Next generation economics of universal HIV treatment
Authors: Charles Birungi
Journal: The Lancet Global Health (2021)

Historically, HIV policy discourses have combined—in various forms—at least three elements: a human rights perspective, a teleological approach whereby HIV strategies are designed in line with overarching objectives such as ending AIDS, and an economic perspective. Good economics informs epidemic control efforts. Advances in economics have the potential to help end the colliding HIV and COVID-19 pandemics and accelerate progress towards universal health coverage. In The Lancet Global Health, Aleksandra Jakubowski and colleagues1Jakubowski A Kabami J Balzer LB et al.Effect of universal HIV testing and treatment on socioeconomic wellbeing in rural Kenya and Uganda: a cluster-randomised controlled trial.Lancet Glob Health. 2022; 10: e96-104Google Scholar provide new and important evidence about the economic benefits of investing in universal HIV testing and treatment, extending foundational science and discussions on treatment as prevention from well before the SEARCH trial.2Attia S Egger M Müller M Zwahlen M Low N Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis.AIDS. 2009; 23: 1397-1404Google Scholar, 3Montaner JS Hogg R Wood E et al.The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic.Lancet. 2006; 368: 531-536Google Scholar, 4Granich RM Gilks CF Dye C De Cock KM Williams BG Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model.Lancet. 2009; 373: 48-57Google Scholar Their results suggest that the considerable investments needed to expand antiretroviral therapy (ART) access might have substantial short-term and long-term economic returns and reduce inequalities and inequities. Compared with adults living with HIV in control communities, adults living with HIV in intervention communities with annual HIV testing and universal ART eligibility were more likely to be employed (difference 9·7% [95% CI 2·1 to 18·3]), less likely to seek health care (–10·3% [–22·0 to 0·1]), and less likely to spend money on health care (–12·7% [–22·4 to 0·6]) 3 years after the intervention. Expanding access to ART is not only cost-effective but is also the right thing to do from a human rights perspective. This paper contributes to the literature on the economics of HIV and universal health coverage. Beyond the health benefits, providing ART makes economic sense, despite not always being understood this way. In the 40 years of HIV, a resounding argument has been framed around the inability of the world to afford financing the so-called AIDS mortgage, the financial costs associated with initiating all people living with HIV on lifesaving ART. By extension, it followed that HIV treatment was reserved for severely immunocompromised individuals (CD4 cell count <200 or <350). For low-income and middle-income countries, this inequitable policy of test and wait only changed to test and treat in the mid-2010s, after incurring millions of infections and AIDS deaths, as well as billions of US dollars in economic losses. One new HIV infection is one too many. The test and wait policy is the true AIDS mortgage we are all still paying in ongoing infections, AIDS deaths, and wellbeing losses. Many countries missed an opportunity to save millions of lives, livelihoods, and billions of US dollars.5Tran H Saleem K Lim M et al.Global estimates for the lifetime cost of managing HIV.AIDS. 2021; 35: 1273-1281Google Scholar, 6Atun R Chang AY Ogbuoji O et al.Long-term financing needs for HIV control in sub-Saharan Africa in 2015–2050: a modelling study.BMJ Open. 2016; 6e009656Google Scholar Taking the positive externalities of universal HIV testing and treatment into consideration, the question is whether we can we afford not to offer earlier testing and treatment, rather than whether or not we can afford it. From individual, health sector, and societal perspectives, the answer is clear: universal HIV testing and treatment is humane, clinically appropriate, averts infections, saves lives, and makes economic sense. Relatedly, Jakubowski and colleagues1Jakubowski A Kabami J Balzer LB et al.Effect of universal HIV testing and treatment on socioeconomic wellbeing in rural Kenya and Uganda: a cluster-randomised controlled trial.Lancet Glob Health. 2022; 10: e96-104Google Scholar raise the question of prioritisation. Policy makers ought to weigh how to prioritise the scarce health-care resources in low-income and middle-income countries. Despite the price reductions of antiretroviral medications, a clear need to rapidly scale-up treatment, and the availability of billions of US dollars, many countries were unable to use the resources to provide earlier diagnosis and treatment for millions of people living with HIV.7Granich R Gupta S Williams B Human immunodeficiency virus funding and access to treatment in sub-Saharan Africa.Int J STD AIDS. 2021; (published online Sept 25.)https://doi.org/10.1177/09564624211042287Google Scholar Intersecting inequalities persist. Although 27·5 million people living with HIV were receiving ART in 2020, more than 10 million remain with no access.8UNAIDSConfronting inequalities: lessons for pandemic responses from 40 years of AIDS. UNAIDS, Geneva2021Google Scholar In the future, optimal resource reallocation ought to prioritise earlier access to testing and scale-up treatment and prevention programmes targeting key populations at greatest risk in each setting.9Kelly SL Martin-Hughes R Stuart RM et al.The global Optima HIV allocative efficiency model: targeting resources in efforts to end AIDS.Lancet HIV. 2018; 5: e190-e198Google Scholar The ongoing COVID-19 pandemic underscores the dire consequences of the absence or partial application of cost-effective and rights-based tools. Like treatment as prevention, COVID-19 vaccines prevent illness, death, and economic losses. To end pandemics and make COVID-19 the last one while progressing towards universal health coverage, lessons can be learnt from the long and tortured road of the global HIV epidemic and response over the past 40 years. Key among these is that ensuring all people with the greatest risks, in the locations with the highest prevalence, have the most effective tools and services available to them in ways that meet their needs, so that they can protect themselves from acquiring the disease. Unfortunately, the long-term suboptimal investments in health systems, ongoing COVID-19 vaccine inequities, and the slow adoption of 6–12-month ART scripting are a few of the examples of the issues that have left much of the work on progressing towards universal health coverage and controlling COVID-19 and HIV undone. In conclusion, it is time the world focused more on testing and treating people to reach near universal ART coverage, achieving at least the 95-95-95 treatment target (or 86% viral suppression). Achieving this target by 2025 will bring the reproductive rate of infection to less than 1, a key step in epidemic transition towards the elimination of HIV. From an allocative efficiency perspective, this means that the basic interventions to end AIDS and prepare for future pandemics should be prioritised. In the coming months and years, we ought to build back better based on a wellbeing economy. The findings of the study by Jakubowski and colleagues should be viewed in an overall context of health, not just for HIV. HIV treatment and prevention scale-up is the right thing to do for more than just humanitarian reasons, it transforms economies.10Lamontagne E Over M Stover J The economic returns of ending the AIDS epidemic as a public health threat.Health Policy. 2019; 123: 104-108Google Scholar Similar research could be extended to other major diseases, such as tuberculosis and malaria, and extrapolated to universal health coverage. I declare no competing interests. The views expressed in this Comment are those of the author and do not necessarily represent the views of the Joint United Nations Programme on HIV/AIDS (UNAIDS). Effect of universal HIV testing and treatment on socioeconomic wellbeing in rural Kenya and Uganda: a cluster-randomised controlled trialUniversal HIV testing and treatment improved employment outcomes and other indicators of socioeconomic wellbeing for HIV-positive adults and children in their households, but had no effect on HIV-negative adults. Our findings suggest that the considerable investments needed to expand ART access might have substantial short-term and long-term economic returns. Full-Text PDF Open Access