Disclaimer: I think the instant USAID cuts are very harmful, they directly affect our organisation’s wonderful nurses and our patients. I’m not endorsing the cuts, I just think exaggurating numbers when communicating for dramatic effect (or out of ignorance) is unhelpful and doesn’t build trust in institutions like the WHO.
Sometimes the lack of understanding, or care in calulations from leading public health bodies befuddles me.
“The head of the United Nations’ programme for tackling HIV/AIDS told the BBC the cuts would have dire impacts across the globe.
“AIDS related deaths in the next five years will increase by 6.3 million” if funding is not restored, UNAIDS executive director Winnie Byanyima said.”
There just isn’t a planet on which AIDS related deaths would increase that much. In 2023 an estimated 630,000 people were estimated to have died from AIDS related deaths. The WHO estimates about 21 million Africans on HIV treatment. Maybe 5 million of these in South Africa aren’t funded by USAID. Other countries like Kenya and Botswana also contribute to their own HIV treatment.
So out of those 16ish million on USAID funded treatment, over 1⁄3 of those would have to die in the next 3 years for that figure would be correct. The only scenario where this could happen is if all of these people went completely untreated, which means that no local government would come in at any stage. This scenario is impossible
I get that the UN HIV program want to put out scary numbers to put the pressure on the US and try and bring other funding in, but it still important to represent reality. Heads of public health institutions and their staff who do this kind of modelling should learn what a counterfactual is.
“AIDS related deaths in the next five years will increase by 6.3 million” if funding is not restored, UNAIDS executive director Winnie Byanyima said.
This is a quote from a BBC news article, mainly about US political and legal developments. We don’t know what the actual statement from the ED said, but I don’t think there’s enough here to infer fault on her part.
For all we know, the original quote could have been something like predicting that deaths will increase by 6.3 million if we can’t get this work funded—which sounds like a reasonable position to take. Space considerations being what they are, I could easily see a somewhat more nuanced quote being turned into something that sounded unaware of counterfactual considerations.
There’s also an inherent limit to how much fidelity can be communicated through a one-sentence channel to a general audience. We can communicate somewhat more in a single sentence here on the Forum, but the ability to make assumptions about what the reader knows helps. For example, in the specific context here, I’d be concerned that many generalist readers would implicitly adjust for other funders picking up some of the slack, which could lead to double-counting of those effects. And in a world that often doesn’t think counterfactually, other readers’ points of comparison will be with counterfactually-unadjusted numbers. Finally, a fair assessment of counterfactual impact would require the reader to understand DALYs or something similar, because at least a fair portion of the mitigation is likely to come from pulling public-health resources away from conditions that do not kill so much as they disable.
So while I would disagree with a statement from UNAIDS that actually said if the U.S. doesn’t fund PEPFAR, 6.3MM more will die, I think there would be significant drawbacks and/or limitations to other ways of quantifying the problem in this context, and think using the 6.3MM number in a public statement could be appropriate if the actual statement were worded appropriately.
Thanks Jason—those are really good points. In general maybe this wasn’t such a useful thing to bring up at this point in time, and in general its good that she is campaigning for funding to be restored. I do think the large exaggeration though means this a bit more than a nitpick.
I’ve been looking for her saying the actual quote, and have struggled to find it. A lot of news agencies have used the same quote I used above with similar context. Mrs. Byanyima even reposted on her twitter the exact quote above...
I also didn’t explain properly but even at the most generous reading of something like After 5 years deaths will increase by 6.3 million if we get zero funding for HIV medication, the number is still wildly exaggurated. Besides the obvious point that many people would self fund the medications if there was zero funding available (I would guess 30%-60%), and that even short periods of self funded treatment (a few months) would greatly increase their lifespan, the 6.3 million is still incorrect at least by a factor of 2.
Untreated HIV in adults in the pre HAART era in Africa had something like an 80% survival rate (maybe even a little higher) 5 years after seroconversion, which would bring a mortality figure of 3.2 million dying in 5 years assuming EVERYONE on PEPFAR drugs remained untreated—about half the 6.3 million figure quoted. Here’s a graph of mortality over time in the Pre HAART era. Its worth keeping in mind that our treatment of AIDS defining infections is far superior to what it was back then, which would keep people alive longer as well.
