If Ontario had done nothing to curb new infections since the start of the epidemic what would be the result? And how have community-based interventions, ART, public health and other factors influenced the business of avoiding new infections also? How much money have these averted new infections saved in costs to the provincial health-care system?
These were just some of the questions answered by long-awaited research just released by the Ontario HIV Treatment Network (OHTN).
This is interesting stuff, not least in understanding how we try to measure new infections that never happened or costs that were not incurred. But there are in fact ways to attempt to do so.
The methodology is a little complicated but I’ll try to simplify it. In a nutshell, the researchers used models to compare new infection rates pre-community based funding versus post community-based funding. They then attributed some, but not all of the reduction in new infections to the positive influence of having community based programs in effect, (The other two factors for which generous allowance was made were public health interventions and the impact of treatment in reducing transmission risk.) Each averted new infection was costed - US research indicates the costs range from $253,000 to $402,000 USD per individual over a lifetime. Compare the cost of providing community based services over the 14-year period to the cost that might be attributable to averted new infections, if they had in fact occurred, and the effectiveness of community based services in reducing costs to the health care system can be estimated.
Anybody else using this methodology? Yes – both the methods and the findings are comparable to similar studies conducted in the Unites States.
Still with me? On to the good stuff.
From 1987 to 2011, community-based HIV prevention programs prevented 16,672 infections and saved the health care system $6.5 billion.
Tax payers saved $5 for every dollar invested in community-based prevention programs in Ontario.
The authors point out that the research has limitations – the number of new infections averted, for example, can never be established accurately and thus must be estimated. As well there is the basic assumption that organizations like AIDS Service Organizations do in fact make a difference to the rate of new infections in Ontario . That being said, there is much research to indicate the effectiveness in reducing infections of many of the prevention and other programs they offer, and that is detailed in the report.
I spoke with Sean Rourke, the Scientific and Executive Director of the OHTN to help me understand some key features of the report. I was interested in particular in the impact of community-based, publicly funded programs versus other efforts which have the capacity to influence the course of the epidemic. Rourke commented “We can’t just look at the impact of front line services but instead need to contextualize that response with what is happening in public health and treatment take-up. There are figures in the paper which show the percentage of savings attributable to those three major contributors. Obviously combination therapy had a major influence when it became available." (The paper conservatively estimates this as responsible for 75% of averted new infections, with a small percentage attributed to public health and the remainder to community-based programming.)
What about other emerging social factors influencing infection rates – the role newspaper and internet coverage may have, what people say to each other, and non-government funded sites like PositiveLite.com or overseas (but widely read in Canada) knowledge providers like aidsmap.com from the UK, for example? Don’t they arguably contribute to averted new infections also, I asked? And isn’t the influence of community-based prevention programs in rural areas like my own quite muted?
Rourke understood the concern. "The aim is to identify regional variations or contributions of other programs is the next later of analysis that needs to be done, particularly to find out what combination of things make sense for the future” he said. “This study was looking at broad brush investment overall but we can really start to tease out, for example; what the (Ontario) AIDS Bureau and others contributed in a particular year and compare it to what infection rates were occurring.”
Rourke added “it’s important too to understand that the costs savings identified were just those related to health care and not elements such as employment and tax contribution.”
Is there a conflict of interest inherent the report, in that the signatories, or some of them, benefit from the funding that is being justified here, I asked? Rourle pointed out ‘the analysis was done independent of the policy makers that contributed to the data. There certainly is room for voicing open concerns as to people having a vested interest in seeing positive results but we didn’t experience that - data was provided without any difficulty, data that is available through free access, independently analyzed and we believe the article and the way the findings are framed is fair and balanced. The peer review process too helps to ensure we don’t overstate the findings.”
The OHTN has always been big on research with real impact so I asked Rourke what he sees as the value of a report like this, particularly in pre-election Canada. “This is further evidence that the investment in front line services works in the context of working with public health and access to combination therapy. We need to make sure those investments continue” he said. “I think this data provides good evidence that progress is being made, that we are using resources in a very good way. We need to make sure they continue. These are public health dollars, so for sure politicians and government decision makers need to be aware of those investments, that they have made commitments for them and those commitments are working and that we have good evidence that they save money and they save lives."
To be honest, research like this where the human element is underplayed – the lengthy paper makes only one reference to the human impact of HIV infection and scores of references to its financial impact on the economy – can be a bit jarring. This is a decidedly non-people-living-with-HIV-centric view of the world you will find. The paper in fact describes itself as coming from the “payer perspective.” So the poz reader must bite the bullet and recognize, if they will, that research with this focus is needed to justify significant public investment in HIV programming, or it will not happen. Thus research like this will inevitably reflect the dollars and cents impact of HIV rather than the human one.
But what an interesting paper and an important resource! Well done OHTN for producing something so potentially useful, thought-provoking and – yes – with real life impact.