Editors' ChoiceGlobal Health

Bang for Development Bucks

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Science Translational Medicine  30 May 2012:
Vol. 4, Issue 136, pp. 136ec94
DOI: 10.1126/scitranslmed.3004351

Calculating the precise amount of health care spending to derive the maximum benefits is tricky—and the implications are paramount. Spend too little, and the death rate among children and economically active adults is unacceptably high. Spend more than the amount necessary to achieve a maximal number of lives saved, and the benefits plateau. Policy-makers have debated the relative costs and benefits of government spending for the treatment of human immunodeficiency virus (HIV) infection, which causes AIDS. Now, Bendavid and colleagues attempt to estimate the impact on adult mortality of the President’s Emergency Plan for AIDS Relief (PEPFAR), which has spent $20.4 billion on HIV treatment and care between 2003 and 2008.

Global health spending aimed at HIV treatment and prevention in countries with high disease is known to be responsible for the observed decrease in HIV mortality. Some critics have argued that the current level of spending on HIV treatment diverts too large a percentage of available resources away from other life-enhancing health care interventions such as malaria therapeutics or childhood vaccines. Others argue that, because the effects of HIV infection are felt throughout the society—such as among uninfected children of infected parents—spending on HIV-related treatments might decrease mortality more broadly, beyond preserving the lives of infected individuals. For example, HIV-related treatment programs could strengthen other health care programs by providing training and infrastructure and by strengthening medical product supply chains.

To investigate this question, Bendavid and colleagues estimated PEPFAR’s impact on adult mortality by comparing individual-level mortality data obtained between 1998 and 2008 from PEPFAR-focus (nine) and non–PEPFAR-focus (18) countries. To strengthen their confidence in the observed mortality differences between countries, the authors also performed within-country comparisons for Tanzania and Rwanda of mortality data from regions with greater or lesser PEPFAR activity. Data from more than 1.5 million adults were analyzed, including more than 60,000 deaths.

Bendavid and colleagues found that the implementation of PEPFAR was associated with a significant decrease in mortality from any cause in PEPFAR-focus countries, from 8.3 to 4.1 per 1000 population (a 50% decrease) compared with 8.5 to 6.8 per 1000 population in non–PEPFAR-focus countries (a 20% decrease). A similar trend was seen when comparing communities in Rawanda and Tanzania that have intense PEPFAR focus versus those with a focus level that was below PEPFAR’s median intensity level. Although a causal link cannot be made between PEPFAR funding and lower levels of all-cause mortality, the overall decrease in deaths observed in this study provides evidence of indirect benefits from spending on HIV treatment programs.

E. Bendavid et al., HIV development assistance and adult mortality in Africa. JAMA 307, 2060–2067 (2012). [Full Text]

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