"President Clinton should lay the foundation for ending the HIV/AIDS crisis by 2030," says Jeffrey Sachs, expert on global economic development and provocateur. "Tell her to knock down drug prices in the U.S. ... raise a miniscule US$10 billion a year needed to double the global number of people on treatment ... and support a systemized cadre of community health workers."
These were his instructions on how to reach the UNAIDS 90-90-90 targets. The intimate audience of high-level influencers at the annual IAPAC meeting, Controlling the HIV Epidemic with Antiretrovirals, responded with emphatic applause. Except, of course, the one Gilead pharmaceutical representative at the back of the room.
Sachs puts forth compelling arguments. His economic take on how to finally put AIDS to rest seems sensible enough and straightforward. But how to apply his broad-stoke remedy to real life and the diversity of micro-epidemics is a lot less clear. Below is a more granular description of his approach along with its challenges.
Money: Ending AIDS Is Merely a Rounding Error
Last time I saw Jeffrey Sachs speak was in Durban, South Africa, in 2000, where he argued the case for what turned out to be the Global Fund. He was not yet director of the Earth Institute at Columbia University, but he was perhaps trying to soften his image. (His leadership role imposing shock privatization policies in several European countries in the post-Soviet era wrought brutal consequences and were still fresh in the mind of the public.) The younger Sachs had said 16 years ago, "AIDS control is hampered by a shocking extent of underfunding and the lack of scientific scrutiny in donor funded-projects." He went on to call for a UNAIDS global fund of some US$4 billion per year.
It was the first time I heard the "billion" dollar figure as a necessary AIDS response. I remember thinking that's a lot. A lot of money. But the fact was that by 2001 there were 20 million cases of HIV globally and, according to Sachs, not one person on the African continent was on donor-supported ARV treatment.
The next decade of North-South activism brought about bilateral and multilateral commitments from high-income countries. Donors began to substantially fund antiretroviral treatment (ART) in 2002 and 2003. Today there are 17 million people on ART worldwide and unrivaled scientific breakthroughs in prevention. As a result, according to Sachs, HIV is currently in the control phase, heading toward its end. (Sachs categorizes the epidemic into four phases -- the first two are silence and awareness, and the final one would be "end of epidemic".)
This month, in the IAPAC meeting room in Geneva there was serious talk of how to end HIV/AIDS as a public health crisis by 2030. However, Sachs is still calling current spending on the AIDS response a sub-therapeutic dose -- in 2015, US$19 billion was invested in low- and middle-income countries. He appeals for an additional US$10 billion per year for the Global Fund and PEPFAR. This is a mere rounding error, Sachs says, when you look at the world's combined high-income economies hovering at around US$50 trillion per year. He points out that an extra US$10 billion for AIDS equals 0.02 percent of annual income of these countries. Underscoring this embarrassment of riches, Sachs quotes the US$2.5 billion the U.S. military spends per day.
Reuben Granich, of IAPAC, and midwife to the model of ending the AIDS crisis through treating all, pokes fun at Sachs' appropriations panacea. He points out that funding has been flat-lined since 2010. "We cannot just print money ... we need efficiencies."
In addition to flat-lined spending, the Global Fund's pivot out of middle-income countries may also thwart Sachs' solution. Médecins Sans Frontières' Sharonann Lynch predicts that a number of countries won't meet the 90-90-90 targets. She specifically cites countries in Eastern Europe and Central Asia. Even before losing Global Fund support, nations in these regions are struggling to meet expectations that they pay for 60 percent of ARVs and diagnostics, and 50 percent of second-line TB drugs.
Drug Prices: Money Spent on Inflated Drug Costs Should Be Reinvested Elsewhere in the AIDS Response
The next ingredient for Sachs' elixir is the fixing of high drug prices in the U.S. and some other countries. Treatment programs in most highly resourced nations show a reasonably strong rate of linking people to care once someone is diagnosed with HIV. Not the case in the U.S.: only 40 percent of those who test HIV-positive are linked to care in the richest economy in the world -- that's lower than the global average of 46 percent.
"U.S. funding goes to drug companies," says Sachs, instead of domestic health spending. He points out that ARVs currently cost US$20,000 per year in the U.S. (compared to about US$235 for the Global Fund). Drug costs are almost half of the annual US$45,000 total price tag per person in the U.S.; this excess cumulatively adds up to US$33 billion per year. Sachs suggests this money would be better spent funding the country's feeble public health system to bring more people into treatment and care. But Sachs fingers the U.S. political system as a major obstacle, "Drug companies own the Congress and price-gouging is killing Americans."
Sachs continues on a rant, raking Gilead in a way one rarely sees at such genial gatherings: "Gilead is pure greed and disgusting," he continues in his Midwestern twang. "It charges US$1,000 for a pill that takes one dollar to make, totaling US$84,000 for a treatment dose." He's referring to the hepatitis C drug, Sovaldi. Then he goes on to say that Gilead's blockbuster drug tenofovir was not even invented by the pharma giant. (Indeed, it was synthesized by an institute of the Czech Republic.) And furthermore, Sachs fumes, the company escapes paying billions in taxes by transferring assets to Ireland.
Labor: A Systemized, Funded Cadre of Community Health Workers as the Backbone of Services
The final addition to Sachs' trifecta for ending HIV/AIDS crisis by 2030 is the deployment of community health workers (CHWs) in all countries to expand and deepen the response. These are community members who provide support, bringing medications and connection to services for hard-to-reach people. They can be members of key populations who receive proper training and are supervised by a clinic. Sachs' calculations show such a corps of CHWs could be implemented at around US$1,000 salary for each worker per year.
Most in the room agree that CHWs are an indispensable part of the answer. Mark Heywood, long-time activist and co-founder of South Africa's Treatment Action Campaign, now director of human rights group Section 27, says no 90-90-90 targets will be reached without robust and funded plans for human resources. However, he challenges Sachs' US$1,000 salary: "It's hypocritical to ask them to play such a critical role for next to nothing." Heywood makes the case that spending US$1 million on CHWs would save US$21.7 billion over time by averting new transmissions and attendant care and treatment costs.
While Sachs is still indeed a provocative speaker, only time will tell if his rhetoric becomes reality. In the meantime, every week 37,000 people are newly infected with HIV and 21,000 more die from AIDS.