Effectiveness and Cost Effectiveness of Expanding Harm Reduction Programs and HIV Antiretroviral Therapy in a Mixed HIV epidemic: An Analysis for Ukraine
Background Injection drug use (IDU) and heterosexual virus transmission both contribute to the growing mixed HIV epidemics in Eastern Europe and Central Asia. In Ukraine—chosen in this study as a representative country—IDU-related risk behaviors cause half of new infections, but few injection drug users (IDUs) receive methadone substitution therapy. Only 10% of eligible individuals receive antiretroviral therapy (ART). The appropriate resource allocation between these programs has not been studied. We estimated the effectiveness and cost-effectiveness of strategies for expanding methadone substitution therapy programs and ART in mixed HIV epidemics, using Ukraine as a case study.
Methods and Findings We developed a dynamic compartmental model of the HIV epidemic in a population of non-IDUs, IDUs using opiates, and IDUs on methadone substitution therapy, stratified by HIV status, and populated it with data from the Ukraine. We considered interventions expanding methadone substitution therapy, increasing access to ART, or both. We measured health care costs, quality-adjusted life years (QALYs), HIV prevalence, infections averted, and incremental cost-effectiveness. Without incremental interventions, HIV prevalence reached 67.2% (IDUs) and 0.88% (non-IDUs) after 20 years. Offering methadone substitution therapy to 25% of IDUs reduced prevalence most effectively (to 53.1% IDUs, 0.80% non-IDUs), and was most cost-effective, averting 4,700 infections and adding 76,000 QALYs compared with no intervention at US$530/QALY gained. Expanding both ART (80% coverage of those eligible for ART according to WHO criteria) and methadone substitution therapy (25% coverage) was the next most cost-effective strategy, adding 105,000 QALYs at US$1,120/QALY gained versus the methadone substitution therapy-only strategy and averting 8,300 infections versus no intervention. Expanding only ART (80% coverage) added 38,000 QALYs at US$2,240/QALY gained versus the methadone substitution therapy-only strategy, and averted 4,080 infections versus no intervention. Offering ART to 80% of non-IDUs eligible for treatment by WHO criteria, but only 10% of IDUs, averted only 1,800 infections versus no intervention and was not cost effective.
Conclusions Methadone substitution therapy is a highly cost-effective option for the growing mixed HIV epidemic in Ukraine. A strategy that expands both methadone substitution therapy and ART to high levels is the most effective intervention, and is very cost effective by WHO criteria. When expanding ART, access to methadone substitution therapy provides additional benefit in infections averted. Our findings are potentially relevant to other settings with mixed HIV epidemics.
Culture and Globalization: A French Perspective
Frédéric Mitterrand is the French Minister of Culture and Communication. Throughout his career, he has been an actor, screenwriter, television presenter, writer, producer and director.
Sponsored by The France-Stanford Center for Interdisciplinary Studies, The San Francisco French Consulate, The Stanford Humanities Center and The Europe Center at the Freeman Spogli Institute, Stanford University.
Oksenberg Conference Room
The World Ahead
John Micklethwait is the Editor-in-Chief of The Economist. After studying history at Magdalen College, Oxford, he worked as a banker at Chase Manhattan between 1985 and 1987 before joining The Economist as a finance correspondent in 1987. Since then his roles at The Economist have included setting up the bureau in Los Angeles, where he worked from 1990‑93; being the newspaper's media correspondent; editing the business section; running the New York bureau; and editing the United States section. The Economist now has a circulation of around 1.4 million worldwide.
Mr. Micklethwait has appeared on radio and television around the world. He has co-authored with Adrian Wooldridge, also an Economist journalist, five books: The Witch Doctors; "A Future Perfect: the Challenge and Hidden Promise of Globalisation; The Company: A Short History of a Revolutionary Idea; The Right Nation: Conservative Power in America and God is Back: How the Global Rise of Faith is Changing the World, published by the Penguin Press in April 2009.
Mr. Micklethwait was named Editors' Editor of the Year at the British Society of Magazine Editors 2010 annual awards.
