Ian Sanne

Hard choices: rationing antiretroviral therapy for HIV/AIDS in Africa

As the world intensifies its fight against the global AIDS epidemic, African countries have begun to develop large-scale prevention and treatment programmes. A combination of funds from African governments and international donors are paying for drugs, diagnostics, clinic and laboratory infrastructure, and medical personnel.

Time for savvy managers to shoulder intervention schemes

Employers are either holding off on treatment or implementing minimalist interventions, in the mistaken belief that they are saving money. In so doing, they throw away yet another year of cost savings and can even render their entire initiative financially unviable. The economic argument for treatment is simple: sick employees cost the employer money, and treatment costs less. If you allow an employee to traverse most of the disease cycle and only initiate treatment in the employee's last six months of life, then you have carried the cost of illness plus the price of treatment. Research has shown that most current HIV/AIDS interventions cannot possibly be financially viable for the company. What these employers fail to realise is that these people identify themselves so late that every rand the company pays is a rand lost, and the company has done absolutely nothing to curtail the impact of HIV on the business. The second problem is more subtle. Some companies truly do intend to manage HIV-positive employees, but audits of patients across several treating companies have shown that most are in an advanced stage of the disease. From an employer's perspective, early treatment is the only financially attractive solution, and the key lies in identifying patients early. This in turn means the employer must drive an education and awareness programme and not leave it up to the paying party. To achieve this, new educational messages are required, to explain the merit of early identification and push the proportion of testing up to the 98 percent, which has been experienced with pregnant mothers. One such message would be to show employees that if they are diagnosed as HIV positive too late, their kids will be orphaned while in primary school, while if they are diagnosed early, they have every chance of seeing their kids through to matriculation and later. The second issue is the timing of the intervention. Most companies feel that since death rates are not yet very high, they can afford to wait. But clearly death rates are an even worse indicator than illness. It is very easy to get started straight away and to ensure that the employer is not locked into anything that cannot be changed in future. First, programmes should be managed by people who are completely independent of the party footing the bill. Second, this management should be outsourced to ensure employee confidentiality. Finally, the right kind of funding model, of the type offered by independent risk management brokers, puts the company in the position of being the financing party. This model allows the employer to recoup costs from a medical aid, yet simultaneously manage uninsured employees within exactly the same programme. (Source: Ian Sanne, Chris Barker & Alizanne Cheetham: Business Report, 20 April 2003) Dr Ian Sanne, the head of Wits Health Consortium's Infectious Diseases unit, has been treating indigent adults for over seven years. Chris Barker is managing partner at FutureForesight, a consulting firm on HIV.