What's the value of a life saved?

Many HIV/AIDS organizations brag about how many lives they've saved.  PEPFAR touts the 2.4 million Africans they've put on antiretroviral therapy (ART).  The Global Fund beats its chest to the tune of over 2.5 million people on AIDS treatment.  But what are these lives saved really worth?  It may be a question too crass for most to ask.  And if you're reading this post you've probably already made the mental leap of faith that a life saved will go on to positively contribute to their family, community, and society.  But where's the evidence?  No, not the health economic evidence of disability adjusted life years which assumes that a healthy life-year is a productive life-year.  Where's the evidence that shows how the people receiving health aid are spending their new lease on life?  To put it bluntly, what's the return on our investment in the health of people living with HIV/AIDS?

Many of us working on the ground in Africa worry that we're only helping people get healthy enough to realize that they're hopeless.  In much of Sub-Saharan Africa there is little opportunity for gainful employment.  The unemployment rate in many countries is over 50%.   And as HIV disproportionately affects people already living in poverty, treatment for HIV is far from a silver bullet for a better life.  Antiretrovirals (ARVs) may restore people's immune systems, but they do little for their livelihoods.  Yet people living with HIV do have valuable skills.  Skills that are in high demand in the developing world.  And increasingly, they are putting those skills to work.

Africa suffers from a severe shortage of trained health workers.  On average, there is just one doctor for every 20,000 people in Africa (in the U.S. the ratio is one doctor for every 400 people).  This dramatic shortage of trained professionals means that many Africans will go their entire lives without ever even seeing a doctor.  More trained professionals are sorely needed. But Africa isn't likely to remedy this shortage anytime soon.  According to WHO estimates, the current workforce in sub-Saharan Africa needs to be scaled up by as much as 140% to attain international health development targets.  Of course, these countries can't wait for a new generation of trained health care workers to emerge to address a health crisis already a generation old.  Nor should they.  Many of their health care needs don't require highly trained personnel. It does not take a doctor to draw blood, counsel HIV patients on ARV adherence, or follow up patients who fall out of care.  Many of these tasks, and others, are now being carried out by community health workers.  People who, depending on the task, only need a few days or a week of training.  In fact, across much of Africa, HIV care is increasingly being provided by community health workers.   And many of them are living with HIV themselves.

People living with HIV are arguably the most effective advocates for HIV awareness, education, and treatment adherence.  They provide a powerful testament for all of society to see that HIV is no longer a death sentence.  They help combat stigma. And they help others living with HIV adhere to treatment.  Here at AMPATH our outreach department is staffed entirely by people living with HIV.  In fact, our outreach program was founded by our very first patient.  What started as a humble operation to follow up patients who fail to attend clinic has grown to become the largest outreach program for HIV positive people in all of Sub-Saharan Africa.  A staff of 70 outreach workers (all HIV positive) manage patient follow up for over 100,000 people living with HIV.  Their work helps maintain the health of our patients and reduce the cost of treatment by mitigating the emergence of drug-resistant HIV.  ARV non-adherence is the single largest contributor to drug resistance.   And outreach workers understand this better than anyone as they themselves are taking ARVs daily.  Which is why they work tirelessly to make sure that no one slips through the cracks.  

Managing patient follow up is just one job that HIV positive people are undertaking.  A recent study showed that HIV-positive care workers can provide a wide range of HIV services.  With the assistance of a pre-programmed PDA, they can measure patient vital signs, review symptoms, and dispense patients' monthly supply of ART and medication for other infections.  This model not only reduces clinic visits - saving costs for both the patient and clinic - but it can help with early diagnosis of opportunistic infections.  A community based care model can also lead to improved support for psychosocial issues relating to HIV such as discrimination, abuse and food insecurity.  This type of task shifting is a radical departure from traditional models of health care delivery.  But it is now widely endorsed as an effective strategy to expand access to HIV care.  Indeed, people receiving care for HIV are proving to be remarkably powerful allies in our efforts to end the epidemic.

So what is the value of a life saved?  When it comes to HIV/AIDS, it seems that the value of one life saved is a whole lot more lives saved.  All across the continent people receiving treatment for HIV are paying it forward.  They are extending the help they were offered to hundreds or even thousands more.  Yes, not every HIV patient winds up working to improve the health of others living with HIV.  But a fair number do.  Enough that I think that mental leap of faith mentioned above is based on a good amount of evidence.  And as far as I can tell, our dollars for health aid are getting a much better return on investment than most of us realize.

Comments

[Chris Watkins]

ITYM "ARV non-adherence is the single largest contributor to drug resistance."

Thanks for a thoughtful and encouraging post.

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for me a value is for a long life.

[Jennifer Lentfer]

Indeed our dollars for health aid are getting a much better return on investment than most of us realize! Thanks for highlighting the strength and "non-measurable" aspects of the community care model.

An estimated 20,000 participants from more than 185 countries were assembled last week in Vienna for the XVIII International AIDS Conference. I wonder of those 20,000 experts, how many have actual “on-the-ground” expertise? A mapping exercise sponsored by UNICEF identified over 1,800 community-based organizations focused on orphans and vulnerable children in Malawi alone (NOVOC, 2005). Most were linked to local churches, schools, or clinics or were independent groups that assist children by extending support and services into areas that are not reached by government or international agencies. Clearly these are folks whose knowledge and expertise could be invaluable to the multi-billion dollar fight against HIV and AIDS.

You can read more at: http://www.how-matters.org/2010/07/21/the-real-experts/

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