Critically Thinking

By Charles Reichley

August 16, 2006

Do we spend enough to fight AIDS?

Every year there is another round of stories saying America isn’t doing enough to stop the spread of AIDS.  To be sure, AIDS is a bad disease, and it once was a death sentence.  While it is now largely treatable with medication, it’s still something nobody should have to endure.

Despite the world’s best efforts, the number of new cases rose to a record of almost 5 million last year.  The real progress has not been prevention, but treatment, with fewer people now dying of AIDS than contracting it.  This means the number of people infected is increasing.

In the United States, the number of new cases has remained steady at about 40,000 a year, thanks in part to over $700 million dollars a year spent on prevention.  Now some people say we could cut that number in half by spending another $400 million (about $20,000 per year per prevented case).  They claim that preventing 12,000 cases would save more than that in medical costs, noting that costs are skyrocketing as patients live longer and have better access to expensive but necessary treatments.

There is doubt as to whether spending more money would help.  In 2001, the Centers for Disease Control launched a major effort to cut new cases, and it had no effect. But why is it that, over 20 years after the discovery of HIV and the ensuing panic, we need to spend more money on prevention?

99 percent of new AIDS cases in 2004 came from three categories:  male-to-male sexual activity (46 percent), heterosexual activity (31 percent), and IV drug use (22 percent). To prevent infection as an illegal drug user, you can stop taking illegal drugs, or use a clean needle each time you shoot up.  To prevent the spread of AIDS by sexual activity, you can stop having sex, use a condom each time you have sex, or have a monogamous relationship with an uninfected partner.

If everybody read my column, we just saved four hundred million dollars.  But obviously it’s not that easy.  One problem is that drug users won’t get clean needles and don’t want to stop taking drugs, and men don’t want to stop having sex, and don’t like using condoms. 

Part of the problem is our success in managing the disease.  You can now live a relatively normal, healthy life with HIV, so people engaging in high-risk behaviors aren’t as concerned with taking precautions to prevent infection.

Also, while the costs of treatment are high, government programs subsidize or pay for treatment for many infected people, removing the monetary incentive high-risk people have to protect themselves.  These programs actually help prop up the cost of the drugs, since otherwise many of those infected wouldn’t be able to afford the prices and the companies would have to reduce the costs.

Government spending on AIDS research for 2007 is almost $3 billion, higher than any other major disease (Heart disease is second at $2.3 billion).  Relative to the number of people affected, HIV spending is vastly higher than other recurring diseases.  We will spend over $3,000 per HIV/AIDS patient next year, while spending only $50 per diabetic patient, even though diabetes kills five times more people than AIDS each year.

We also spend billions on treatment programs for those who have HIV.  We spend more for HIV/AIDS than any other disease including heart disease and cancer, which can strike anybody at any time with little chance of prevention.

Part of the problem is political.  For most communicable diseases, the health care strategy is to isolate and report cases to prevent the spread of disease.  But with HIV/AIDS we adopted a strategy of silence, hiding the identities of those infected.

The argument against publicizing HIV infection was that it can’t be spread casually – in other words, because it is hard to spread, we don’t provide the information people need to make informed decisions to prevent the spread.  And when people suggest ways to provide that information, they are often called bigots or homophobes.

Still, if spending $400 million would save over $650 million in health care costs, it would be a good thing, freeing up millions to spend on other diseases.  But until there is good evidence that spending more money would actually change the behavior of the at-risk population, the money can be better spent on prevention and cure for illnesses that can’t be so easily prevented, or successfully treated.   Medical funding shouldn’t be driven by special-interest politics.