And my 3.2 million figure doesn’t take into account the not-insignificant number of people who would die within 5 years even while on ARVs which further reduces the extra deaths figure.
Also many countries like Uganda have about 1 years supply of medications left, so we should perhaps be considering the 10% mortality after 4 years of no medications rather than 20% at 5 in this calculation, which would halve the death numbers again.
So I still think the statement remains a long way off being accurate, even if we allow some wiggle room for wording like you rightly say we should.
The only scenario where this could happen is if all of these people went completely untreated, which means that no local government would come in at any stage. This scenario is impossible
Can you elaborate why this is impossible, or at least unlikely?
The idea that no (or even few) Sub-Saharan African countres would stand in the gap for their most vulnerable people with HIV, abandoning them to horrendous sickness and death from HIV that would overwhelm their health systems shows lack of insight.
Countries simply can’t afford to leave people with HIV completely high and dry, economically and politcally. HIV medication would be a priority for most African countries—either extra fundng would be allocated or money switched from other funds to HIV treatment. As much as governments aren’t utilitarian, they know the disaster that would ensue if HIV medications were not given and their heallth systems were overwhelmed. AIDS is a horrible condition which lasts a long time and robs individuals and families of their productivity.
Granted care might be far worse. Funding for tests like viral load cold be cut, there might be disastrous medicaion stockouts. Hundreds of thousands or even more could die because of these USAID cuts. Funding for malaria, tuberculosis and other treatments might fall by the wayside but I believe for most countries HIV care would be a top priority.
There would be some countries that are either too poor or unstable where this might not happen. Countrie like South Sudan, DRC, Somalia—but I strongly believe that most countries would provide most people with HIV most of their treatment for free.
Besides this, given it is life saving I would estimate maybe half (uncertain) of peopl ewith HIV would buy their own medication if there was no other option—if the alternative is death their family would pool money to keep them alive.
Another minor point is that I think drug companies would likely hugely drop the cost of medication as well—otherwise they wouldn’t be able to sell much of it.
Disclaimer: I think the instant USAID cuts are very harmful, they directly affect our organisation’s wonderful nurses and our patients. I’m not endorsing the cuts, I just think exaggurating numbers when communicating for dramatic effect (or out of ignorance) is unhelpful and doesn’t build trust in institutions like the WHO.
Sometimes the lack of understanding, or care in calulations from leading public health bodies befuddles me.
“The head of the United Nations’ programme for tackling HIV/AIDS told the BBC the cuts would have dire impacts across the globe.
“AIDS related deaths in the next five years will increase by 6.3 million” if funding is not restored, UNAIDS executive director Winnie Byanyima said.”
https://www.bbc.com/news/articles/cdd9p8g405no
There just isn’t a planet on which AIDS related deaths would increase that much. In 2023 an estimated 630,000 people were estimated to have died from AIDS related deaths. The WHO estimates about 21 million Africans on HIV treatment. Maybe 5 million of these in South Africa aren’t funded by USAID. Other countries like Kenya and Botswana also contribute to their own HIV treatment.
So out of those 16ish million on USAID funded treatment, over 1⁄3 of those would have to die in the next 3 years for that figure would be correct. The only scenario where this could happen is if all of these people went completely untreated, which means that no local government would come in at any stage. This scenario is impossible
I get that the UN HIV program want to put out scary numbers to put the pressure on the US and try and bring other funding in, but it still important to represent reality. Heads of public health institutions and their staff who do this kind of modelling should learn what a counterfactual is.
This is a quote from a BBC news article, mainly about US political and legal developments. We don’t know what the actual statement from the ED said, but I don’t think there’s enough here to infer fault on her part.
For all we know, the original quote could have been something like predicting that deaths will increase by 6.3 million if we can’t get this work funded—which sounds like a reasonable position to take. Space considerations being what they are, I could easily see a somewhat more nuanced quote being turned into something that sounded unaware of counterfactual considerations.
