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Comments from Laurie Garrett on the AIDS Transition
November 23, 2011
Last week’s launch event for my book proved to be an entertaining and thought-provoking discussion on achieving an AIDS transition – the idea that ending the AIDS pandemic will require reducing the number of new infections below the number of AIDS deaths so that the total number of people with HIV/AIDS declines (for more details read the brief, listen to the wonkcast, or buy the book). In my book I assert that achieving an AIDS transition will require meeting our commitments to currently enrolled patients, enrolling enough new patients to prevent a resurgence in AIDS mortality, and pushing new infections below the number of deaths (which could be accomplished with either behavioral or medical prevention interventions). One of several ways to do this is to use a cash-on-delivery (COD) incentive to reward the recipient government – be it national or provincial – for every HIV infection averted (more on this idea here).
Each of the four panelists provided insightful and challenging food for thought about the idea of an AIDS transition in general and about the idea of COD for HIV infections averted in particular. In this blog, I feature the comments of panelist Laurie Garrett, senior fellow on global health at the Council on Foreign Relations. The following quote is from an e-mail she sent us after the event, which elaborates on a major thrust of her comments at the event: a critique of my proposal to use repeated surveys of the prevalence of HIV in order to estimate the incidence of new infections and reward the recipient government with (say) $100 for every infection fewer than a pre-agreed level.
I present her comments here and invite readers to add their own thoughts in the comment section below (where I also reserve the right to rebut!)
Excerpt of e-mail from Laurie Garrett
Overall I would make a couple of suggestions:
1) Prevalence does NOT equal incidence. Here in the USA, with all the technology and money we have, the CDC officially declared the annual INCIDENCE of new HIV infections to be 40,000, every year from 1983-2007. This was ludicrous. In 1983 the CDC could be forgiven a back-of-the-envelope guess because we didn’t even have a valid HIV test. But by 2000 — long after the SF Dept of Health invented the “de-tuned assay” for incidence measurement, it was unforgiveable. Either the hundreds of millions of $$’s spent annually on HIV prevention were an utter failure, allowing 40,000 new cases annually, or nobody knew what they were doing. In 2008 the CDC finally started creating valid ways to measure incidence, and discovered their data was off by 40%: There were some 60,000 new cases/year in 2005-7. Moreover, the incidence was overwhelmingly African American and gay. For the first time in more than 2 decades the USA was applying a reasonable toolkit to prevention of HIV. Folks at Hopkins estimated the newly discovered incidence amounted to a $250 million/year increase in treatment costs, alone. That is why the Obama Admin has put so much prevention energy into DC and Baltimore, where things are exploding and incidence now surpasses Uganda.
2) If you are going to hold GOVERNMENTS accountable in a COD approach for HIV prevention, you had better have a toolkit better than the ones we have used in the USA. Even now, post-2008 I am not sure the USA could meet your COD standards.
3) Confusing prevalence and incidence is forgivable in general conversation, but not as a basis for cutting off funding to a nation. As the numbers of people surviving HIV thanks to ARVs grows worldwide prevalence is an increasingly irrelevant and misleading number. [Mead is proposing to estimate incidence by first subtracting prevalence in a baseline serosurvey from prevalence in a follow-up serosurvey and then using a model to correct for mortality and ARVs. However,] creating a valid serosurvey on a national basis for annual incidence assessment is a daunting, expensive, scientifically extremely difficult task. In our UNAIDS effort we determined that it would be impossible in a country without head-of-state and legislative full support: the logistic, political and ethical dilemmas are so large that only top-of-government mandates can make the effort doable. Do you think that is possible in Swaziland? Perhaps even more relevant, in Uganda where Museveni has a stake in downplaying incidence, due to his advocacy in ABCs?
4) The actual HIV Transition is a moving target. As mortality declines with ongoing roll-out of ARVs the magic point for incidence targets also gets harder to attain. Here in the USA our HIV-related mortality is now so low that corresponding incidence would probably have to drop from the current 60,000/year to less than 10,000 (maybe even 5,000) to come close to the transition. (At the mortality peak in the USA in 1995-6 we experienced about 17:100,000 deaths annually due to AIDS. For the last 8 years we’ve held at 8:100,000. In July a multi-country survey found that death rates in the US and Western Europe were rising among elderly HIV+ individuals, but had dropped significantly for most people on ARVs. A summary stated: “The authors calculated an 88 percent reduction in excess mortality in 2000-2001 compared with the period prior to 1996. This was very close to the 87 percent reduction seen in 1997-2001. In 2004-2006, the excess mortality was 94 percent lower than pre-1996 levels.”) Imagine what it would take for us to achieve that! For a generalized epidemic like Kwazulu-Natal the first few years of effort would require an incidence target FAR easier to attain, but if treatment rollout achieves Mead’s 80% uptake target mortality should plummet so dramatically that the incidence target gets down to the less than 3%/annual level — a very hard threshold to pass in such an epidemic.
