San Francisco Chronicle - Friday, May 24, 2002
Christopher Heredia, Chronicle Staff Writer

The highly controversial idea is already drawing flak from experts and activists who have clamored for cheaper AIDS drugs for people suffering from the disease in poor nations.

In a study to be published today in the journal the Lancet, the epidemiologists from UC San Francisco Institute for Health Policy Studies suggest that scarce dollars should be spent on prevention before treatment in AIDS-ravaged sub-Saharan Africa, where more than 25 million of the world's 36 million people infected with HIV reside and the death toll has exceeded 17 million.

Thus far, $1.5 billion has been committed to the Global Fund to Fight AIDS, Tuberculosis and Malaria, well short of the $7 billion to $10 billion per year experts say is needed.

"The real problem here is that the (Global) Fund is woefully underfunded," said Dr. James G. Kahn, associate professor of Health Policy and Epidemiology at UCSF, a co-author of the study. "If it were properly funded, then we wouldn't even be having this discussion."

Up to now, the dominant theme in the global AIDS fight has been: Prevention and treatment go hand-in-hand.

A spokeswoman for the group Doctors Without Borders, which has advocated low-cost drugs for AIDS patients, said that should still be the case. She lambasted the report as archaic and small-minded.

By comparing programs that prescribe low-cost antiviral medications to HIV- positive patients with prevention programs that ensure a safe blood supply, use drugs to prevent mother-to-child transmission and provide voluntary counseling and testing, the researchers found prevention programs to be 28 percent more cost-effective than paying for medications.

The researchers suggest prevention programs could be provided at a cost of $12.50 per life year saved versus medication at a cost of $350 per life year saved.

"Offering treatment gives people incentive to come forward to get tested," said Rachel Cohen, U.S. advocacy liaison for Doctors Without Borders. "It's the first step to prevention. The two go hand in hand. They can't be unlinked."

Cohen said people under treatment could go on to be peer leaders discussing risk reduction. She also cited studies showing that providing people in poor countries with antiviral medications had reduced hospital costs and enabled people to become productive members of society again.

"These are economists talking, not the doctors, nurses, mothers, fathers and children who are watching people die, knowing that effective medications could improve and extend their lives," she said.

Dr. Richard Marlink, executive director of the Harvard AIDS Institute, said it was unacceptable to weigh prevention against treatment.

"Do we compare whether we should be doing public service announcements for anti-smoking to whether we should be treating cancer which is caused by smoking?" Marlink said. "It's the wrong message. We need both. We need to treat those who are suffering. That we accept we have to make these decisions is what is the moral outrage."

The cost of AIDS drugs has driven much of the debate. In recent years, activists clamoring for cheaper medications have won key concessions from pharmaceutical companies and leveraged government rules to drive down prices.

Mark Grayson, spokesman for the Pharmaceutical Research and Manufacturers Association of America, said that while he hadn't read the study, it didn't seem to be breaking new ground.

"Certainly, prevention should be the major focus of most of the funds, as well as more education about what AIDS is, what causes it and what behaviors to avoid," he said. "That said, there's still a place for therapy. You need, in every case, to balance all the needs with what can be provided with the funds available."

Kahn said he welcomed the debate and hoped it would bring more attention to the issue.

"There's no question we should redouble our effort to get more money into the international fund, so we're not faced with these extraordinarily difficult choices," he said.

E-mail Christopher Heredia at cheredia@sfchronicle.com.
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