Interview: AIDS economist Mead Over on sustainable treatment

Last week, I sat down with Mead Over, a senior fellow at the Center for Global Development. He’s an expert AIDS economist, and his new book offers thought-provoking (some might even say controversial!) ideas about how we can improve our efforts to combat HIV/AIDS. Below are excerpts from our conversation.


Your new book is called Achieving an AIDS Transition: Preventing Infections to Sustain Treatment. Define for us what you mean by an “AIDS transition.”

When we place people on treatment, we accomplish a great good because we prolong their lives, and in the case of the adults, we allow them to continue parenting, contributing to their local economy, enjoying their lives. Unfortunately, medicines cost hundreds a year and must be taken every day for the rest of an individual’s life, so when we expand treatment, the positive effect is counterbalanced by the fact that we’ve added to the fiscal burden of AIDS treatment. I would also argue that it’s not good for a country for a large percentage of its citizens to be reliant on a pill that comes from another country. I believe that young Africans, as they grow older and remain dependent, will come to resent this.

So the challenge is to find a path towards sustainability of AIDS programs in poor countries. We need a milestone we can reach on the way to a world without AIDS. The AIDS transition is such a milestone for a given country or for Africa as a whole. I define it as holding down the annual number of AIDS deaths, while pushing the annual number of new infections even lower. To hold the mortality rate down, it’s not sufficient just to sustain current treatment levels. We have to add a substantial number of new people to treatment each year to sustain progress. But the more people we add to treatment rolls the more effectively we must reduce new infections in order to achieve the AIDS transition in any given year. And the larger the fiscal burden until the transition is reached. Donors and recipient governments must decide how to trade off the goals of treatment access and fiscal burden.

In her remarks at your book launch, Nancy Birdsall likened the moment we’re in for AIDS to that of John F. Kennedy announcing to Americans, “we’re going to the moon.” Would you agree with that assessment?

When JFK made those remarks, there were two aspects of context which we don’t have now. One of those was rapid economic growth in the 1960s and 1970s, and the other was a competitive relationship with the Soviet Union which imparted a national security rationale to investment in the space program. Neither pertains now. On the economic side, donors are suffering from a financial crisis. On the security side, there is no external pressure that’s comparable to that which existed around the control of space. One might hope there would be a friendly and virtuous competition between European donors and the US, such that each would try to outdo the other in helping people with AIDS in poor countries, but given the current European financial situation, that’s not likely — leaving the US with a larger portion of the fiscal burden. So unfortunately, it’s not very realistic to think we’re at a moment when we can think big and aspire to greatly increased resources for AIDS with the hope of overcoming the epidemic in 10 years. And I think that having unrealistic hopes is dangerous, primarily for the people who, without assistance, won’t be able to access AIDS treatment. If we attempt to do something beyond our means, there’s a real danger that we will retreat altogether and leave the AIDS problem entirely to countries most affected and least capable of financing the response.

Given limited resources, what should donors do differently in their financing of AIDS programs?

Rather than giving money year to year, the right thing for donors to do would be to commit to multi-year funding for treatment — in a set of countries established upfront — for a specific percentage of the HIV-positive people in a given country. For some countries that percentage might be funding for 80 percent of people in need, in other countries 20 percent. In some cases, we might combine a US bilateral offer with a Global Fund program. The donors jointly should make a promise of a percentage and stick to it, unless fraud is demonstrated.

If we were to promise a solid percentage (even if less than 100 percent), it would be much more fair to recipients, because it would allow recipient countries to plan. They can choose, as the poorest might, not to contribute their own tax resources to AIDS treatment, or they can choose to add additional people to treatment, knowing that by doing so, they will not be punished by withdrawal of funds by donors.

Percentages are politically difficult; politicians don’t like to make commitments of less than 100 percent. But vague promises are unfair to recipient countries and leave them without incentive or political support they need to come forward with matching efforts. And the benefit of the model is that if treatment costs fall, the donor resources required would fall proportionately. The recipient government, as it is led to contribute to treatment, would also see costs fall.

How would you define recipient governments’ role in all of this?

If I were a minister of health or finance in a recipient country, I would be concerned with trying to improve the welfare of my population. But I’m also likely to be concerned with my political survival, and I’m likely to think that if I take on a responsibility which I’m unable to fulfill, that my survival will be threatened. I think that many ministers will see AIDS treatment as a burdensome responsibility which, while they might be able to meet it for a few years, will grow without limit and eventually be beyond their capacity. So, many governments are reluctant to assume a share of the AIDS treatment burden for fear of political downside. On the prevention side, one can point out that there’s a similar pair of motives. Government officials want to prevent HIV infections for good of their population, but a more explicit political calculus may lead them to believe that as long as donors are paying the costs of AIDS treatment, they won’t receive political benefits as a government for financing HIV prevention for their citizens. We need to radically change the relationship between donors and recipients to ensure that recipient countries have incentives to do a better job of financing treatment and prevention.

In some ways, “prevented an infection” sounds like “prevented a recession” — it doesn’t sell well because there’s no counter-factual to point to. How do we better sell and finance prevention?

We could do a much better job of measuring infections averted. If donors were to step forward with an offer to fund much more comprehensive HIV prevalence measures at more frequent intervals, the results would be quantifiable and we could sell that number politically to the public.

In the book I propose we should offer rewards to governments for averting HIV infections, where we let them figure out at local level what might reduce infections. We think that in some cases, those innovations will be social inventions which lead to changes in behavioral norms. We don’t think that foreign experts know how to change the social norms of African societies, but if there are ways to change norms toward safer sexual behavior, they will come from the ground. In some cases, prevention might be free, if we can only understand how donors can better support local innovation.

You’ve spent decades doing economic analysis of the AIDS pandemic. What’s kept you in this line of work?

I was one of the first economists to work on AIDS, and I think it’s always exciting to get in on the ground floor of an issue. Second, the epidemic has the complexity of any epidemic of infectious disease, but it’s an epidemic in slow motion. A pandemic like SARS flashes through the world in a matter of months; AIDS is like stop-motion photography, so there’s much more opportunity for clear thinking and analysis to try and improve the effectiveness of government policies to cope with and curb the epidemic. Third, the epidemic is in some sense unique in its combination of the two words Woody Allen put together in the title of a movie: “Love and Death.” The attraction to love/sexuality on one hand and the aversion to mortality on the other are arguably the two most emotionally charged themes in civilization, so it’s inherently interesting, intriguing, and (dare I say) stimulating to study an epidemic which is characterized by those dimensions.