From Death Sentence to Debt Sentence

• Author: Paul Collier, Richard Manning, and Olivier Sterck

From Death Sentence to Debt Sentence Finance & Development, December 2015, Vol. 52, No. 4

Paul Collier, Richard Manning, and Olivier Sterck

Now that AIDS is a controllable disease, countries and donors must focus on financing treatment and investing in prevention

TWENTY years ago, a diagnosis of AIDS meant certain death. Now, thanks to antiretroviral therapies, people living with the HIV virus in low-income countries can enjoy a near-normal life at a cost of a few hundred dollars a year. Initially, it was thought that these therapies might not be viable in Africa given the difficulty of adhering to the demanding routine of treatment (Stevens, Kaye, and Corrah, 2004). But these fears have proved groundless: millions of Africans are alive and healthy today thanks to such therapies.

Reflecting this perception that the medical battle against AIDS is now winnable, an Economist cover story marking the 30th anniversary of the disease was titled “The End of AIDS?” But as the end of AIDS as a medical disaster comes within reach, it has become a potential fiscal calamity. Vastly improved survival rates for people who are HIV positive mean that poor countries with high HIV prevalence face a major new fiscal liability (Haacker and Lule, 2011).

Moral dilemmaThe HIV virus gradually destroys white blood cells, essential to the operation of a person’s immune system. Without treatment, people whose CD4 count—a measure of these white blood cells—falls below 350 cells/cubic millimeter are likely to die within five years; with treatment they can live nearly normal lives. Despite the availability of generic and discounted drugs in poor countries, the cost of treatment is too high for sufferers who are poor—and too high for poor societies to bear on their behalf. But from the perspective of high-income countries this cost is trivial—a few hundred dollars to save a life. These features give rise to an obligation of rescue: identifiable HIV-positive people cannot be left to die when it is so readily in our power to prevent it. That is why past leaders, such as U.S. President George W. Bush and French President Jacques Chirac, who did not regard development aid as a high priority, nevertheless launched massive and dedicated funding for HIV/AIDS programs.

But the cost of financing antiretroviral treatment poses its own unique moral issues. Once treatment is started, it would be abhorrent to stop it because funds run out. Choosing to discontinue treatment is an “act of commission” that ends the lives of identifiable people rather than the “act of omission” of failing to start treatment. But expenditures on antiretroviral treatment are long lasting precisely because treatment enables normal life spans: currently young sufferers will have to be treated for decades.

Thanks to antiretroviral therapies and prevention, the number of people who are newly infected with HIV is declining in most parts of the world. Between 2001 and 2013, the number of new HIV infections declined by 38 percent, from 3.4 million to 2.1 million (UNAIDS, 2014). AIDS-related deaths have also fallen thanks to treatment, by 35 percent since 2005. However, since the number of new infections in many countries is still well above the number of deaths, the stock of HIV-positive citizens continues to increase, meaning that the costs are likely to escalate for many years. In addition, most of the people already infected with HIV are not yet on antiretroviral therapy, either because their CD4 count has not yet fallen to the point at which treatment is warranted or because they have not yet been diagnosed. So many more people will at some stage need treatment. And worse, many of the people receiving therapy—and those who will need it in the future—will eventually become resistant to the standard...