Former President George W. Bush met with Stanford students for an hourlong conversation that touched on many of the defining moments and policies of his presidency.

In a relaxed and sometimes self-deprecating exchange on May 5, Bush talked about the limits of congressional power and his relationships and personal diplomacy with other world leaders. His tone was more serious when discussing what he described as universal desires for freedom, his military strategies following 9/11, and his commitment to addressing Africa’s HIV/AIDS pandemic.

Mariano-Florentino Cuéllar, director of the university’s Freeman Spogli Institute for International Studies, moderated the session. Stanford President John Hennessy and Condoleezza Rice – Bush’s secretary of state and national security adviser who has returned to teaching political science and business at Stanford – joined the conversation.

"FSI has a terrific track record of convening leaders at Stanford, from the head of the International Monetary Fund to prime ministers and presidents,” Cuéllar said. “On this occasion, we wanted our students to have an opportunity for a candid conversation with one of the key policymakers of the early 21^st century, and we think such experiences will further prepare them for leadership in a complex world."

About 30 students were invited to the session at Encina Hall, but they didn’t know they were meeting Bush until the 43^rd president walked into the room.

“I suspect he misses this sort of engagement,” said Gregory Schweizer, a second-year law school student who was part of the discussion that also covered immigration reform, national education policies and the Edward Snowden affair.

“The media always portrays him as being disengaged from current affairs,” Schweizer said. “But I’m impressed with how interested and engaged he still is.”

Along with representatives from Stanford Law School, other students were invited from the Ford Dorsey Program in International Policy Studies. Honors students from FSI’s Center for International Security and Cooperation and Center on Democracy, Development, and the Rule of Law also joined the conversation.

Bush’s visit was arranged with the help of  Brad Freeman, a former university trustee and Ronald Spogli, who is currently on Stanford's board of trustees. Freeman and Spogli are longtime friends of the former president and philanthropists who donated a naming gift to FSI in 2005. Bush appointed Spogli as ambassador to Italy in 2005 and as ambassador to San Marino a year later. 

Stanford has a tradition of hosting current and former heads of state, including German Chancellor Angela Merkel and former Russian President Dmitry Medvedev – both of whom visited in 2010.

A once-a-day pill to help prevent HIV infection could significantly reduce the spread of AIDS, but only makes economic sense if used in select, high-risk groups, Stanford researchers conclude in a new study.

The researchers looked at the cost-effectiveness of the combination drug tenofovir-emtricitabine, which was found in a landmark 2010 trial to reduce an individual’s risk of HIV infection by 44 percent when taken daily. Patients who were particularly faithful about taking the drug reduced their risk to an even greater extent – by 73 percent.

The results generated so much interest that the Stanford researchers decided to see if it would be cost-effective to prescribe the pill daily in large populations, a prevention technique known as pre-exposure prophylaxis, or PrEP.

They created an economic model focused on gay men, as they account for more than half of the estimated 56,000 new infections annually in the United States, according to the Centers for Disease Control and Prevention.

“Promoting PrEP to all men who have sex with men could be prohibitively expensive,” said Jessie Juusola, a PhD candidate in management science and engineering in the School of Engineering and first author of the study. “Adopting it for men who have sex with men at high risk of acquiring HIV, however, is an investment with good value that does not break the bank.”

For instance, using the pill in the general population of gay men would cost $495 billion over 20 years, compared to $85 billion when targeted to those at particularly high risk, the researchers found. The study will be published in the April 17 issue of the Annals of Internal Medicine.

Senior author Eran Bendavid, an affiliate of Stanford Health Policy at the Freeman Spogli Institute, said the results are a departure from a previous study. Earlier research found PrEP was not cost-effective when compared with other commonly accepted prevention programs.

The new Stanford study differs in a few important respects, taking into consideration the decline in transmission rates over time as more individuals take the pill. The Stanford team also assumed individuals would stop taking PrEP after 20 years, not stay on the drug for life, as the previous study had assumed.

The pill combination, marketed under the brand name Truvada, is widely used for treating HIV infection. But it wasn’t until a landmark trial, published in the New England Journal of Medicine in November 2010, that individuals and their doctors began to seriously consider using the drug as a preventive therapy. The drug’s maker, Foster City, Calif.-based Gilead Sciences Inc., has filed a supplemental new drug application to market it for prevention purposes.

The CDC issued interim guidelines on the drug’s use in January 2011, suggesting that if practitioners prescribe it as a preventive measure, they regularly monitor patients for side effects and counsel them about adherence, condom use and other methods to reduce their risk of infection.

In developing their model, the Stanford researchers took into account the cost of the drug – about $26 a day, or almost $10,000 a year – as well as the expenses for physician visits, periodic monitoring of kidney function affected by the drug, and regular testing for HIV and sexually transmitted diseases.

“We’re talking about giving uninfected people a drug that has some toxicities, so it’s crucial to have them monitored regularly,” said Bendavid, who is an assistant professor of medicine in Stanford’s School of Medicine.

Without PrEP, the researchers calculated there would be more than 490,000 new infections among gay men in the United States in the next 20 years. If just 20 percent of these men took the pill daily, there would be nearly 63,000 fewer infections.

