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Post00618        RethinkHIV Expert Panel Outcome       10 October 2011

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1. RethinkHIV Expert Panel Outcome

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1. RethinkHIV Expert Panel Outcome

Crossposted from with thanks

RethinkHIV Expert Panel Outcome

RethinkHIV commissioned research papers from teams of top health
economists, epidemiologists, and demographers, ranking competing HIV/AIDS
interventions based upon benefit-cost metrics to help policy-makers and
donors prioritize investments with the highest pay-offs in a world of
limited resources.

Download at:  or:

Read athe document:

A panel of economic experts, comprising five of the world’s most
distinguished economists, was invited to consider the eighteen new research
papers. The members of the Expert Panel were:

Professor Ernest Aryeetey, Vice Chancellor, University of Ghana;
Professor Paul Collier, Director, Centre for the Study of African
Economies, Oxford University;
Professor Edward Prescott, Arizona State University (Nobel laureate);
Professor Thomas Schelling, University of Maryland (Nobel laureate);
Professor Vernon L. Smith, Chapman University (Nobel laureate)

The Expert Panel was tasked with answering the question:

* If we successfully raised an additional US$10 billion over the next 5
years to combat HIV/AIDS in sub-Saharan Africa, how could it best be spent?

Six Assessment Papers, commissioned from acknowledged authorities in each
area of HIV/AIDS research, set out 18 proposals for the Expert Panel’s
consideration. Over the course of 2011, the panel examined these proposals
in detail. They gathered at Georgetown University with all the researchers
and discussed each paper with its authors.

Papers were commissioned from three sets of researchers for each topic, in
order to ensure that a range of expert views were presented. Based on the
costs and benefits of the solutions, the panel ranked the proposals, in
descending order of desirability, as follows:

The Ranking by the Expert Panel

1. Scale-up vaccine funding by $100 million per year
2. Introduce medical infant male circumcision
3. Prevent mother-to-child transmission

4. Make blood transfusions safe

5. Scale-up ART enrolment

** 6. Make medical injections safe

7. Scale-up male circumcision
8. Mass media info campaigns
9. Large-scale testing and counseling
10. Cash transfer to keep girls in schooling

** 11. Reduce risky injecting drug user behavior

12. Prevent Cryptococcal Meningitis
13. Add gender and HIV training
14. Introduce alcohol taxation
15. Invest in community mobilization
16. Cash transfer for counseling and testing
17. Deploy community health workers
18. Create an Abuja Goals Fund

In ordering the proposals, the Expert Panel was guided predominantly by
consideration of economic costs and benefits. The Expert Panel agreed that
the cost-benefit approach was an indispensable organizing method. In
setting priorities, the Expert Panel took account of the strengths and
weaknesses of the specific cost-benefit appraisals under review, and gave
weight both to the institutional preconditions for success and to the
demands of ethical or humanitarian urgency.

As a general point, the Expert Panel concluded that there is a clear and
urgent need for more high-quality analysis of the costs and benefits of
many responses to the HIV/AIDS epidemic. Considering the toll of the
epidemic, the amount of money that is being allocated, the Expert Panel
found the lack of evaluation of interventions alarming. The Expert Panel
found an overwhelming need for policy-makers to be better informed when
making decisions among competing HIV/AIDS priorities.

Each expert assigned his own ranking to the proposals. The individual
rankings, together with commentaries prepared by each expert, will be
published in due course. (The research papers and other material have
already been placed in the public domain, at The panel
jointly endorses the priority list shown above as representing their
agreed, consensus view on priorities.

Notes on Ranking

The Expert Panel found that the first five-ranked investments should be
considered ‘Excellent’, with a compelling need for investment; the 8
middle-ranked investments should be considered ‘Good’, with a strong case
for investment; and the 5 bottom-ranked investments should be considered
‘Poor’, with the Expert Panel not endorsing the case that funds be spent on
these initiatives.

Notes on the Topics

Vaccine Research and Development

Unlike every other investment option examined, the proposal to increase
vaccine research spending has, at the upper-end of possible outcomes, the
opportunity of achieving potential long-term eradication of HIV.

