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PEPFAR Cut AIDS Death by 10%, 1.2 Million in Africa
  "We evaluated the contribution of PEPFAR to the abatement of the epidemic in the focus countries, which has implications for the program's economic efficiency. By the end of 2007, PEPFAR spent more than $6 billion on HIV care, prevention, and treatment in the 12 focus countries examined in this study. In those countries, a reduction in the death rate of 10.5% implies about 1.2 million deaths were averted because of PEPFAR's activities. This large benefit cost about $2450 per death averted, assuming that PEPFAR directed half of its budget towards treatment. This is a rough estimate, and it may change as the treatment infrastructure and supply chains become more established, but it could allow an evaluation of the program's efficiency. A formal cost-effectiveness analysis will also allow a comparison with other interventions for HIV in Africa (33)."
PEPFAR Cut AIDS Death Rate in 12 African Nations

MedPage Today
April 06, 2009
TORONTO, April 6 -- The President's Emergency Plan for AIDS Relief, initiated by President Bush in 2003, averted about 1.1 million deaths in Africa, California researchers said.
Action Points
* Explain to interested patients that the President's Emergency Plan for AIDS Relief was started by President Bush in 2003 and allocated $15 billion over five years to fighting HIV/AIDS internationally.
* Note that this study said the program had a marked effect on the death rate in the 12 countries in Africa where the program focused its efforts.
In the 12 countries where it focused attention, the program -- shortened to PEPFAR -- was associated with a significant reduction in the AIDS death rate, compared with rates in 29 similar nations, according to Eran Bendavid, M.D., and Jayanta Bhattacharya, M.D., Ph.D., both of Stanford University.
On the other hand, there was little difference in two other health markers -- the prevalence of HIV and the number of people living with HIV/AIDS, the researchers said online in Annals of Internal Medicine.
The study is the first to scrutinize health-related outcomes of the $15 billion program, they said, although in 2007 the Institute of Medicine reported on the ability of PEPFAR to meet its targets.
"This is a lot of money, with a lot of people's lives at stake," Dr. Bendavid said in a statement, "so this type of evaluation is crucial."
PEPFAR was maligned by some as overly moralistic because 30% of its budget was required to be spent on promoting abstinence and fidelity. Others criticized its emphasis on treatment.
Opinions changed over time, however, and the program was later praised for the vast sums it poured into the battle against HIV/AIDS. (See: IAC: PEPFAR Wins Plaudits at AIDS 2008 Opening and IAC: HIV/AIDS Science Regains Center Stage)
One of the last acts of the Bush administration was to expand the program to cover HIV/AIDS, tuberculosis, and malaria and raise its budget to $48 billion, with $39 billion reserved for HIV/AIDS.
To evaluate the effect of PEPFAR, the researchers compared the 12 focus countries with others in Africa with similar problems -- HIV prevalence of more than 1% in prenatal clinics and a predominantly heterosexual mode of transmission.
The countries were compared before PEPFAR, during the years 1997 to 2002, and after it was under way, from 2004 through 2007. The first year of the program -- 2003 -- was not examined because it was just starting up.
Analysis found:
* Before PEPFAR, the mean annual change in the death rate in the focus countries was 14.1% and slightly higher -- 17.2% -- in the control countries. The difference was not significant.
* In the later period, the comparable rates were _-6.3% and 1.2%, a difference that was significant at P<0.001.
* Before PEPFAR the mean annual percent change in the number of people living with HIV/AIDS was higher in the control countries (nearly reaching significance), but during PEPFAR there was no significant difference.
* There was no difference in HIV prevalence in either period.
The change in the death rates, the researchers said, amounted to about 1.1 million deaths averted, at a cost of about $2,700 per death averted.
"It has averted deaths -- a lot of deaths -- with about a 10% reduction compared with neighboring African countries," Dr. Bendavid said.
Prevalence and the number of people living with HIV are more complicated measures, and the lack of a difference between focus and control countries might have several explanations.
For instance, the researchers said, they observed a "relative acceleration" in the number living with HIV in the focus countries, compared with controls, during PEPFAR's activities. A decreased death rate is the probable explanation, they said.
The study was limited by use of UNAIDS data (although the investigators did a sensitivity analysis), focus countries that were not randomly selected affecting both comparisons and generalizability, and the possibility that the epidemic was in different phases among the countries.
The authors stressed that outcome measures are critical to examine in evaluating the effectiveness of this type of aid.
The former executive director of the Joint United Nations Programme on HIV/AIDS, Peter Piot, M.D., Ph.D., said the research is an important step in assessing the response to AIDS.
"Studies such as this one are critical as they demonstrate what can be achieved with development aid," Dr. Piot said in a statement. "PEPFAR is changing the course of the AIDS epidemic."
The study was supported by the Agency for Healthcare Research and Quality and the National Institute on Aging. The researchers reported no conflicts.
Primary source: Annals of Internal Medicine
Source reference:
Bendavid E, Bhattacharya J "The President's Emergency Plan for AIDS Relief in Africa: An evaluation of outcomes" Ann Intern Med 2009; 150(10).
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