
  12. Focused treatment of HIV patients to reduce the opportunistic infection of Cryptococcal Meningitis
  13. Add gender and HIV training to micro-finance and livelihood programs to reach 1.7 million adults or 20 per cent of the adult population currently enrolled
  14. Introduce 25 per cent increase in alcohol tax in countries with moderate-to-high levels of drinking and high adult mortality
  15. Increase  coverage of community mobilization and stigma reduction programs by 30 per cent or 18 million adults
  16. Create incentive for universal testing, information and counseling with a conditional cash transfer of US$5 to all 400 million adults
  17. Enhance numbers, training and skill-development of community health workers to strengthen basic health services for the rural population
  18. Create an Abuja Goals Fund offering a 'cash-on-delivery ' incentive to nations that meet Abuja Declaration target of spending 15 per cent of public revenues on public health

In ordering the proposals, the Expert Panel was guided predominantly by consideration of economic costs and benefits. The Expert Panel agreed that the cost‐benefit approach was an indispensable organizing method. In setting priorities, the Expert Panel took account of the strengths and weaknesses of the specific cost‐benefit appraisals under review, and gave weight both to the institutional preconditions for success and to the demands of ethical or humanitarian urgency.

As a general point, the Expert Panel concluded that there is a clear and urgent need for more high-quality analysis of the costs and benefits of many responses to the HIV/AIDS epidemic. Considering the toll of the epidemic, the amount of money that is being allocated, the Expert Panel found the lack of evaluation of interventions alarming. The Expert Panel found an overwhelming need for policy-makers to be better informed when making decisions among competing HIV/AIDS priorities.

Each expert assigned his own ranking to the proposals. The individual rankings, together with commentaries prepared by each expert, will be published in due course. (The research papers and other material have already been placed in the public domain, at www.rethinkhiv.com) The panel jointly endorses the priority list shown above as representing their agreed, consensus view on priorities.

Notes on Ranking

The Expert Panel found that the first five-ranked investments should be considered ‘Excellent’, with a compelling need for investment; the 8 middle-ranked investments should be considered ‘Good’, with a strong case for investment; and the 5 bottom-ranked investments should be considered ‘Poor’, with the Expert Panel not endorsing the case that funds be spent on these initiatives.

Notes on the Topics

Vaccine Research and Development

Unlike every other investment option examined, the proposal to increase vaccine research spending has, at the upper-end of possible outcomes, the opportunity of achieving potential long-term eradication of HIV. 

Even using extremely cautious assumptions and focusing on lower-end possible outcomes, it is likely that spending an extra $100 million per year on vaccine research will meaningfully shorten the time in which a vaccine is developed. This represents around a ten-percent increase in current funding levels. This spending could accelerate the number of years to the introduction of a vaccine by at least half to one-and-a-half years, even using conservative assumptions. 

Another important consideration is that the bulk of the overall costs of this investment will come not from developing, but from distribution of the vaccine, which is a future cost.

Based on these considerations, the Expert Panel found Vaccine Research to be a compelling investment.

Prevention of Sexual Transmission

The Expert Panel found that, in general, male circumcision offers considerable opportunities to reduce the scale of the epidemic. However, the Expert Panel’s ranking of adult male circumcision was influenced, among other things, by the possibility of substantial disinhibition behaviors. Circumcision is protective, but only to a certain extent. It is possible that, as a consequence of large-scale male circumcision with an accompanying information campaign about its protective effect, males and their partners opt for less safe sexual practices and for example become less likely to use condoms or more likely to engage in concurrent partnerships.

The Expert Panel noted that the possibility of disinhibition behavior is much less likely in the case of the introduction of infant male circumcision, and that there were considerable opportunities for investment in this. This also offers the possibility over time of reducing the scale of the epidemic across societies.

The lower rankings assigned to mass media information campaigns and large-scale testing and counseling reflected the lack of reliable data and analysis showing where and how these campaigns work.

Prevention of Non-Sexual Infection

Scaling up the prevention of mother-to-child transmission was a compelling investment not just for ethical reasons but also because of the considerable benefit-to-cost ratio, very low costs, and strong evidence of its effectiveness.

Making blood transfusions safer was also considered a compelling investment. Apart from the number of lives saved, the Expert Panel found value in the increase in public trust of health systems should transfusions be made safer. 

The other two investment options considered by the Expert Panel under this topic, Making medical injections safer, and reducing risky injecting drug-user behavior, were given a lower (but still fair) ranking based on their lower benefit-cost ratios.

Treatment

The Expert Panel gave a high ranking to the proposal of scaling up ART Enrolment, focusing on extending coverage to patients with low CD4 counts. Despite its high costs, the preventative effect of ART means that the benefits of scaling up ART are considerable.

Social Policy

The Expert Panel endorses Social Policy levers in an effort to reduce the economic and social factors that fuel HIV risk behaviors and undermine proven HIV interventions. While the Expert Panel believes that the use of cash transfers to keep girls in schooling is a sound policy choice, they formed the view that the benefits relating to HIV/AIDS were a small element of its overall effects. 

They gave a lower ranking to the use of an alcohol tax, reflecting concerns about its implementation given its politically inflammatory nature and the possibility it could reduce overall revenue for developing nations. 

Adding Gender and HIV training to livelihood programs and community mobilization investment show promise, and the Expert Panel find a need for further analysis and research into these.

Strengthening Health Systems

The Expert Panel found the Prevention of Cryptococcal Meningitis an overlooked policy with merit.

In examining the cash transfer for counseling and testing, the Expert Panel noted that while cash transfers can be used successfully, design is very important. There is a significant risk that this intervention could ruin natural incentives for knowledge about one’s own health status. They did not find that the proposed cash transfer had an optimal set-up, and ranked this as a poor policy option.

While recognizing the potential benefits of deploying community health workers, the Expert Panel found that costs could be considerably higher than those identified.

The Expert Panel feared that the set-up of an Abuja Goals Fund would lead to spending on health with little measure of whether or not the spending was optimal.

Spending $10bn on AIDS

When the budgetary constraints of the RethinkHIV framework are applied to the Expert Panel’s prioritized list, money can be allocated to five of the solutions. The yearly budget examined is $2 billion over five years or $10bn in total, and provides for a broad range of investments:

Intervention

Cost (Five years, Million USD)

1. Accelerate AIDS vaccine development by scaling up funding for innovative vaccine research by 10 per cent or $100 million per year

500

2. Introduce and scale-up medical infant male circumcision to reach  50 per cent coverage

3,150

3. Prevent mother-to-child transmission by scaling up Option A treatment of pregnant women and breast feeding infants to 90 per cent coverage in all countries

140

4. Make blood transfusions safe by achieving 100 per cent coverage of quality-assured HIV testing of donated blood

2

5. Scale-up antiretroviral treatment starting with the most sick and most infectious patients first

6,208