The government’s far-reaching health care foreign aid program has contributed to a significant decline in adult death rates in Africa, according to a new study by Stanford researchers. 

Between 2004 and 2008, the U.S. President’s Emergency Plan for AIDS Relief was associated with a reduction in the odds of death of nearly 20 percent in the countries where it operated. The researchers found that more than 740,000 lives were saved during this period in nine countries targeted by the program, known by its acronym, PEPFAR.

“We were surprised and impressed to find these mortality reductions,” said Eran Bendavid, an affiliate at Stanford Health Policy, part of the university’s Freeman Spogli Institute for International Studies.

“While many assume that foreign aid works, most evaluations of aid suggest it does not work or even causes harm,” said Bendavid, an assistant professor of medicine at Stanford’s School of Medicine. “Despite all the challenges to making aid work and to implementing HIV treatment in Africa, the benefits of PEPFAR were large and measurable across many African countries.”



The study is the first to show a decline in all causes of death related to the program. It appears in the May 16 issue of the Journal of the American Medical Association.

Bendavid is the lead author of the study. It was co-authored by Grant Miller and Jay Bhattacharya, who are both core faculty members of Stanford Health Policy and associate professors of medicine. The study was funded by the National Institutes of Health and the Dr. George Rosenkranz Prize for Health Care Research in Developing Countries.

PEPFAR began in 2003 under the Bush administration with a five-year, $15 billion investment in fighting AIDS around the world and a focus on treatment and prevention in 15 countries. It was reauthorized by Congress in 2008 and has expanded its reach to 31 countries.

To measure the impact of the program, Bendavid and his colleagues analyzed health and survival information for more than 1.5 million adults in 27 African countries, including nine countries where PEPFAR has focused its efforts. The researchers examined data available in the Demographic and Health Surveys, a USAID-funded project that involves a representative sampling of in-person interviews among women in which they discuss their health and the health of their family members. These surveys form the foundation of many health measurements in developing countries.

They found the odds of death from any cause among adults were 16 to 20 percent lower in the PEPFAR-targeted countries.

To bolster the results, the scientists did a separate analysis using specific data on PEPFAR programs in Rwanda and Tanzania. They compared regions of the two countries where PEPFAR’s investments led to widespread increases in the number and size of sites providing antiretroviral therapy, with areas where PEPFAR had fewer services available.



“We observed a similar reduction in mortality when exploring PEPFAR’s effects using a different lens,” Bendavid said.

In Tanzania, the odds of death were found to be 17 percent lower and in Rwanda 25 percent lower in the districts with greater support from PEPFAR.

Bendavid speculates that the program’s commitment to building an infrastructure that includes drug distribution systems, clinics, pharmacies, laboratories and testing facilities has been an important factor for its success.

“The scale of PEPFAR’s investment was unprecedented,” Bendavid said. “People working in PEPFAR’s focus countries describe working supply chains, stocked pharmacies and staffed clinics.”



Although the program was targeted to address HIV, these services could have benefitted patients with a variety of other health concerns. For example, one study found that some uninfected, pregnant women in Ethiopia, Rwanda and Tanzania chose to deliver their babies in facilities supported by PEPFAR, Bendavid said.

Some have argued that focusing resources on a specific disease, such as AIDS, may detract efforts from other diseases and activities, undermining some of the benefits of such programs. But the latest study does not support this argument. Rather, it suggests that PEPFAR helped prevent additional deaths from causes other than HIV/AIDS.

“Whether disease-specific programs like PEPFAR have synergies with other health improvement efforts – or instead undermine them, as some have worried – is really an open question,” Miller said. “There are reasons to think either scenario is possible, and more research is needed. We don’t find much evidence of PEPFAR undercutting other initiatives. If anything, we see hints of synergies.”



Bendavid said the program managed to accomplish the reduction in mortality in the face of enormous challenges – from persuading people to go for HIV testing and treatment to dealing with problems of drug shortages and drug resistance.

Historically, few other large-scale health initiatives have succeeded to such an extent. Smallpox, which was eradicated by 1979, is among the rare and more notable examples.

“PEPFAR’s success with HIV … may be considered the clearest demonstration of aid’s effectiveness in recent years,” the researchers concluded.

In 2009, PEPFAR was folded into a new Global Health Initiative that calls for a broader agenda, with some resources redistributed to other programs, such as maternal and child health.

Its budget, which rose dramatically in the early years, has remained relatively flat or declined slightly since then. It peaked at $6.8 billion in fiscal year 2010, then declined to $6.7 billion and $6.6 billion in fiscal years 2011 and 2012, respectively, according to figures from the Kaiser Family Foundation. The Obama administration’s budget request for the 2013 fiscal year is $6.4 billion.