Bechtel Conference Center
The NATO-EU-Russia Triangle: Different Perceptions and Approaches to International Security
About the speaker:
Dr. Franz Cede is a retired Austrian diplomat who served as the Austrian Ambassador to Russia (1999-2003) and to NATO (2003-2007). He also was the Legal Advisor to the Austrian Foreign Ministry. He has a strong California connection dating back to the time when he was the Austrian Consul General in Los Angeles 20 years ago. Dr Cede holds the degree "Doctor of Law" from Innsbruck University. He received an M.A. in international affairs from the School of Advanced International Studies (SAIS) in Washington, D.C., and is currently an associate professor at the Andrassy University in Budapest, Hungary. Dr. Cede has published several books and articles in the field of international relations, international law and diplomacy.
Jointly sponsored by The Europe Center at the Freeman Spogli Institute for International Studies, and the Center for Russian, East European and Eurasian Studies.
Audio Synopsis:
In this talk, Dr. Cede details his views on Russia's evolving relationships with the EU, NATO, and the US, drawing on his experiences as Austrian ambassador to the Soviet Union from1999 to 2003. Cede first outlines his perceptions of present-day Russia-US and Russia-NATO relations. Russia, he explains, still thinks in Cold War terms of bilateral relations and considers the United States to be its primary strategic partner on global security issues, especially in light of the Obama administration's recent "reset" of relations and ratification of the new START treaty. In contrast, Russia views NATO as outdated and yet still a threat. Its expansion to the East is viewed with suspicion by Putin's administration, which considers these developments to be distinctly anti-Russian. Russia engages with NATO only to the extent that it believes it can influence the organization's behavior and policies toward Moscow. Still, in Cede's experience, the NATO-US-Russia triangle continues to be at the forefront of Russian policymakers' dialogue. Russian leaders prefer to avoid dealing with the EU because it lacks a coherent foreign policy, and also because Russia prefers bilateral relations with countries that offer a strategic benefit. Dr. Cede quotes Timothy Garton Ash, who wrote in a recent op-ed that "much of the Russian foreign policy elite treats the European Union as a kind of transient, post-modern late 20th century anachronism: flawed in principle, and feeble in practice. What matters in the 21st century, as much as it did in the 19th century, is the...determination of great powers." Dr. Cede cites the Georgian military intervention and recent Ukrainian gas crisis as examples of Russia's renewed attempts to reestablish dominance in its neighborhood.
In the second portion of his talk Dr. Cede traces the evolution of Russian views of the EU and NATO. Ten years ago, the EU-Russia relationship was largely ignored in the Russian media. When Cede asked Russian citizens for their views on the EU, they "either didn't know or didn't care." As Ambassador, Dr. Cede found Russian officials better informed, but disdainful of being given orders by EU donors and "treated like a developing country." Cede illustrates this dynamic by recounting the 2004 incident in which the EU forced the residents of Russia's Kaliningrad Oblast region to apply for EU Shengen visas, which then required special permits to travel throughout Russia. Western assurances that EU expansion to the east was not an attack on Russia but rather an attempt to extend stability to the Eastern bloc fell on deaf ears. Cede believes that notwithstanding Russia's attitude, the country is too big to ever join the EU, or to be influenced by Europe in its policy decisions. Because Russia still views itself as "one of the poles in a multipolar world," Dr. Cede insists that any change must come from within the country. However, Cede views Russia's candidacy to the WTO, which would require a clearer commitment to democracy and open economic policies, as a glimmer of hope.
Finally, Dr. Cede outlines several "permanent" features of Russia's relationship with the world, including economic interdependence, lack of cooperation on security policy, and weak relations with stateless organizations like the EU and NATO. He lays out several recommendations, which are elaborated on during the Q&A session:
- EU policymakers and other Western powers (notably the US) should strengthen their common Russia policy. Given the EU's dependence on Russia for oil and gas, it should also diversify its own energy sources to strengthen its bargaining position.
- The EU should consider membership for "bridge countries" such as Ukraine, Moldova, and Belarus.
- Personal diplomacy between universities, civil society, and citizens is important. This includes reevaluation of visa policy. Cede hopes that the advent of the internet will also help improve attitudes between Russia and the rest of the world.
