Humanosphere

Mike Urban, 2003

Nisha visits her son Allwyn's grave in Delhi. He died from AIDS, unknowingly transmitted to her by her husband.

A $258 million initiative sponsored by the Bill & Melinda Gates Foundation aimed at preventing AIDS in India appears to have paid off overall, researchers say, resulting in more than 100,000 fewer new HIV infections over five years.

Many aren’t quite ready to judge this project, Avahan, a success, however.

The project failed in three of the six Indian states where it was tested. And many are concerned that the amount of money spent to achieve these mixed results makes the approach highly impractical for poor countries.

The analysis of this project’s impact was done by the University of Washington’s Institute for Health Metrics and Evaluation, also sponsored by the Gates Foundation. This awkward situation is hardly unusual, as the Seattle philanthropy is now one of the primary funding sources for all things global health.

But before anyone gets too excited about the potential conflict of interest, which is real but which I can also attest has been repeatedly and vigorously debated within the UW Institute, it should be emphasized that the analysis was peer-reviewed by editors at The Lancet before publication.

The UW authors admit that their study results are preliminary and incomplete. Even with all the caveats, lead author Marie Ng says:

“The take-home message here is that prevention programs can be effective. Despite the heterogeneity of these results, it is clearly significant that we found more than 100,000 HIV infections were prevented.”

Avahan, which means “call to action” in Sanskrit, was launched in 2003 by the Gates Foundation in six Indian states with a population of 300 million and relatively high HIV rates. The goal was to prevent HIV transmission in high-risk groups like sex workers, long-haul truck drivers and injection drug users.

Sounds non-controversial and simple? Nothing in India is ever simple or without controversy.

I happened to be in India reporting on AIDS issues for the Seattle Post-Intelligencer when Bill Gates came to town to announce his intention to give India hundreds of millions of dollars to fight AIDS.

Gates was pilloried by leading politicians and in the media for suggesting India’s HIV/AIDS epidemic was much larger than the government’s official estimates. Though hailed as a business folk hero and an icon of India’s burgeoning geek community, Gates was also criticized for setting up the private initiative Avahan, rather than just donating the money to the Indian government’s programs.

I think it’s fair to say some have eagerly awaited proof that Avahan was a bust.

Analyzing the results

According to Ng and her colleagues at IHME, the project was clearly successful at preventing HIV infection in the three Indian states of Andhra Pradesh, Karnataka and Maharashtra. Avahan had little or no impact in three other states, Tamil Nadu and the smaller, northeastern states of Manipur and Nagaland.

It’s not clear yet why Avahan failed to have an impact in these other states, Ng said. In Tamil Nadu, she said, it could have been that the HIV rates had already been reduced significantly. In the northeast, Ng said it’s possible the programs tailored for lowland communities were less effective at reaching people living in hilly, more isolated mountain communities.

“Every community had a slightly different approach, tailored for their needs,” she said.

Avahan’s approach — which recruits businesses, employers and trade associations into the HIV prevention efforts — is probably applicable elsewhere, Ng said. But more study is needed to figure out why it worked in some communities and not in others.

The researchers estimated that the Gates project spent about $2,500 per HIV infection prevented, noting that this was still less than the cost of HIV/AIDS care over a lifetime.

Failure or success? Maybe we can’t say

Some experts questioned whether the study did, in fact, document evidence of successful HIV prevention. One AIDS expert quoted by the Washington Post said the methods of IHME are questionable:

Dr. Prabhat Jha, director of the Centre for Global Health Research in Canada, who has conducted large-scale HIV studies in India, said those data are typically used to monitor trends or changes in the epidemic, not to estimate infections averted in the general population.

“Right from the start, it just doesn’t work,” he said. “I’m not going to judge how high my plane is flying by how many times my ears pop. It doesn’t tell you where you’re at.”

Jha also noted that other prevention programs were in place before Avahan began and that HIV infections were already in decline. Instead of focusing on infections averted, he said it makes more sense to assess the program more broadly.