Even using extremely cautious assumptions and focusing on lower-end
possible outcomes, it is likely that spending an extra $100 million per
year on vaccine research will meaningfully shorten the time in which a
vaccine is developed. This represents around a ten-percent increase in
current funding levels. This spending could accelerate the number of years
to the introduction of a vaccine by at least half to one-and-a-half years,
even using conservative assumptions.

Another important consideration is that the bulk of the overall costs of
this investment will come not from developing, but from distribution of the
vaccine, which is a future cost.

Based on these considerations, the Expert Panel found Vaccine Research to
be a compelling investment.

Prevention of Sexual Transmission

The Expert Panel found that, in general, male circumcision offers
considerable opportunities to reduce the scale of the epidemic. However,
the Expert Panel’s ranking of adult male circumcision was influenced, among
other things, by the possibility of substantial disinhibition behaviors.
Circumcision is protective, but only to a certain extent. It is possible
that, as a consequence of large-scale male circumcision with an
accompanying information campaign about its protective effect, males and
their partners opt for less safe sexual practices and for example become
less likely to use condoms or more likely to engage in concurrent

The Expert Panel noted that the possibility of disinhibition behavior is
much less likely in the case of the introduction of infant male
circumcision, and that there were considerable opportunities for investment
in this. This also offers the possibility over time of reducing the scale
of the epidemic across societies.

The lower rankings assigned to mass media information campaigns and large-
scale testing and counseling reflected the lack of reliable data and
analysis showing where and how these campaigns work.

Prevention of Non-Sexual Infection

Scaling up the prevention of mother-to-child transmission was a compelling
investment not just for ethical reasons but also because of the
considerable benefit-to-cost ratio, very low costs, and strong evidence of
its effectiveness.

Making blood transfusions safer was also considered a compelling
investment. Apart from the number of lives saved, the Expert Panel found
value in the increase in public trust of health systems should transfusions
be made safer.

The other two investment options considered by the Expert Panel under this
topic, Making medical injections safer, and reducing risky injecting drug-
user behavior, were given a lower (but still fair) ranking based on their
lower benefit-cost ratios.


The Expert Panel gave a high ranking to the proposal of scaling up ART
Enrolment, focusing on extending coverage to patients with low CD4 counts.
Despite its high costs, the preventative effect of ART means that the
benefits of scaling up ART are considerable.

Social Policy

The Expert Panel endorses Social Policy levers in an effort to reduce the
economic and social factors that fuel HIV risk behaviors and undermine
proven HIV interventions. While the Expert Panel believes that the use of
cash transfers to keep girls in schooling is a sound policy choice, they
formed the view that the benefits relating to HIV/AIDS were a small element
of its overall effects.

They gave a lower ranking to the use of an alcohol tax, reflecting concerns
about its implementation given its politically inflammatory nature and the
possibility it could reduce overall revenue for developing nations.

Adding Gender and HIV training to livelihood programs and community
mobilization investment show promise, and the Expert Panel find a need for
further analysis and research into these.

Strengthening Health Systems

The Expert Panel found the Prevention of Cryptococcal Meningitis an
overlooked policy with merit.

In examining the cash transfer for counseling and testing, the Expert Panel
noted that while cash transfers can be used successfully, design is very
important. There is a significant risk that this intervention could ruin
natural incentives for knowledge about one’s own health status. They did
not find that the proposed cash transfer had an optimal set-up, and ranked
this as a poor policy option.

While recognizing the potential benefits of deploying community health
workers, the Expert Panel found that costs could be considerably higher
than those identified.

The Expert Panel feared that the set-up of an Abuja Goals Fund would lead
to spending on health with little measure of whether or not the spending
was optimal.

Spending $10bn on AIDS

When the budgetary constraints of the RethinkHIV framework are applied to
the Expert Panel’s prioritized list, money can be allocated to five of the
solutions. The yearly budget examined is $2 billion over five years or
$10bn in total, and provides for a broad range of investments:

     Cost (Five years, Million US$)

1   Scale-up vaccine funding by $100 million per year   500
2   Introduce medical infant male circumcision       	3,150
3   Prevent mother-to-child transmission               	140
4    Make blood transfusions safe                      	2
5    Scale-up ART enrollment                           	6,208
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