Expert panel picks 'best buys' for HIV prevention

If $10 billion of new money can be spent on HIV prevention over the next five years, the priorities should be more investment in vaccine research, mass infant circumcision, preventing mother to child transmission, safer blood supplies and a scale up of antiretroviral treatment, according to a panel of five of the world’s most distinguished economists.

Their recommendations, released on 28 September, are the product of a review process managed by the Copenhagen Consensus Center, a think-tank funded by the Danish government to evaluate the most effective solutions to global development problems.

Investing in vaccine research and development

Overall, the panel found this to be the most compelling investment. “It is likely that spending an extra $100 million a year on vaccine research will meaningfully shorten the time in which a vaccine is developed,” the panel noted.

Although a vaccine is found to be highly cost-effective in itself, it is the speeding up of vaccine research by spending a relatively small amount over the next five years that makes it the panel’s `best buy`. Having a vaccine in 2030 rather than 2040 would save around $100 billion according to the most conservative calculation, which doesn’t factor in the gains in productivity that could be achieved by infections averted.

Introduce medical infant male circumcision

Circumcising all male infants in countries with a high HIV burden, at a cost of $3.15 billion over five years, would be a better investment than campaigns for adult male circumcision. This is partly because the panel feared that circumcision campaigns will lead men to have more unprotected sex in the long run because they feel less vulnerable to infection. It is worth noting that five-year follow-up of men who took part in the first major randomised trial of circumcision for HIV prevention found no evidence of an increase in risky sex.

Prevention of mother-to-child transmission

A scale-up of interventions to prevent mother-to-child transmission would be highly cost-effective, but also remarkably cheap – just $140 million over five years to avert an estimated 265,000 infections. The potential costs averted could be as high as $32 billion. The challenge in making this investment lies in improving access to services and reducing the stigma of HIV diagnosis, noted Lori Bollinger of the Futures Institute in a paper analysing the cost-effectiveness of interventions to prevent non-sexual HIV transmission.

Improving safety of the blood supply

The cheapest and most cost-effective intervention recommended by the panel is making blood transfusions safer by ensuring that all countries have a high-quality system for screening blood donations. An investment of $2 million over 5 years could avert around 150,000 new infections and would benefit nearly half a billion people who live in countries with unsound screening systems.

Maximising treatment coverage in people with low CD4 counts

The panel concluded that maximising treatment coverage for people with low CD4 counts by spending an extra $6.2 billion over five years would have the biggest impact on new infections, but only if it was accompanied by comprehensive prevention activities. Mead Over and Professor Geoff Garnett of Imperial College, London, who carried out the modelling on treatment, said that neither treatment nor prevention alone would have sufficient impact on new infections.

They say that their modelling suggests that economic growth after 2020 will allow many more African countries to follow the lead of South Africa and Botswana in taking responsibility for their HIV treatment costs, suggesting that an early investment could reap long-term rewards.

Other measures

Measures which proved less attractive to the panel, but which are still cost-effective, include:

• Cash transfers to keep girls in school: although a sound policy choice, the HIV-related benefit of this expenditure would be quite limited.
• Reducing risky drug injecting behaviours: although cost-effective, the impact is likely to be limited in sub-Saharan Africa in comparison to investments in blood safety or prevention of mother-to-child transmission.

Further information

Detailed research papers and further information on the Rethink HIV project is available at the Rethink HIV website.