While the program appears to have had an impact within a few years of its implementation, Bendavid noted that reduced investments in fighting AIDS, both through PEPFAR and other international aid programs, could have implications for the future of the epidemic.

“We are transforming the face of the epidemic but funding shortfalls will change the road ahead,” he said.



Ruthann Richter is Director of Media Relations for the Stanford School of Medicine.

Retraction: In June 2012, Stanford researchers Rajaie Batniji and Eran Bendavid retracted the research findings explained in the following article. Their findings, presented in the essay, "Does development assistance for health really displace government health spending? Reassessing the evidence," contained errors in statistical model choice and reporting. The essay was published May 8, 2012, by the journal PLoS Medicine. The researchers erroneously concluded that there was no significant displacement of foreign aid. When they discovered their mistake, they informed editors at PLoS Medicine and moved to correct the record. The editors agreed with the need for the retraction and accepted the authors’ explanation of their error. The retraction can be read at www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001214.

When a 2010 study concluded that about half the money given to international governments for providing health care services isn’t used as intended, skeptics who argued that foreign aid is largely wasted were handed a powerful piece of data to bolster their claims.

But Stanford researchers Rajaie S. Batniji and Eran Bendavid say those findings are flawed. In an article featured in the May 8th edition of PLoS Medicine, Batniji and Bendavid say the two-year-old study by researchers at the University of Washington should not be used to guide decisions about how much money to give and who should get it.

“We can’t say that there’s absolutely no displacement of foreign aid, but these earlier findings are too tenuous for the basis of policy,” said Batniji, an affiliate of the Center on Democracy, Development, and the Rule of Law at the Freeman Spogli Institute for International Studies.

Batniji and Bendavid, an affiliate of FSI’s Stanford Health Policy and an assistant professor of medicine, are taking on the 2010 study – which appeared in the Lancet – at a critical time for foreign assistance programs.

The United States, which gives about half of all the world’s health aid, plans to chop its $10 billion budget by about 4 percent in the coming fiscal year. That’s the first cut in more than a decade. And officials have shown no signs of switching their preference of bypassing national governments as recipients of health aid, funneling more than half of U.S. support to non-governmental organizations instead.

Batniji and Bendavid decided to re-analyze the data used by the University of Washington researchers after meeting with policymakers who pointed to the study as a cautionary tale of foreign governments that waste and mismanage money earmarked for health programs.

“People were citing the Lancet piece, saying this was starting to shape how they thought about giving money,” said Batniji, who is also a resident physician at Stanford Medical Center. “But when we started asking questions about what the actual displacement looks like, the answers didn’t seem very compelling or reasonable.”

Taking a fresh look at the same numbers used for the 2010 study – public financing data culled from the World Health Organization and the International Monetary Fund – the researchers saw a different story emerge about the use of foreign aid in the health sector.

Once Batniji and Bendavid excluded conflicting and outlying data, such as huge discrepancies between WHO and IMF estimates and information about countries that were getting very small amounts of money from other countries, “there was no significant displacement of foreign aid,” Bendavid said.

The Stanford researchers’ findings are poised to influence a debate among policymakers and donors over whether it’s more efficient to give international assistance slated for health spending to government agencies or NGOs.

“We want to free donors of feeling that if they give money directly to governments, the money will be offset and used for an unintended purpose,” Batniji said. “The concern about displacement really amplifies the demands we make on governments for how they use the money. And that is at odds with a recent movement to let foreign governments set their own agendas for how to spend money.”

The research conducted by Batniji and Bendavid was supported by FSI’s Global Underdevelopment Action Fund and the Dr. George Rosenkranz Prize awarded to Bendavid 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.

Young Stanford researchers focusing on improving health care access in developing countries are eligible for the Dr. George Rosenkranz Prize.

The $100,000 award is given to a non-tenured professor, post-doctoral student or research associate during a two-year period. The deadline to apply is May 11. The recipient will be announced in early June

Rosenkranz, who helped first synthesize Cortisone in 1951 and went on to synthesize progestin  – the active ingredient for the first oral birth control – dedicated his career to improving health care access around the world. Born in Hungary in 1916, the chemist started his career in Mexico and helped establish the Mexican National Institute for Genomic Medicine. He lives with his wife in Menlo Park.

The award is being funded by the Rosenkranz family and administered by Stanford Health Policy, a center within the Freeman Spogli Institute for International Studies and the Center for Primary Care and Outcomes Research. It also is designed to give its recipients access to a network that will help them develop their careers.

Eran Bendavid, a SHP affiliate and Stanford Medical School instructor, received the first award in 2010 to support his analysis of whether money going to HIV and malaria programs in sub-Saharan Africa has improved the overall health of children and their mothers.

More application information is available at http://healthpolicy.stanford.edu/fellowships/rosenkranz_prize.

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.”