Could the cost of interrupting the transmission of AIDS in Africa be just 32 cents? That's the revolutionary idea raised in a piece published this week in the journal PLoS Neglected Tropical Diseases. The authors write that schistosomiasis -- long considered one of the central Neglected Tropical Diseases (NTDs) -- may triple the risk of contracting HIV/AIDS. These are promising and startling findings, but what is even more exciting is the cost of treating schistosomiasis: a mere 32 cents per treatment.
AIDS activists have fought long and hard to lower the cost of AIDS treatment from the tens of thousands of dollars it cost in the 1990s to the less than $100 annual cost today. That's still an enormous amount of money particularly in countries that average less than $10 per year on per capita health care expenditures. There are over 200 million cases of schistosomiasis, and all could be treated with the simple administration of the drug praziquantel. "The 32 cents solution could have enormous benefits for young African women and a huge potential beneficial impact on Africa's AIDS epidemic," authors Hotez, Kjetland and Fenwick wrote. This may be understating the issue.
Schistosomiasis is one of the most common and debilitating of the NTDs, and sub-Saharan Africa is ground zero for this disease. What the new analysis shows is that an underreported manifestation of the disease -- female genital schistosomiasis -- produces lesions that may make girls and women far more susceptible to HIV infection. Mass administration of praziquantel of school aged children -- who are not yet sexually active -- can essentially inoculate girls against developing the disease; repeat treatments can keep girls and young women healthy, not to mention lowering the disease burden in the community.
Programs to reduce and eliminate NTDs have a proven track record. In Japan in the 1950s, mass administration of drugs to kill intestinal worms brought the country's workforce from languishing in sickness to an energetic juggernaut that would eventually help fuel an economic recovery miracle. Just last month in Rwanda, nearly four million children were treated over the course of just four days to combat a wide array of NTDs at minimal cost. The Rwandan Ministry of Finance and Economic Planning is setting out to follow Japan's example, transforming Rwanda's economy to middle income status by 2020. This cannot be achieved without a mentally and physically strong workforce, which in turn cannot exist until NTDs are eliminated.
Although irrefutably effective, you may be surprised to learn that mass drug administration to combat NTDs isn't a global health priority. Hotez, one of the report's lead authors, emphasized to me on Friday that "fewer than 2% of people in Africa who should be getting treated for schistosomiasis are currently getting treated, so this is a wakeup call to enhance coverage with praziquantel."
Why is this? Too often, the suite of disorders and parasitic infestations that comprise NTDs are overlooked by foundations and funders looking to make a difference. Instead, the focus of major efforts tends to center on higher profile diseases such as AIDS, malaria and tuberculosis. While these diseases are killers and must be addressed, failing to treat NTDs (for which simple, inexpensive and effective solutions exist) has far-reaching, devastating, consequences.
The need to address schistosomiasis -- which ought to be treated in its own right -- becomes ever more pressing given its apparent connection to AIDS. Why fight a disease like AIDS without also trying to prevent its transmission? We can never hope to get ahead of infection rates unless we do all possible to stop the spread in the first place. Schistosomiasis may prove to be one of the missing explanations for why some populations exhibit higher AIDS infection rates than models would ordinarily predict.
Although AIDS treatment has improved over the years, its monitoring and complexity remains a drain on health systems. Treatment of schistosomiasis, on the other hand, is as simple as taking a vitamin a couple of times per year. Hotez and his colleagues have shown that a single mass treatment of praziquantel administered in Burkina Faso and Niger in West Africa reduced prevalence of schistosomiasis by 84 percent among girls; they cite similar results in other pilot programs. At 32 cents per treatment, 70 million children could initially be treated for a mere $22 million; with biannual treatments for 10 years, the cost is about $112 million. Dr. Hotez wrote that for a "relatively small investment, the reproductive health of young women would be improved, and there is a reasonable chance that HIV/AIDS transmission can be reduced."
Hotez and his co-authors rightly conclude that President Obama has an opportunity to reap huge dividends across the global health spectrum by investing in mass drug administration programs to fight NTDs. The benefits will also be realized in our successful on-the-ground fights against malaria and AIDS. We already know that this solution will work to prevent Africa's young women from contracting a pernicious NTD that - in concert with other diseases - can be deadly.
In the end, how can we afford not to spend the 32 cents?
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