UNIDENTIFIED MAN: The plenary session began with a cost-benefit analysis of AIDS treatment provided by Dr. Michael Saag of the University of Alabama.

DR. MICHAEL SAAG: How does what we do, treatment of patients, make a difference? We have a lot of data now, at least in the United States and in Europe that shows that treatment is associated with improved outcome dramatically, especially in terms of survival.

Well, what about the cost of therapy? What I’m going to share with you today for the first time is a cost analysis based on actual utilization in a clinic setting, and again, going back to our patient base in Birmingham, what we were able to do as a cost outcomes analysis over the course of several years. But as you can see here when you break it down by CD4 count category, there is about $34,000 per year for those with advanced disease compared to around $14,000 or $13,000, $14,000 per year for those with CD4 counts greater than 350 and gradations in between. This is really striking in terms of showing a direct cost benefit of keeping patients healthy. And again, remember that the less than 50 group do not include those who died within the year.

So, in conclusion, the cost of care in the United States is directly related to stage of disease, and I would argue around the world that’s going to be the case as well. Medication is the prime cost driver, not ART costs and hospitalization cost increase with advanced disease. Disease improvement is associated with significant decrease in cost. Clinic reimbursements are insufficient to sustain operations at any clinic. And you’re seeing private practice physicians in the United States not able to continue their practices anymore because of that and, in essence, government support in the United States and, I would argue, around the world, is essential. Because we are having our care, cost of care subsidized by Ryan White (MS?) programs and other government programs, and we would not be able to keep our doors open were it not for that. So, as we think about putting care into resource-poor countries, we should keep in mind that the infrastructure investment has to be there.

UNIDENTIFIED MAN: Dr. Anthony Fauci of the National Institutes of Health gave a very technical lecture about how lethal HIV is and presented further evidence showing that HIV infection is intrinsically incurable with current medications.

[Inaudible and cross-talking].

DR. ANTHONY FAUCI: --even in a viremic patient, the reservoir persists. And the point that I wanted to make is that that should not be what I would call a serious excuse not to treat people because when you do bring the level of virus down, people may lead healthier lives and longer lives. But on the other hand, since you cannot eradicate the virus, that gives you even more reason to push for prevention together with treatment. The fact that you cannot eradicate the virus is important to underscore the importance of prevention, so resources must be put in prevention. But I also say that that should not be used as an excuse not to treat people. You cannot abandon tens and tens of millions of people when you could possibly get therapy for them because we know in the developed world that the impact of treatment, though not perfect, is very favorable in the sense of healthier and longer lives. And that’s the reason why I say you’ve got to use those two words in the same sentence. I know it’s stressing on resources, but I think the issue should be to get the resources as opposed to abandoning HIV infected individuals.

You see as the years go by that in addition to some of the immediate toxicities, there are long-range cumulative toxicities such as some of the metabolic abnormalities that lead to potential cardiovascular negative affects. I think that’s a very good argument for the continued investment of the development of new drugs against new targets like we’ve heard at this meeting, the fusion inhibitors and the blockers are binding to cells, it integrates inhibitors, as well as less toxic versions of drugs that are directed against targets that we already have drugs against, like the protease enzyme and the reverse (MS?). It’s a very good point. It’s extremely relevant to the whole strategy and philosophy of long-term treatment. So, although we have many good drugs, as Michael Sag has shown us today in his discussion about the State of the Art, there still is a lot to be done to get drugs that are less toxic, more user friendly, and even more capable of blocking HIV replication.

UNIDENTIFIED MAN: I’m really sorry not to be able to be with you today. However, when we lost (MS?) we had hope and we had arguments about HIV treatment. Today, we have facts. In (MS?) outside Cape Town, Medicines on Frontier (MS?), Doctors without Borders (MS?) have illustrated that people with HIV and AIDS, the majority with long existent or severely damaged immune systems, would recover life, health and dignity with antiretroviral therapy.

Research commissioned by the Department of Health indicates that in the year 2000, an estimated 628,000 admissions to public hospitals were for AIDs-related illnesses, which amounts to 24 percent of all public hospital admissions. The model indicates very clearly that as more people who were already HIV positive become sick every year, this demand for hospitalization will increase steadily every year in the absence of significant alternative interventions. We would like to ask what are these interventions? To us, this is not only a matter of cost to the state and some (MS?), but the lives of mothers, the lives of women, the lives of children, the lives of men, all of us in productive years, many of us not yet having reached the prime of our lives.

Central to all our work of HIV prevention and treatment are the issues of life, dignity and access to health care. HIV prevention and treatment cannot be separated. If in fact all HIV and AIDS of already-infected people under public healthcare system, the healthcare system itself, will buckle under the burden of disease. And therefore, not to treat HIV effectively will destroy the already weakened healthcare systems in poor countries. And therefore, just from a purely public healthcare perspective, it is shortsighted to say that only we should focus on prevention and exclude treatment. On the other hand, it is unconscionable because what we are speaking of are cold statistics and not our lives. Our lives matter. The five million people in South Africa with HIV matter and the millions of people throughout the world already infected with HIV, their lives matter.

And so, it is not simply a question of the cold statistics that we’re putting to you, but a question of valuing every person’s life equally. Just because we are poor, just because we are Black, just because we live in environments and continents that are far from you, does not mean that our lives should be valued any less. It is critical that every treatment activist also becomes a prevention activist. Active prevention of mother-to-child transmission, assisting rape survivors, all these issues, and above all the use of condoms, condoms, condoms by everyone who is positive, making clear that people with HIV should use condoms, such a prevention message is critical to all our treatment efforts, and therefore, the dichotomy between prevention and treatment is one that this conference should lay to rest immediately and we need to stop the counterproductive debate.