PEPFAR: “One of the greatest global health achievements in recent history”

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Data shows HIV investments in PEPFAR focus countries lowered mortality by 20 percent compared to non-focus countries

A slide from Dr. Bendavid's presentation superimposing data on HIV deaths in South Africa (red dots) against the amount of international assistance disbursements given to sub-Saharan Africa (green dots) from 1990 to 2010.

Dr. Eran Bendavid of Stanford University set out to convince an audience at the 19th Conference of Retroviruses and Opportunistic Infections (CROI) Wednesday that assistance to Africa through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program has resulted in, “one of the greatest global health achievements in recent history.”

Bendavid and colleagues looked at the dramatic change in health assistance given to the African continent from all sources – which increased from some $90 million in 1994 to more than $4 billion in 2009 – and sought to explain if this surge in assistance contributed to the bend downward in the HIV mortality curve in Africa (see slide to the right). His team also compared mortality data in similarly situated African countries that were not PEPFAR focus countries.

Announced in 2003 at the State of the Union address, PEPFAR is the largest programmatic HIV assistance plan on the planet. Implemented in 2004, the program’s first iteration committed $15 billion to combat HIV/AIDS in 15 high-burden “focus” countries, 12 of which were in Africa. An article in Foreign Affairs suggested that “disease-specific programs such as PEPFAR were draining resources and attention from other health priorities, raising the possibility of unintended harms.”  Bendavid looked at how changes in “all-cause adult mortality” associated with PEPFAR compare with changes in HIV-specific deaths associated with PEPFAR – to assess whether or not some PEPFAR benefits spilled over to the broader communities.

The team used adult mortality data from Demographic and Health Surveys — where all women ages 15 to 49 in sampled households were interviewed about the survival status of their siblings, age of those alive, etcetera. This was conducted in 27 countries among more than 1.6 million adults, gathering nine million observations and more than 6 million deaths were recorded.

Adult mortality declined preferentially in the PEPFAR focus countries as compared to non-focus countries after PEPFAR implementation. (See graph at left.) Statistical analysis found that adults living in focus countries between 2004 and 2008 had about a 20 percent lower odds of mortality compared to adults in non-focus countries.

Evidence for unintended health effects with respect to adult mortality is inconclusive, Bendavid said, but the likelihood of PEPFAR interventions eliciting unintended harms is low.

Dr. Eran Bendavid of Stanford University presents Wednesday at the Conference on Retroviruses and Opportunistic Infections in Seattle.

Despite a mixed history in other domains of development (e.g. economic development), health development stands out with some key examples of positive interventions, Bendavid said, highlighting smallpox eradication, polio, and guinea worm as all-star examples of relatively simple technologies used and simple implementation yielding big results. HIV is different in that antiretroviral therapy costs are relatively high and ART is more complex to administer and scale up, but given the data shown HIV development assistance could still enter this “hall of fame,” he said.

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