The failure, or perhaps the disinclination, of the Canadian media adequately to inform the public in regard to the cost of medical care for patients with HIV/AIDS was a subject of discussion in the editorial in the January 2004 issue of Catholic Insight. Here is provided a cursory review of the facts presently available.
It is important to realize that "studies of HIV/AIDS costs often report costs that are three or four years old, do not reflect current needs or trends and cannot be used on an ongoing basis."1 Ann Silversides reported in Extra magazine on Feb. 5, 2004, that Health Canada officials have no information on what AIDS patients died of and caution that AIDS cases are under reported as are AIDS deaths, since it is not mandatory to report them. That said, Statistics Canada reported that in Canada in 2001, there were 50,259 persons who were HIV positive, and 18,018 who suffered from AIDS. That year also, Health Canada gave the number of new HIV infections per year as 3000. The Canadian AIDS Society said it was 5000 and that over half of them were under 25 years old. Extrapolating from these figures, one could estimate that the number of persons in Canada in 2003 who are HIV positive was between 56,000 and 60,000. Health Canada estimates that HIV infection costs employee benefit programs 100,000 dollars per employee per year. It also estimated that Canada lost eight billion dollars in 1995 in lost productivity and that the loss could be fifteen billion dollars by the year 2000. These figures agree with the estimates originally made by John McCallum, the Royal Banks chief economist, at the World AIDS Conference in Vancouver in 1996. At that time, McCallum predicted the cost of AIDS as thirty-eight billion dollars before 2011.2
The Genuine Progress Index (GPI) for Atlantic Canada reported in 1999 that the overall cost of HIV/AIDS in Canada was over two billion dollars. Health care was 560 million, prevention research and support, 40 million and lost economic production due to premature death or disability, nearly 1.5 billion. They also reported that since 1990, the average age at death due to AIDS had increased from 36 to 41 years.3
A research paper in 2003, based on data from southern Alberta, demonstrated that the cost of anti-viral drug treatment per patient per month had increased from $655 in 1995-96 to $1119 in 2000-01.4 Using these estimates of population numbers and costs, one could calculate that the cost of anti-viral drug therapy for HIV in Canada had risen to 806 million dollars per year by 2003. The use of triple anti-retroviral drug therapy has increased the life span and quality of life and also decreased in-hospital treatment costs. However, overall costs are still rising in Canada because this optimal therapy with three anti-viral drugs is 3.5 times more expensive than dual therapy including generic AZT. Lack of financial resources has created a dilemma for decision makers in third world countries who can afford to give therapy with only two drugs at the most; should they treat a smaller number of patients with dual therapy or a larger number with sub optimal therapy?5
A similar dilemma faces caregivers in Canada. The use of highly active anti-retroviral therapy (HAART) including protease inhibitors and more recently, non-nucleoside reverse transcriptase inhibitors has led to a substantial decline in mortality and morbidity of persons with HIV infection. HAART however, has resulted in an increase in cost per patient per month and an increase in the size of the infected population. If provincial health budgets are not to be exceeded, some other health care programs may have to be down sized or cancelled, or additional funds may have to be obtained from taxation or from the budget of other ministries. The value of any anticipated health care benefits would have to be judged to be greater than the value using the same resources elsewhere, e.g. roads or education. On the other hand, if other "new" health care programs compete for the same dollar, another moral problem is presented. How can one offer better treatment to some, while others with equally serious medical conditions would receive "old" less effective and less costly treatment? It is simply impossible to know, for example, if an increase of 10% in the budget for an anti-viral program will be as effective in terms of patient care outcomes, as a similar increase in the budget for cancer treatment.
Pedram Sendi and Amiram Gafni state that the Alberta study did not tell us whether the cost of HAART represented the efficient use of health care resources, or even if the current mix of services provided these patients was the most cost effective. They emphasize that the need for decisions about which services to provide should be based on opportunity cost considerations in order to insure that they will result in the maximization of the communitys health benefits generated from existing resources. Failing to do so they said, would be likely to result, yet again, in uncontrolled growth in expenditures without any demonstrated improvement in community health.6
The appalling reality of human suffering and death caused by HIV is plain for all to see. More obscure however, are its economic costs in the long run. Writing about the problems in South Africa, Bell et al state that the current estimates of macroeconomic costs of AIDS as 0.3 to 1.5% annually are much to low. These estimates are based on the assumption that increased mortality will relieve pressure on existing land and physical capital so that output per head is little affected. What is more plausible, these researchers say, is that AIDS not only kills people, but by killing mostly young adults, it weakens the mechanism through which knowledge and abilities are transmitted from one generation to the next. The children of AIDS victims will be left without one or both parents to love, raise and educate. It was predicted that in Africa, if nothing is done to combat the epidemic "a complete economic collapse will occur within three generations."7
This prediction is a sobering reminder that "ideas have consequences". The notion that one can act as if sexual promiscuity is morally acceptable is wrong. The notion that if a condom is used, sexual promiscuity is without hazard to health, is also wrong. One of the logical outcomes of these assumptions is our current HIV crisis. It is a given in medical care that prevention is better than a cure.
Despite the innumerable proclamations of health "authorities", there is no "safe" promiscuous sex. The condom has been shown, even if used consistently and correctly, (which often is not the case) to fail to prevent HIV transmission in 15% of cases.8 The disease is incurable and uniformly fatal. Would one fly on an airline if one out of every six of their planes crashed?
1 Hartmut B. Krentz et al, The changing direct cost of medical care for patients with HIV/AIDS, CMAJ, July 22, 2003; 169(2), pp.106-110. [Back]
2 John McCallum, Chief Economist, Royal Bank of Canada, The Globe and Mail, July 11, 1996. [Back]
3 2004 GPI Atlantic, webmaster@gpiatlantic.org. [Back]
5 Panita Pathipvanich et al., Journal of Acquired Immune Deficiency Syndromes, 02.01., 2003; Vol. 32: p. 15760. [Back]
6 Pedram Sendi and Amiram Gafni, The HAART side of resource allocation. Commentary. CMAJ. July 22, 2003; 169(2):120. [Back]
7 Clive Bell et al., The Long-Run Economic Costs of AIDS: Theory and Application to South Africa. Oct.6. 2003. World Bank Research. 2002. The World Bank Group. [Back]
8 National Institute of Allergy and Infectious Diseases, Work Shop Summary: Scientific Evidence of Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention. July 20, 2001. [Back]