Correspondence
3
4
5
Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet 2009; 373: 48–57. Amornkul PN, Karita E, Kamali A, et al. Disease progression by infecting HIV-1 subtype in a seroconverter cohort in sub-Saharan Africa. AIDS 2013; published online Oct 9. DOI:10.1097/QAD.0000000000000012. Karita E, Ketter N, Price MA, et al. CLSI-derived hematology and biochemistry reference intervals for healthy adults in Eastern and Southern Africa. PLoS One 2009; 4: e4401.
Authors’ reply Mary Bassett and Karen Brudney expand the discussion on important challenges created by the promulgation of WHO’s 2013 guidelines for the initiation of highly active antiretroviral therapy (HAART), 1 which were mentioned in our Comment.2 They raise concerns about the scalability of expanded treatment, noting the operational and resource challenges that higher CD4 thresholds for the initiation of treatment create. Healthcare inequities might increase because guidelines recommend that more people initiate treatment, since those who are least advantaged might be last in the queue, but this does not diminish the moral and public health imperative to test more people, so that they are aware of their HIV serostatus, and to offer more newly diagnosed individuals access to treatment. Their last point is to question whether there is benefit to the earlier initiation of treatment, and to suggest that “the WHO has been dazzled by a medical model of unproven benefit”. People might disagree about the interpretation of the findings from recent studies, but the NA-ACCORD consortium found that individuals who initiated treatment at CD4 counts between 350 and 500 cells per μL were less likely to have HIV-related sequelae;3 HPTN 052 investigators found that HIV transmission decreased by 96% among the HIV-infected partners who initiated treatment when their CD4 counts were between 350 and 550 cells per μL;4 and the African Center study found reductions in HIV incidence with higher rates of ART coverage at population www.thelancet.com Vol 382 November 30, 2013
levels in KwaZulu-Natal,5 so it seems polemical to imply that there are no data. The history of treatment rollout of HAART in low-income countries demonstrates that operational and resource limitations can be overcome. Patricia Fast and colleagues document rapid rates of CD4 decline in newly diagnosed African patients, suggesting that whatever CD4 threshold is selected for the initiation of treatment, it will soon be reached once individuals are diagnosed. The challenges to the optimal implementation of WHO’s new guidelines are not the threshold they have selected for the initiation of therapy, but the reality that too many new HIV diagnoses are made when patients present with advanced disease. People who are diagnosed with HIV who are not offered treatment might be less likely to engage in care, more likely to be lost to follow-up, and presenting later with more advanced HIV disease. Emerging data suggest that more people on treatment will benefit all in terms of decreased disease burden and new transmissions. KM has received unrestricted research and educational grants from Gilead and Bristol-Myers Squibb. CB declares that he has no conflicts of interest.
*Kenneth Mayer, Chris Beyrer [email protected] Fenway Health, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA (KM); and Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (CB) 1
2
3
4
5
WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a public health approach. June, 2013. Geneva: World health Organization, 2013. http://www.who. int/hiv/pub/guidelines/arv2013/download/en/ index.html (accessed Nov 4, 2013). Mayer K, Beyrer C. WHO’s new HIV guidelines: opportunities and challenges. Lancet 2013; 382: 287–88. Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med 2009; 360: 1815–26. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 Infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493–505. Tanser F, Bärnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZuluNatal, South Africa. Science 2013; 339: 966–71.
Singapore’s health-care financing We read with interest Lincoln Chen and Kai Hong Phua’s review of William Haseltine’s book Affordable Excellence: The Singapore Healthcare Story (Sept 14, p 930).1 However, we think that Singapore’s successful healthcare cost control deserves some more comments. First, as presented in the table, the so-called 3Ms (Medisave, Medishield, and Medifund) finance less than 10% of the total national health-care expenditure. 2 Second, Singapore’s health system uses copayments. This promotes individual responsibility, but, because there are no limits on copayments, many Singaporeans are worried about catastrophic expenditures, despite the existence of a safety net (Medifund) for the poorest individuals. Moreover, the market-driven efficiency, enthusiastically applauded by some, threatens the doctor–patient relationship because of the rationing of clinical care to manage costs. The government has historically not provided step-down and long-term care (ie, community hospitals, nursing homes, home care services), leaving charities to provide these services with variable results. Hospitals often have difficulties discharging patients to convalescent beds. Public hospitals even hire debt collectors to recover patients’ unpaid bills.3 Finally, Chen and Phua only hint at what really works in Singapore’s health care: a strong government commitment to primary care, in 2011
2002–2011 average
31·0%
28·6%
Medifund
0·7%
0·6%
Medisave
5·5%
5·5%
Medishield
2·1%
1·6%
Medifund + Medisave + Medishield
8·3%
7·7%
Government outlay
Data are % of national health-care expenditure.2
Table: Health-care financing in Singapore
1779
3
4
5
Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet 2009; 373: 48–57. Amornkul PN, Karita E, Kamali A, et al. Disease progression by infecting HIV-1 subtype in a seroconverter cohort in sub-Saharan Africa. AIDS 2013; published online Oct 9. DOI:10.1097/QAD.0000000000000012. Karita E, Ketter N, Price MA, et al. CLSI-derived hematology and biochemistry reference intervals for healthy adults in Eastern and Southern Africa. PLoS One 2009; 4: e4401.
