The moral cost of HIV and AIDS

A new book titled “The Moral Economy of AIDS” by University of Cape Town economist Dr Nicoli Nattrass was published recently, adding to the canon of South African literature on HIV/AIDS. Health-e News Service asked her what she meant by a ‘€œmoral economy’€.

NN: I use the term moral economy deliberately to flag that all economic analyses have a normative component to them, that is, they involve social value judgements in every economic decision. So, for example, when [finance minister] Trevor Manuel says ‘€œwe can’€™t afford to provide antiretroviral treatment’€, what he’€™s really saying is, he doesn’€™t think that citizens are prepared to dig deeper into their tax pockets and actually give him more revenue to spend more on antiretroviral drugs and that he doesn’€™t want to change the spending priorities to accommodate them. So he’€™s actually making a set of judgements and I’€™m trying to flag in this book that we shouldn’€™t be letting these sorts of judgements rest solely in the hands of technocrats like Trevor Manuel but that we should be confronting this challenge ourselves.

 SV: What are some of the points that we need to debate in society and what are some of the trade-offs that they imply?

I think the first thing we need to do is get a clear understanding of what the costs and benefits are in addressing this pandemic. It certainly is going to cost a lot of money to have a full-scale AIDS intervention that would require that we all pay more taxation. I estimate that this will be the equivalent of raising Value Added Tax by 5 percentage points for the next 20 years, so we would have to pay for it. But the question is, is it worth it? When you get down that route it’€™s really raising questions about what it means to be a society. To pay more taxation, to reach everybody who needs treatment, makes us a more egalitarian place to live in. If we as the elite, rather choose not to treat everybody and have a much smaller response, effectively what we’€™re saying is that those people who are too poor to access medicines on their own or are stuck out in rural areas, are going to be condemned to die. So what we would be doing under that scenario, would be taking the big gap between rich and poor and turning it into a divide between those who are going to live and those who are going to die and that really does have implications for social solidarity.

The finance minister has said and cited evidence to prove that the impact of HIV is not going to be that huge on the economy ‘€“ so to be very blunt and crude, it is cheaper to let those people die and not treat them. What is your response?

Well this is a very interesting question. Certainly because there is a close connection between HIV infection and poverty, it is the case that most people with HIV are poor and unemployed. So when they die, they have no direct impact on the economy other than to pull what meagre household savings and resources there might have been into their care in the last years that they live. So there is an impact there, but it’€™s quite small. Where the economic modelling shows a big impact is when AIDS starts to get into the highly skilled occupations which it is beginning to at the moment, so the problem is getting worse. But given that most people with HIV infection tend not to be economically active, most economic models do in fact show that AIDS will shrink the population and it’€™s going to shrink the size of the economic pie. But because there are fewer people, each remaining person will have a larger slice. Put differently, per capita incomes may well rise as a result of the AIDS pandemic. If that happens, it is in the interests of the economic elite to stand back, protect themselves from the pandemic as best they can and wait for it to burn out because they could be in a better position afterwards.

 But that has serious implications for a society and its coherence.

It absolutely does which is why we need to have a very serious discussion about what we all need to contribute through extra revenues and through maybe sacrificing other spending priorities to address that. And what worries me about the current debate is that we as a society are sitting enthralled to the finance minister. He almost appears to us like some high priest of finance, he comes across and he sermonises about what we can and cannot afford and what is feasible and this is really deflecting attention from a much-needed social debate about how we actually as a society ought to respond. Because you can’€™t just tax people without having a discussion and getting people on board so they understand that this is what’€™s really necessary. And this government has not actually confronted that social implication at all, they’€™ve been burying in a discourse of what’€™s technically affordable and what isn’€™t.

 And in this respect I think we have a lot to learn from the Irish case in the last ten years or so. The Irish societies had a long series of social discussions and debates about what they should be doing about welfare spending and education policies and wages and employment going all the way down to local levee. And this accord process has really helped the Irish system far more into a social democracy than it was before.   I think that’€™s the path we should be going down.

 In your book you challenge the conventional wisdom that providing antiretrovirals is unaffordable for poor countries. What’€™s your argument?

Certainly the conventional wisdom among health economists looking at developing countries in Africa is that developing countries cannot afford to provide treatment and they should rather concentrate their resources purely on prevention. I argue in the book that this is not a good way to look at the economics of the problem from a middle-income country like South Africa because we already have a fairly developed health sector and we’€™re already treating people that have AIDS for their opportunistic infections. So what in a middle income developing country context you need to do, is look at the costs of what we are already spending and set them off against the costs of preventing those particular health sector costs, i.e. the costs of opportunistic infections. So in other words, by giving somebody an antiretroviral drug you prevent new infections, so therefore you prevent new people coming to the health sector to get treated, you also lower the amount of illness that each person who’€™s on antiretrovirals experiences and for that reason also you lower the cost to the health sector.

And I argue that certainly in a developing country like South Africa and also in Brazil and there’€™s good evidence to show this is working in Brazil too, is that a great deal of the costs you put out for the drugs are more than clawed back by the savings you get in the health sector of not having to treat the opportunistic infections of people with AIDS who do not have access to ARV treatment. In fact, the studies from Brazil show that it’€™s actually cost savings, the Brazilians estimate that they’€™ve actually saved the health sector costs by providing antiretroviral drugs. My costing exercise suggests that you don’€™t actually save money but that you claw back an awful lot of those costs.

