Paper: Complexity, cofactors, and the failure of AIDS policy in Africa

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Abstract

Global AIDS policy still treats HIV as an exceptional case, abstracting from the context in which infection occurs. Policy is based on a simplistic theory of HIV causation, and evaluated using outdated tools of health economics. Recent calls for a health systems strategy – preventing and treating HIV within a programme of comprehensive health care – have not yet influenced the silo approach of AIDS policy.

Evidence continues to accumulate, showing that multiple factors, such as malnutrition, malaria and helminthes, increase the risk of sexual and vertical transmission of HIV. Moreover, complementary interventions that reduce viral load, improve immune response, and interrupt pathways of transmission could increase the effectiveness of antiretroviral drugs and other tools of AIDS policy.

In health economics, the omission of estimates of increasing returns generated by disease or treatment synergies biases cost-effectiveness analysis against multiple, yet inexpensive, interventions. Current tools of cost-effectiveness analysis only identify local maxima in a complex landscape, and can play, at best, a marginal role in the epidemic, especially where it is already generalized.

Complexity, cofactors, and the failure of AIDS policy in Africa

Eileen Stillwaggon¹

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Reference:
Stillwaggon, E. (2009). Complexity, cofactors, and the failure of AIDS policy in Africa. Journal of the International AIDS Society, 12, 12. http://doi.org/10.1186/1758-2652-12-12

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2717915/

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Conclusion

HIV epidemics, like other complex systems, are influenced by multiple factors. The issue is not that sexual behaviour is unimportant. It is that behaviour explains so little about why poor people get sick, especially in tropical areas with little access to safe medical care, clean water, sanitation and good housing to protect them from disease vectors.

Standard HIV-prevention policies, and thus cost-effectiveness analyses evaluating those interventions, have overlooked complementary investments for treating coinfections. Treatment for TB, schistosomiasis, malaria, malnutrition and helminthes is relatively inexpensive, highly effective, and essential for improving immune status in HIV-negative persons and decreasing viral load in HIV-infected persons.

Such investments are not a diversion of funds from HIV prevention; they are necessary complements. Deworming is safe, effective and easily dosed; it generates positive externalities [79]; and it might also prevent the failure of first-line ART – at a cost of as little as 2 US cents per person. The cost of moving to second-line therapy will far exceed the cost of treating coinfections.

We need cost-effectiveness tools that reflect complexity and attempt to measure the costs of multiple inputs distributed over multiple outputs in which interactions play a prominent role. Those tools would recognize conventional economies of scale and scope, which are extensive in multi-purpose programmes, as well as biological externalities, both intra-individual and population-wide, that, if exploited, reduce overall cost. With those tools, we can achieve our goal of healthy individuals in healthy populations, rather than chasing after one virus, one person at a time.