Reuben W. Hills Conference Room
Larry Diamond: Transition traps
After the peaceful mass uprising that toppled one of the world's oldest autocracies, it is now possible to imagine the emergence of a genuine democracy in Egypt-the most important country in the Arab world. The very possibility of it marks an historic turning point for the entire region. However, there is a long and often treacherous distance between the demise of an authoritarian regime and the rise of a democracy.
With no experience of democracy in recent decades, and no apparent government leadership that is committed to bringing it about, Egypt's transition faces more formidable challenges than the transitions that led to democracy in recent decades in countries like Spain, Greece, Argentina, Brazil, Chile, the Philippines, Poland, South Africa, Indonesia, and Ukraine. (Which isn't to say these were easy: We forget how difficult each of these transitions seemed at the time, and how fraught they were with dangers and uncertainties.) With an energized civil society and deep resources of youthful talent, creativity, and mobilizing skill, Egypt has a real chance to get to democracy in the next few years. But doing so will require a keen analysis of the numerous potential traps that could sandbag the process.
The first trap is the Machiavellian opaqueness of the aging generals who are now running the country. Beginning with the Defense Minister (and now junta leader) Mohamed Tantawi, until a few days ago a close ally of the deposed President Mubarak, Egypt's new military rulers cannot be trusted to structure the political process and emergent rules in a way that will favor genuine democracy. Their principal goal, it appears, is to preserve as much of the old order as possible-Mubarakism without Mubarak (the father or the son). This means another round of the old shell game of Arab regimes-what Daniel Brumberg has called "liberalized autocracy." The process of liberalization-which runs in cycles, and which countries like Morocco and Jordan have seen many iterations of-institutes just enough change in the rules and faces to give the appearance of movement toward democracy without any of the dangers (for the ruling elite). But the changes, imposed from above, stop well short of the sweeping institutional transformations that would open wide the political arena (and the functioning of government) while leveling the playing field.
In their initial "communiqués," Egypt's ruling generals show signs of treading down this duplicitous path. Their initial choices have evinced the seductive veneer of democratic change but the closure and control of authoritarian continuity. To begin with, there appears so far to be little consultation with democratic forces in determining the character and pace of transition. Despite opposition demands, emergency rule remains in place, and so do many political prisoners. The military's initial decisions have been unilateral and preemptory. We learn there will be a constitution drafted within two months, followed by a referendum. A respected retired judge will head the process. This will produce "amendments" to the now-suspended authoritarian constitution. But what will be the role for Egyptian opposition and civil society in this process? What will be the scope down the road to draft a completely new, more democratic and legitimate constitution with broad popular participation and support? Will the president to be elected later this year serve another imperial six-year term, or be a caretaker heading a neutral government until a new constitution can be adopted and fresh elections held? At this point, if anyone knows the answers to these questions, it is only the junta.
The military is talking about early presidential and legislative elections, within six months. What could be more democratic than that? But, in fact, after the fall of a longstanding autocracy, it typically takes a lot longer than six months to organize competitive, free, and fair elections. Think of the steps. A neutral and independent electoral administration must be established. This requires not just legal authorization but also new leadership, and recruitment, training, funding, and deployment of new staff and equipment. If Egypt's generals intend to have elections administered by the same Ministry of Interior that shamelessly rigged the vote for Mubarak and his ruling National Democratic Party (NDP), that will be a sure sign that they do not intend to deliver democracy-or are too incompetent and cavalier to care. Then, the next step must be to produce a new register of voters. Experts believe only a quarter of eligible Egyptians are registered to vote today. The exclusion was very useful to perpetuating autocracy but could be deadly for an emerging democracy. That will take months, money, and far-reaching organization to do even reasonably well.
