HIV prevention efforts have curbed the US AIDS epidemic

November 22, 2002

If not for HIV prevention efforts, it is likely that the number of additional individuals infected with HIV in the United States would be equivalent to the population of a moderate-sized to large city, according to research conducted by David Holtgrave, PhD, from Emory University's Center for AIDS Research.

The research, published in the Nov. 22, 2002 edition of AIDS: The Official Journal of the International AIDS Society, is significant because it begins to answer two of the most frequently asked questions related to the AIDS epidemic in the United States: (1) roughly how many individual lives may have been saved because of our nation's investment in HIV prevention since the onset of the epidemic and (2) have these HIV prevention efforts ultimately resulted in cost-savings to society?

"It is impossible to count exactly how many HIV infections would have occurred if efforts to prevent the spread of the virus had never been put in place," said Dr. Holtgrave, professor of behavioral science and health education in the Rollins School of Public Health. "However, we can do the next best thing and explore through statistical modeling the course the U.S.. epidemic might have followed without HIV prevention programs."

To accomplish this, Dr. Holtgrave began by charting the HIV incidence patterns (or yearly patterns of new HIV cases) in order to highlight the incidence curve (or the point at which new HIV cases begin to level off). To gauge the effectiveness of HIV prevention, one would have to compare the HIV incidence curve, as experienced, with the HIV incidence curve that would have occurred had there been no HIV prevention activities. The area between these two curves would then represent the number of HIV infections prevented. The challenge researchers have had in developing even general estimates of effectiveness of HIV prevention efforts is that no one can say for certain how high the U.S. incidence curve would have gotten without HIV prevention efforts, before naturally decreasing and eventually leveling off..

Dr. Holtgrave's research utilized scenario analysis to estimate where the incidence curve could have leveled off under a wide range of plausible possibilities, and then assessed (a) the order of magnitude of the number of HIV infections prevented in the U.S. from 1978 to 2000; and (b) whether national HIV prevention efforts could generally be considered cost-effective.

Under four conservative scenarios regarding the course the AIDS epidemic might have taken had there been no prevention efforts in place, it is estimated that our nation's investment in HIV prevention has averted at least 204,000 and as many as 1.585 million HIV infections (see attachment below for specific details). If the actual number of infections prevented were 204,000 (the bottom of the range), it is estimated that the cost per infection prevented would be a little under $50,000, which is less than the lifetime medical cost of treating an individual with AIDS (approximately $154,000 to $195,000 currently; and approximately $56,000 before advanced HIV/AIDS treatment regimens).

If the actual number of infections prevented were closer to the top of the range, at 1,585,000, then it is estimated that the cost per infection prevented would be around $6,400, which is only a small fraction of the cost of treating an individual with AIDS. "Either way," said Dr. Holtgrave, "although limited by multiple sources of uncertainty, the findings indicate a strong likelihood that HIV prevention efforts to date in the United States have literally saved hundreds of thousands of Americans, and have resulted in significant cost savings to society."

"Another way of stating these results," he added, " is that each of the 204,000 to 1.5 million HIV infections that were prevented saved society $56,000 to $195,000 in averted medical costs -- or a total of at least $11 billion saved. These analyses do not include other real benefits of prevented HIV infections such as increased worker productivity and decreased pain and suffering."
Background Information: Scenario and cost-effectiveness analyses were used to estimate the effectiveness and efficiency of HIV prevention activities in the United States from 1978 until 2000. Under four conservative scenarios on the course the AIDS epidemic might have taken had there been no prevention efforts, the findings estimate that prevention activities averted between 204,000 and 1,585,000 HIV infections at a cost of between $49,700.00 and $6,400.00 per infection prevented.

Description of HIV Prevention Budget:

Up to and including fiscal year 2000, the federal Centers for Disease Control and Prevention (CDC) had a budget for HIV prevention of approximately $7.2 billion (summed over all years as raw dollar figures). However, this is not the entire national contribution to HIV prevention; other federal, state and private contributions must be added. We estimated that an additional 8.1% was spent on other federal programs, another 27% on state-funded efforts, and a further 5.6% from private sources. (There is uncertainty as these additional percentages were based on limited data available for a short time period and extrapolated across the time frame of the epidemic; further, since these figures are budgetary, the true costs of the programs may have been more or less than budgeted.) Including all of these sources of funding, the estimated expenditure on HIV prevention programs in the United States through fiscal year 2000 is $10.1 billion.

Emory University Health Sciences Center

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