 You also challenge the research that warns that the provision of antiretroviral drugs may result in an increase in unsafe sexual behaviour as people see the drugs as a long-term treatment option and even a cure.

The underlying demographic model that I use in my costing is the ASSA 2000 (Actuarial Society of SA model). They predict that if you give people antiretrovirals you will get fewer infections for two reasons: the first is that there’€™s a lower viral load, so even if the person is going out and behaving badly as you’€™re suggesting, they’€™re less likely to pass on the virus because their viral loads are so low and viral loads are really important in driving down HIV infections. So that’€™s the first thing, there’€™s a medical benefit.

But there’€™s also a behavioural benefit. This model that I use in my book assumes that because each antiretroviral programme will be linked to voluntary counselling and testing intervention, that people on antiretrovirals will be educated how to behave better. Now of course you can assume that maybe they won’€™t in fact listen to the education and do the opposite and for this reason I have an entire chapter on this question ‘€“ does providing antiretroviral drugs lead to increased risky sexual behaviour or not and in this sense I found that most of the literature on this refers to sexual behaviour amongst gay men in America mainly, where the assumption has long been that antiretroviral drugs has resulted in an increase in sexual risk behaviour, but if you actually look at the literature what most of the surveys that show this are based on, are based on a whole set of interviews at gay clubs and gay meeting places over time. So if it’€™s the case, which is likely, that gay people who decide that AIDS is quite risky, I think I’€™d rather stay at home or go out to movies or have a more stable relationship and not go off to gay pick-up places, if they’€™re staying away then you’€™re not going to be surveying them, you get what economists call ‘€œadverse selection’€ and a selection bias which could be why we’€™re seeing these surveys picking up an increase in risky sexual behaviour. And those surveys that try and avoid this selection bias actually show very low levels of risky sexual behaviour amongst gay men. In fact less than 5% have said they are increasing their risky sex behaviour because of the presence of antiretrovirals. Most of them, the vast majority say ‘€˜no’€™, antiretrovirals are not very nice drugs to take, they’€™re not cures, so in fact we should just behave more safely in our sexual behaviour.

 So I think there is no basis for assuming in South Africa that if we give out antiretrovirals we’€™re going to see an increase in risky sexual behaviour and HIV infection. In fact I think, there’€™s pretty good evidence showing that if we don’€™t go out there and give people hope, we’€™re probably more likely to see AIDS spreading much faster as young people say, ‘€˜well if there’€™s no hope why I should not just spread it?’€™ And there is some anthropological evidence showing that young people are in fact doing this.

 Is there any evidence form other resource poor settings or middle-income countries that might show that the provision of ARV treatment doesn’€™t result in risky sexual behaviour besides the examples of men who have sex with men in the United States?

I haven’€™t seen a single study that is convincing about risky sexual behaviour. What I have seen is a resource poor environment, which show that levels of stigma have gone down and people are happier about disclosing their HIV status and so therefore the assumption is that under those conditions you’€™re more likely to get people disclosing to their partners and therefore protecting their partners. But I haven’€™t seen any study that asks people directly about their risky sexual behaviour. It is in fact a huge gap in the literature.   And in fact as we roll out treatment in this country that’€™s one of the areas we need to learn a lot more about. In fact how are people responding, how are people understanding the riskiness of antiretrovirals and the responsibilities involved of in fact having safer sex?

 Do you think there’€™s any way to begin to have the moral debate? What place does morality have in our society and our economy?

If you leave it up to individual self-interest then I suspect it’€™s very likely that the rich, say through a secret ballot, would agree to have higher taxation in order to fund poor people. They would figure out it’€™s in their interest to have lower taxation to protect themselves not to fund the treatment. This is why in my book I draw a distinction between what’€™s rational and what’€™s reasonable. This is quite an important distinction. It’€™s also the basis on which social democratic societies forge consensus. The idea is you might have a rational self-interest which you want to pursue in private, but if you were ever forced to articulate your views in public, and in public is where we forge a society, it’€™s in the public space that we become reasonable. The more we force people to have reasonable discussions about what we need to do as a society, the more likely we are going to forge social consensus about what is needed in terms of taxation. Which is why I think the more we have this debate in public the better it’€™s going to be to force people to confront the moral implications of actions which they might otherwise take out of narrow self-interest.

 Surely it’€™s in society’€™s interest not to be so polarised. The greater your inequity the gulf between rich and poor the more unstable your society?

International agencies and organisations which are trying to get the rich countries to provide more financing to address the AIDS pandemic have been highlighting issues around global security and AIDS. They have been making arguments to the effect that if you don’€™t address the AIDS pandemic it’€™s likely to cause instability, possibly even undermining democracy. The problem with this argument is that not everybody believes it. Because the people who are suffering from AIDS are actually very ill and they die.   It’€™s not as if they’€™re out there undermining government structures and throwing stones. Most of them are lying in horrible circumstances in rural areas.

  So you could go down that route but I’€™m not sure it’€™s all that credible a route as an organising strategy. It might be correct, but as a political strategy to get more money for AIDS funding I don’€™t think it works. I think what we need to do is to confront people and say look, ‘€˜if we had a less selfish approach to this and we put more money into AIDS programmes we will have a better society and it’€™s much kinder place to live in if it were more egalitarian’€™. And we ourselves will probably be under less threat from crime if we did this but that ultimately it’€™s not about narrow self interest, it’€™s really about is this the kind of society I want to live in and have my children growing up in, which is a much more social democratic kind of question.

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