Possibly Related Posts
- Secretary Clinton: How Will We “Transition” to an AIDS-Free Generation?
- Can Couples Testing Contribute to Achieving the AIDS Transition?
2 Responses to “Comments from Laurie Garrett on the AIDS Transition”
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November 24th, 2011 at 1:10 pm
Some comments on the critique of Laurie Garrett.
1) Countries do already have nationally-representative surveys – the Demographic and Health Surveys and the AIDS Inidcator Surveys, in particular. These come around every 5 years or so; more often in some countries, such as Kenya in recent years. These surveys provide data that is enormously important to the state on all sorts of things besides monitoring HIV epidemic trends.
2) Prevalence does not equal incidence: but, if we know about numbers on ART (which we could) and AIDS mortality (which we do and could so more), then it’s an old trick to make inferences on what incidence must be doing to drive observed changes in prevalence. It’s not as simple as ‘subtraction’ though and the method is not perfect and there will be uncertainty (sometimes a lot of uncertainty). But, if we think about those errors and the incentive structure that they would create through different pay-off functions, we can understand how they would influence the contract. And, with repeated iterations of the contract, these errors should become less important.
3) There are important concerns that the incidence assays (for measuring HIV incidence in a single cross-sectional survey) that are currently available could lead to biased estimates in some settings (especially high prevalence settings) without further calibration. See Guy et al. (http://www.ncbi.nlm.nih.gov/pubmed/19926035) for some examples. But, it is an exciting field and we hope that in the next few years, something better could become available (see this article in PLoS Medicine: http://www.plosmedicine.org/ar.....ed.1001045) which could be very useful in this application.
November 26th, 2011 at 2:22 pm
I also attended the book launch and found the discussion fascinating, but the time too short. The book seems to combine two innovative ideas (AIDS transition concept and Cash on Delivery) that might be, but don’t have to be combined or combined as Mead proposes.
I think the concept of the AIDS transition is an excellent one to guide planning and AIDS mitigation strategies. I think, however, tracking the transition in practice would be very messy. For the reasons that Laurie Garrett has pointed out, trying to reach the transition by creating incentives for something that is very difficult to measure like incidence is highly problematic. If the performance indicator is subject to estimates and modeling, it will be very easy to cheat, so a COD program risks creating incentives to cheat. Alternatively it risks discouraging countries who make good do the right things, but who fail to reduce incidence for reasons that are beyond the control of the government investing the resources. Surely there are better ways to use the COD or performance based financing concepst to support AIDS control? Why not incentivize programs based on the number of ART patients maintaining their adherence? Or on better case detection? Or on the number of men circumcised? These are all indicators that are more objectively verifiable and support different elements of AIDS control that could lead to a transition.
Another issue that did not come up in the discussion is the problem of creating incentives for governments which are large bureaucracies in which the beneficiaries of the incentive may not be the same people improving the performance. How does one ensure that the people who have to do the case detection, monitor patients for adherence, circumcise the men, etc. are in a position to mobilize resources, ensure supplies and training that are needed to improve performance? The incentives have to work at all levels if they are to support improved performance. This is not impossible, but very difficult to do in governments that have no culture of accountability or transparency.
One way to make the AIDS prevention dollars go farther is to make better use of the private health sector. Private medical practices in Africa were among the first to treat AIDS patients, but when the PEPFAR push came in, they could not compete with free care. Few AIDS prevention programs thought about including private providers in training or finding ways to make care in their facilities more affordable. Moreover, private facilities are very well placed to respond to performance based incentive schemes. The gap between decision makers and service providers is generally much smaller in the private sector and in single provider practices, it doesn’t exist at all. These providers can respond quickly and flexibly to COD or other incentives and they have infrastructure that can be leveraged in the public interest. Numerous schemes that involve prequalification of private providers and incentive payments through vouchers or demand side financing have already shown this approach to be feasible. If low resource countries are to achieve the AIDS transition, these providers should be part of the strategy.