There’s also an inherent limit to how much fidelity can be communicated through a one-sentence channel to a general audience. We can communicate somewhat more in a single sentence here on the Forum, but the ability to make assumptions about what the reader knows helps. For example, in the specific context here, I’d be concerned that many generalist readers would implicitly adjust for other funders picking up some of the slack, which could lead to double-counting of those effects. And in a world that often doesn’t think counterfactually, other readers’ points of comparison will be with counterfactually-unadjusted numbers. Finally, a fair assessment of counterfactual impact would require the reader to understand DALYs or something similar, because at least a fair portion of the mitigation is likely to come from pulling public-health resources away from conditions that do not kill so much as they disable.
So while I would disagree with a statement from UNAIDS that actually said if the U.S. doesn’t fund PEPFAR, 6.3MM more will die, I think there would be significant drawbacks and/or limitations to other ways of quantifying the problem in this context, and think using the 6.3MM number in a public statement could be appropriate if the actual statement were worded appropriately.
Thanks Jason—those are really good points. In general maybe this wasn’t such a useful thing to bring up at this point in time, and in general its good that she is campaigning for funding to be restored. I do think the large exaggeration though means this a bit more than a nitpick.
I’ve been looking for her saying the actual quote, and have struggled to find it. A lot of news agencies have used the same quote I used above with similar context. Mrs. Byanyima even reposted on her twitter the exact quote above...
”AIDS-related deaths in the next 5 years will increase by 6.3 million”
I also didn’t explain properly but even at the most generous reading of something like After 5 years deaths will increase by 6.3 million if we get zero funding for HIV medication, the number is still wildly exaggurated. Besides the obvious point that many people would self fund the medications if there was zero funding available (I would guess 30%-60%), and that even short periods of self funded treatment (a few months) would greatly increase their lifespan, the 6.3 million is still incorrect at least by a factor of 2.
Untreated HIV in adults in the pre HAART era in Africa had something like an 80% survival rate (maybe even a little higher) 5 years after seroconversion, which would bring a mortality figure of 3.2 million dying in 5 years assuming EVERYONE on PEPFAR drugs remained untreated—about half the 6.3 million figure quoted. Here’s a graph of mortality over time in the Pre HAART era. Its worth keeping in mind that our treatment of AIDS defining infections is far superior to what it was back then, which would keep people alive longer as well.
https://pmc.ncbi.nlm.nih.gov/articles/PMC5784803/
And my 3.2 million figure doesn’t take into account the not-insignificant number of people who would die within 5 years even while on ARVs which further reduces the extra deaths figure.
Also many countries like Uganda have about 1 years supply of medications left, so we should perhaps be considering the 10% mortality after 4 years of no medications rather than 20% at 5 in this calculation, which would halve the death numbers again.
So I still think the statement remains a long way off being accurate, even if we allow some wiggle room for wording like you rightly say we should.
Can you elaborate why this is impossible, or at least unlikely?
The idea that no (or even few) Sub-Saharan African countres would stand in the gap for their most vulnerable people with HIV, abandoning them to horrendous sickness and death from HIV that would overwhelm their health systems shows lack of insight.
Countries simply can’t afford to leave people with HIV completely high and dry, economically and politcally. HIV medication would be a priority for most African countries—either extra fundng would be allocated or money switched from other funds to HIV treatment. As much as governments aren’t utilitarian, they know the disaster that would ensue if HIV medications were not given and their heallth systems were overwhelmed. AIDS is a horrible condition which lasts a long time and robs individuals and families of their productivity.
Granted care might be far worse. Funding for tests like viral load cold be cut, there might be disastrous medicaion stockouts. Hundreds of thousands or even more could die because of these USAID cuts. Funding for malaria, tuberculosis and other treatments might fall by the wayside but I believe for most countries HIV care would be a top priority.
There would be some countries that are either too poor or unstable where this might not happen. Countrie like South Sudan, DRC, Somalia—but I strongly believe that most countries would provide most people with HIV most of their treatment for free.
Besides this, given it is life saving I would estimate maybe half (uncertain) of peopl ewith HIV would buy their own medication if there was no other option—if the alternative is death their family would pool money to keep them alive.
Another minor point is that I think drug companies would likely hugely drop the cost of medication as well—otherwise they wouldn’t be able to sell much of it.