Global challenges and opportunities in fighting HIV/AIDS and neglected diseases

Responding to the HIV/AIDS pandemic and tackling so-called neglected tropical diseases are the focus of the November/December 2009 edition of Health Affairs. The articles, by leading global health experts from around the world, show that although these challenges differ dramatically, rising to meet them could save millions of lives.

Increasing prevalence of HIV infection, coupled with the current global economic slowdown, portends a drastic funding shortfall for addressing the HIV/AIDS pandemic in both the short and long run. By the year 2031, when the pandemic enters its 50th year, funding needed for developing countries could reach $35 billion annually -- three times the current level, according to a paper coauthored by Robert Hecht. Even then, more than 1 million people will be newly infected each year; some 33 million people worldwide are infected currently.

"We are staring at the face of a huge crisis," says Hecht, managing director of the Results for Development Institute in Washington, D.C. "However, we have an opportunity and an obligation to mitigate this crisis by making difficult but necessary policy choices now." He and his coauthors predict that by investing in high-impact prevention and efficient treatment efforts, world policymakers could cut the cost of fighting the pandemic by more than half.

Hecht's paper is one of a series of articles in this issue of Health Affairs devoted to the economic, political, scientific, and ethical challenges facing world policymakers in their response to HIV/AIDS treatment and prevention. The articles, supported by the Bill & Melinda Gates Foundation, focus on steps policymakers can take to change the dynamics of the pandemic so that millions of lives will be saved, infections prevented, and overall costs made more affordable.

Other highlights include the following:

• Stefano M. Bertozzi, HIV director at the Bill & Melinda Gates Foundation, and co-authors offer a timeline of the world's response to the pandemic and urge policymakers to shift from the "emergency response" mode of recent years to a more effective and efficient set of initiatives today. "An emergency response is appropriate for an earthquake, but wasteful and ineffective for an epidemic that has been with us for more than twenty-five years," they write. They urge a new focus on evidence-based prevention programs, longer-term interventions designed to change fundamental social drivers of transmission, investments in training a new generation of health care professionals and managers, and more coordinated oversight of programs characterized by modern management practices.
  
• Across the board, HIV treatment programs must be restructured to maximize benefits at the lowest possible costs, according to Anil Soni of the Clinton HIV/AIDS Initiative and Rajat Gupta of the Global Fund to Fight HIV, TB, and Malaria. They urge far broader use of the most cost-effective drug regimens for treating patients with HIV/AIDS. They also urge better use of available medical personnel through such strategies as "task shifting." For example, in Rwanda, trained nurses with some physician supervision are conducting patient consultations for HIV treatment. By reducing the demand on physicians for HIV services, the authors say, task shifting reduces costs so that money can be used to improve and expand care.
  
• Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, and colleague Gregory K. Folkers call for increased global funding of a robust research agenda on everything from vaccines to new prevention modalities. They argue that new revenue sources to combat HIV/AIDS globally are needed, including investment by rich and middle-income countries whose contributions so far have been limited.
  
• Although much attention has focused on the scientific obstacles to developing an HIV vaccine, the Massachusetts Institute of Technology's Jeffrey E. Harris contends that the economic challenges are just as real. Among the issues that need to be addressed are a lack of incentives for fostering cooperation among private-sector parties and regulatory conflicts that promote public welfare but impinge on individual rights.
  
• Meanwhile, Judith Auerbach of the San Francisco AIDS Foundation argues that the focus of HIV prevention needs to be broadened, from changing the behavior of individuals to enabling societal-level health promotion and disease prevention that will have positive impacts beyond HIV/AIDS. She cites cost-effective interventions -- such as empowering women in poor countries and providing stable housing for the homeless -- that have shown good results.
  
• The global response to the AIDS pandemic aims for universal access to treatment and for pursuing every avenue for prevention. But given limited funding availability, Dan W. Brock, a professor at the Harvard School of Medicine, and Daniel Wikler of the Harvard School of Public Health assert that there is a moral imperative for shifting priorities to prevention, which ultimately will save more lives -- even if such a change in course slows progress toward the goal of universal treatment access.

Approximately 1 billion people, mostly in the developing world, die or are sickened by a class of infectious diseases often referred to as "neglected" tropical diseases. Today, more than 30 diseases caused by worms, protozoa, bacteria, fungi, or viruses afflict the poorest people in the poorest countries, and collectively cause as much burden as does malaria or AIDS. Global health researchers argue these conditions are demonstrably treatable and can even be eliminated without a large investment of dollars.

Another cluster of papers and perspectives in Health Affairs focuses on strategies and policies for fighting neglected diseases. Publication of the cluster was supported by Global Health Progress, an initiative of Pharmaceutical Research and Manufacturers of America (PhRMA). In the series:

• Health Affairs deputy editor Philip Musgrove and coauthor Peter Hotez argue that concerted efforts -- from mass drug administration to nondrug interventions -- could conquer many neglected diseases. Research, they say, is needed on four fronts: for diseases where no cheap, effective drugs exist; for backup drugs as protection against development of resistance; for vaccines wherever feasible; and for better understanding of nonbiological obstacles to effective delivery. "Neglected diseases affect millions of lives, yet can be treated or eliminated at a relatively small cost," says Musgrove. "It's time for the world to act."
  
• To date, global efforts to control tropical diseases have relied on mass drug administration. But this "magic bullet" approach in most cases will not be sufficient to stay ahead of constantly evolving microbes and parasites, according to Princeton University's Adel Mahmoud and former National Institutes of Health director Elias Zerhouni. They support a comprehensive approach that includes a combined set of scientific, socioeconomic, educational, environmental, and workforce strategies.
  
• Kenneth Gustavsen of Merck and Co. Inc. and Christy Hanson of the United States Agency for International Development see public-private partnerships as key to fighting neglected diseases, including collaborative efforts among global pharmaceutical and biotech companies and other stakeholders. Continued success of these partnerships, they say, depends on having a supportive policy environment.
  
• Similarly, Genzyme Corporation's James A. Geraghty also calls for expanding the biotech industry's involvement in fighting neglected diseases, arguing that companies have a responsibility to help in disease control. Policy changes that could attract more companies to do such work include federal income tax credits, as proposed in a paper by Gerard Anderson. At a modest cost, these could help usher in a new generation of treatment options for neglected diseases.
  
• Researchers Sarah E. Frew, Victor Y. Liu, and Peter A. Singer of the McLaughlin-Rotman Centre for Global Health (MRC) in Toronto, Ontario, write that health biotech firms in the global South are spurring growth in these economies by developing and selling vaccines, diagnostics, and therapeutics to local markets. These efforts should be accelerated through a business plan to support and grow sources of affordable innovation for neglected tropical diseases, the authors say.