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I moderated a debate this morning, one in a series on HIV/AIDS issues sponsored by the World Bank and USAID. This was the topic: “Countries should spend a majority of what is likely to be a flat or even declining HIV prevention budget on ‘treatment as prevention.’” The pro and con sides were each represented by two eminent and articulate medical doctor/scientist/researcher/public health experts. On the pro side were Wafaa El-Sadr and Sten Vermund, and on the con side Stefano Bertozzi and Myron (Mike) Cohen. (They were assigned sides.) You can see the debate itself here.

I had these reactions:

The HIV/AIDS international subculture is big and impressive.

They enjoy for the moment a kind of dream world in which they are able to debate optimal use of a pie (public money to deal with AIDS prevention and treatment) which they assume is fixed or increasing.

It’s hard for an economist to buy into that world (as it is for doctors to conceive that it doesn’t exist).

The debate about allocation of this (apparently fixed) HIV/AIDS pie between prevention and treatment (see Mead Over’s new CGD book here – the book launch is next week) is newly raging because of new evidence from a randomized controlled trial: much earlier use of anti-AIDS drugs (“treatment”) is in a biological sense hugely effective in preventing transmission of HIV infected people to their partners. In her speech on HIV/AIDS this week, Hillary Clinton was upbeat about the new promise of this new evidence (for a comment on the speech go here), bringing new hope to the medical community and AIDS advocates that the world is now at the beginning of the end of the pandemic.

That takes me back to the pie. What about the pie? Even if it grows, there will be tradeoffs… No one mentioned discount rates (lives lost now vs. more lives saved later…); tradeoffs are still a taboo in AIDS-world if not in AIDS-policy world. No one mentioned other lower-cost (right now) ways to make life better for more people-- reduce malarial deaths, combat sex trafficking, educate more girls.

I came away with a question, perhaps for social psychologists. What is the effect of big dreams (let’s go to the moon/we can eliminate AIDS altogether) on the psychology of policymakers and legislators? Does shooting for the moon generate ADDITIONAL money for the moon shot, eliminating tradeoffs? Could this new exciting evidence mean the AIDS pie, which has stopped growing in the last couple of years, will now grow again?