However, the costs are substantial. Use of the drug by 20 percent of gay men would cost $98 billion over 20 years; if every man in this group took PrEP for 20 years, the costs would be a staggering $495 billion.

Given these figures, the researchers looked at the option of giving PrEP only to men who are at high risk – those who have five or more sexual partners in a year. If just 20 percent of these high-risk individuals took the drug, 41,000 new infections would be prevented over 20 years at a cost of about $16.6 billion.

At less than $50,000 per quality-adjusted life year gained (a measure of how long people live and their quality of life), that strategy represents relatively good value, according to Juusola.

“However, even though it provides good value, it is still very expensive,” she said. “In the current health care climate, PrEP’s costs may become prohibitive, especially given the other competing priorities for HIV resources, such as providing treatment for infected individuals.”

She said the costs could be significantly reduced if the pill is found to be effective when used intermittently, rather than on a daily basis. Current trials are examining the effectiveness of the drug when used less often.

Other co-authors are Margaret L. Brandeau, the Coleman F. Fung Professor of Engineering, and Douglas K. Owens, the Henry J. Kaiser, Jr. Professor at Stanford and senior investigator at the Veterans Affairs Palo Alto Health Care System. Owens also is director of Stanford’s Center for Health Policy and Center for Primary Care and Outcomes Research.

The study was funded by the National Institutes of Health and the Department of Veterans Affairs and supported by Stanford’s departments of Medicine and Management Science and Engineering.

As incomes rise around the world, health experts expect a more troubling figure to increase as well: the number of diabetics in developing countries.

In China and India – two of the world’s most populous nations with fast-paced economies – the prevalence of diabetes is expected to double by 2025. Between 15 and 20 percent of their adult population will develop the disease as household budgets increase, diets change to include more calories and new health problems emerge.

But China, India and other developing countries are not fully prepared to deal with the rising trend of diabetes. And a growing number of diabetics aren’t getting the care they need to prevent serious complications, Stanford researchers say.

Even with insurance, many diabetics don’t have essential medications that could help them manage their conditions. In many cases, people are spending a great deal of their household incomes to pay for their treatment, said Jeremy Goldhaber-Fiebert, an assistant professor of medicine who led the research team.

“Public and private health insurance programs aren’t providing sufficient protection for diabetics in many developing countries,” said Goldhaber-Fiebert, a faculty member at Stanford Health Policy at the university’s Freeman Spogli Institute for International Studies. “People with insurance aren’t doing markedly better than those who don’t have it. Health insurance and health systems need to be re-oriented to better address chronic diseases like diabetes.”

Findings from the study are online and will be published in the Jan. 24 edition of Diabetes Care, the journal of the American Diabetes Association. The journal article was co-authored by Jay Bhattacharya, an associate professor of medicine and Stanford Health Policy faculty member; and Crystal Smith-Spangler, an instructor at Stanford’s Department of Medicine and an investigator at the Palo Alto VA Health Care System.

Failure to adequately manage diabetes will lead to more severe health problems like blindness, heart disease and kidney failure. It also harms the otherwise healthy, Goldhaber-Fiebert said.

Diabetes often strikes people at an age when they’re taking care of children and elderly parents. To sideline these primary caretakers as dependants will lead to a heavy burden for communities and create an obstacle for economic growth, he added.

Using responses to a global survey conducted by the World Health Organization in 2002 and 2003, Goldhaber-Fiebert and his colleagues examined data from 35 low- and middle-income countries in Asia, Latin America, Africa and Eastern Europe to determine whether diabetics with insurance were more likely to have medication than those without insurance.

They also wanted to know whether insured diabetics have a lower risk of “catastrophic medical spending,” a term the researchers define as spending more than 25 percent of a household income on medical care.

“Surprisingly, diabetics with insurance were no more likely to have the medications they need than uninsured diabetics,” Goldhaber-Fiebert said. “They were also no less likely to suffer catastrophic medical spending.”

There are many reasons why health insurance may not protect diabetics in developing countries against high out-of-pocket spending. In some cases, there’s a lack of sufficient medication – such as insulin – that regulate glucose levels. Without those drugs, there’s a greater risk of complications that often lead to more hospitalizations and more expenses.

In other cases, co-payments and deductibles are too high. Sometimes, drugs and medical services to prevent diabetes complications are not covered. And doctors and hospitals don’t always accept insurance.

“Better policies are needed to provide sufficient protection and care for diabetics in the developing world,” Goldhaber-Fiebert said.

Without medications to manage diabetes and prevent secondary complications, the condition will worsen and the burden of catastrophic spending will increase, he said.

“It’s important to get ahead of the curve and prepare so there’s an infrastructure in place to deal with these health and cost issues,” he said.

While preventing diabetes in the first place would be ideal, programs and policies must be established to care for the many cases that will surely continue to exist.

“There isn’t a single country that’s managed to entirely arrest or reverse the trend of diabetes,” he said. “Programs that focus on primary prevention are extremely important, but the reality is that the developing world faces hundreds of millions of diabetes cases that are unlikely to all be prevented.”