Authors’ reply Mary Bassett and Karen Brudney expand the discussion on important challenges created by the promulgation of WHO’s 2013 guidelines for the initiation of highly active antiretroviral therapy (HAART), 1 which were mentioned in our Comment.2 They raise concerns about the scalability of expanded treatment, noting the operational and resource challenges that higher CD4 thresholds for the initiation of treatment create. Healthcare inequities might increase because guidelines recommend that more people initiate treatment, since those who are least advantaged might be last in the queue, but this does not diminish the moral and public health imperative to test more people, so that they are aware of their HIV serostatus, and to offer more newly diagnosed individuals access to treatment. Their last point is to question whether there is benefit to the earlier initiation of treatment, and to suggest that “the WHO has been dazzled by a medical model of unproven benefit”. People might disagree about the interpretation of the findings from recent studies, but the NA-ACCORD consortium found that individuals who initiated treatment at CD4 counts between 350 and 500 cells per μL were less likely to have HIV-related sequelae;3 HPTN 052 investigators found that HIV transmission decreased by 96% among the HIV-infected partners who initiated treatment when their CD4 counts were between 350 and 550 cells per μL;4 and the African Center study found reductions in HIV incidence with higher rates of ART coverage at population www.thelancet.com Vol 382 November 30, 2013
levels in KwaZulu-Natal,5 so it seems polemical to imply that there are no data. The history of treatment rollout of HAART in low-income countries demonstrates that operational and resource limitations can be overcome. Patricia Fast and colleagues document rapid rates of CD4 decline in newly diagnosed African patients, suggesting that whatever CD4 threshold is selected for the initiation of treatment, it will soon be reached once individuals are diagnosed. The challenges to the optimal implementation of WHO’s new guidelines are not the threshold they have selected for the initiation of therapy, but the reality that too many new HIV diagnoses are made when patients present with advanced disease. People who are diagnosed with HIV who are not offered treatment might be less likely to engage in care, more likely to be lost to follow-up, and presenting later with more advanced HIV disease. Emerging data suggest that more people on treatment will benefit all in terms of decreased disease burden and new transmissions. KM has received unrestricted research and educational grants from Gilead and Bristol-Myers Squibb. CB declares that he has no conflicts of interest.
*Kenneth Mayer, Chris Beyrer [email protected] Fenway Health, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA (KM); and Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (CB) 1
2
3
4
5
WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a public health approach. June, 2013. Geneva: World health Organization, 2013. http://www.who. int/hiv/pub/guidelines/arv2013/download/en/ index.html (accessed Nov 4, 2013). Mayer K, Beyrer C. WHO’s new HIV guidelines: opportunities and challenges. Lancet 2013; 382: 287–88. Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med 2009; 360: 1815–26. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 Infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493–505. Tanser F, Bärnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZuluNatal, South Africa. Science 2013; 339: 966–71.
Singapore’s health-care financing We read with interest Lincoln Chen and Kai Hong Phua’s review of William Haseltine’s book Affordable Excellence: The Singapore Healthcare Story (Sept 14, p 930).1 However, we think that Singapore’s successful healthcare cost control deserves some more comments. First, as presented in the table, the so-called 3Ms (Medisave, Medishield, and Medifund) finance less than 10% of the total national health-care expenditure. 2 Second, Singapore’s health system uses copayments. This promotes individual responsibility, but, because there are no limits on copayments, many Singaporeans are worried about catastrophic expenditures, despite the existence of a safety net (Medifund) for the poorest individuals. Moreover, the market-driven efficiency, enthusiastically applauded by some, threatens the doctor–patient relationship because of the rationing of clinical care to manage costs. The government has historically not provided step-down and long-term care (ie, community hospitals, nursing homes, home care services), leaving charities to provide these services with variable results. Hospitals often have difficulties discharging patients to convalescent beds. Public hospitals even hire debt collectors to recover patients’ unpaid bills.3 Finally, Chen and Phua only hint at what really works in Singapore’s health care: a strong government commitment to primary care, in 2011
2002–2011 average
31·0%
28·6%
Medifund
0·7%
0·6%
Medisave
5·5%
5·5%
Medishield
2·1%
1·6%
Medifund + Medisave + Medishield
8·3%
7·7%
Government outlay
Data are % of national health-care expenditure.2
Table: Health-care financing in Singapore
1779
