How Would You Spend an Additional $10 Billion on AIDS in Africa Over the Next Five Years?

This is the question which the Rush Foundation has asked the Copenhagen Consensus Centre to address by deploying their buzz-producing approach of:(1) commissioning “Assessment Papers” on competing ways to spend a hypothetical additional $10 billion on HIV/AIDS in Africa over five years;(2) commissioning “Perspective Papers” by discussants who critique the Assessment Papers and suggest alternatives;(3) commissioning a “Nobel Laureate Expert Panel” to judge the competitors and rank the alternatives from most to least advantageous for the developing world populations they are intended to help.Together with Geoff Garnett, formally of Imperial College, London and now at the Bill & Melinda Gates Foundation, I am the author of one of the six competing assessment papers in this competitive endeavor.  On Monday and Tuesday Bjorn Lomberg, Director of the Copenhagen Consensus Centre, and Marina Galanti, co-founder of the Rush Foundation will be chairing sessions at which the Nobel Laureate Expert Panel will hear all six of the authorial teams argue our analyses of our respective assigned interventions.The six competing interventions are;

1. Prevention of sexual infections
2. Prevention of non-sexual transmission
3. Vaccine research
4. Social policy
5. Health systems strengthening
6. AIDS treatment

Geof Garnett and I are the authors of the Assessment Paper on AIDS treatment.  I am honored to be included with such a distinguished set of authors, whose names you can find on the project the RethinkHIV website.  The papers should be posted in draft form on Monday.The rules of the exercise have been:

1. Compute the benefit-cost ratio of spending $10 billion over five years on our assigned intervention in sub-Saharan Africa
2. Show the sensitivity of the benefit-cost ratio to two alternative values of a life-year, $1,000 and $5,000, and two alternative discount rates, 3% and 5%.
3. Compare the increased $10 billion of spending to a plausible counterfactual, which might be a continuation of the current trend in program expansion.
4. Use the $10 billion five-year budget to select a trajectory for policy for coming decades from among the trajectories that would cost $10 billion in the first five years, and then evaluate the benefit-cost ratio of that trajectory.  (For a very long-period event, like the HIV epidemic or a climate intervention, it would be nonsensical to restrict a benefit-cost analysis to the benefits that occur within five years.  Most of the benefits of today’s AIDS treatment or HIV prevention will be reaped more than five years from now.)

Though I have given countless presentations in my life, I am somewhat intimidated about this one.  I’m used to the prospect that a discussant can sometimes ask pointed and challenging questions, but never since my thesis defense (an embarrassingly long time ago) have I been in the position of being grilled by a panel, and this panel consists of extremely distinguished members of my own discipline.My discomfiture is partly that neither Geoff nor I, if we had to choose how to spend an additional $10 billion on AIDS in Africa, would spend every penny of it on AIDS treatment.  And we are pretty sure that the other five authorial teams would feel the same way about their interventions.  The stated goal of the Rush Foundation is to ”fund disruptive ideas in the fight against HIV in sub-Saharan Africa”.  Currently the most disruptive idea is “combination prevention,” an approach to combatting HIV/AIDS that combines in creative ways AIDS treatment, various medical and behavioral HIV prevention ideas and social policy in an attempt to benefit from synergy among them and create a winning mix.  (See the information here, here, here and here.)   By constraining the authors of the Assessment Papers to analyze interventions in isolation from one another, we may have been constrained from offering the most “disruptive” or beneficial ideas.In defense of the Copenhagen Consensus approach, we are asked to analyze our interventions in a context where all the things currently funded continue to be scaled up at plausible current rates of expansion.  So when Geoff and I estimate a benefit-cost ratio for AIDS treatment, the rules permit us to suppose that the incremental $10 billion on treatment will be in addition to the trend levels of behavioral prevention and vaccine research, etc...   Furthermore, while the Assessment Paper authors were constrained, the Perspective Paper authors could propose more disruptive approaches, including combination prevention.  And of course the overarching panel of experts is free to be as creative and disruptive as they wish.Watch this space for a report from inside the closed meetings.  In the meantime, please feel free to offer your own assessment.  How would you spend an additional $10 billion over five years on AIDS in sub-Saharan Africa?