It will be one thing to elect a new president and quite another to choose a new parliament in Egypt's transitional flux. The military now suggests the two elections can be held together within six months. But they will have very different logics and requirements. A presidential election will be much simpler. The old order will no doubt throw up a somewhat more palatable face, perhaps the former Foreign Minister Amr Moussa. The democratic opposition may well rally behind a single candidate (though the regime, no longer able to exclude a democratic alternative, will probably try to fragment the field with as many opposition candidates as possible). Still, voters will be faced with a few principal choices for national leadership, and it won't matter where people vote, so long as they are of voting age and only vote once. This kind of election can be done more roughly and quickly, tossing aside the voter register and just dipping every forefinger in indelible ink after it has marked a ballot for one presidential candidate or another. It will be important in this election-and every future one-to ensure transparency and citizen monitoring of the vote, as well as to have Egypt's judiciary oversee the balloting (as it did in previous elections until the judges got too good at it and Mubarak cut them out). But, otherwise, a presidential election won't be a complicated affair.
By contrast, new parliamentary elections present formidable challenges. First, Egyptians (and hopefully not just the military) must decide what electoral system will be used. This choice can invoke arcane debate, but it may be one of the most important that Egypt makes in pursuit of democracy. If the electoral rules are "majoritarian," in that they make it hard for small minorities to get elected, they will work to the disadvantage of not just small ideological tendencies but also the welter of new, emerging parties and political forces-many of them liberal and secular-that will just be taking shape and starting to test their strength. This will inflate the strength of the only two political forces that now have effective political organizations on the ground-the old ruling party and the Muslim Brotherhood (with a smattering of some of the other older opposition parties). If Egypt retains the current electoral system of two-member districts (with each voter getting two votes), these two established political forces could sweep most of the seats between them, marginalizing the moderates, polarizing the parliament and political system, and dooming democracy from the start. Creating a liberal center in democratic politics requires more than moral and technical support for these parties to function; it also requires rules that enable them to get traction.
A much better-and fairer-alternative would be to elect the new parliament using some form of proportional representation, so that parties would win seats roughly in proportion to their vote shares. That way, new parties could begin to gain a foothold in the political process. Perhaps ironically, the best way to do this might be the way Iraq now does, by using the existing governorates (29 in Egypt) as multimember districts, and having each district then elect a share of seats equivalent to its share of the population. This would allow for very proportional results, with districts generally containing ten to 25 seats, while still enabling some accountability and candidate familiarity at the local level.
A truly democratic parliamentary election in Egypt cannot be pulled off in six months. In fact, it might require well over a year to prepare. But the alternative would be to rush to a vote with a flawed system that would leave Egypt's new democratic forces on the margins not just of legislating but of constitution-making as well.
How a new permanent constitution will be drafted-if it is even intended by the military-also remains a mystery at this point. The worst option would be to have a closed and hurried process dominated from above by the military. But that seems to be what the junta intends for the transitional period. Successful democratic transitions either use an expert but broadly representative constitutional drafting commission, and then a popular referendum to confirm the draft, or an elected constitutional assembly (often acting simultaneously as a parliament), possibly followed also by a popular referendum (as in Iraq). Some have used all of these methods combined. Experience of recent decades underscores the importance for future democratic legitimacy and stability of eliciting extensive public dialogue and broad popular participation in the constitution-making process, with adequate preparation and civic education and widespread media exposure, as in South Africa. A thorough, inclusive, and deliberate process of constitutional drafting and debate can also help to breed a more democratic culture at both the elite and mass levels. A rushed and closed process perpetuates authoritarian mentalities (and, often, authoritarian rules as well).
Prior to all of this is the most basic question of who writes the rules, the timetable, and the mode of transition. Egypt has now entered a classic transition game where the authoritarian regime and the democratic opposition have sharply different interests and little basis for cooperation and trust. As an institution, Egypt's military may not be hated the way Mubarak and his cronies were, but many of the generals were Mubarak's cronies. And the military's core interests are not freedom and democracy for the people, but preserving their own power, wealth, privilege, and impunity. The core lesson of numerous prior transitions is the need for a negotiated way out of this potentially fatal impasse. Democrats want democracy with no guarantees to autocrats. Autocrats want guarantees, with no real democracy.
There is an obvious generic compromise, and every successful negotiated transition-from Spain and Brazil to Poland, South Africa, and Indonesia-has settled on a version of it. The old order gets to hang on to most of its wealth and privilege, along with military autonomy at least for a time. Few, if any, henchmen of the old order are prosecuted for their past crimes, unless it is for the last, desperate excesses of a few diehards trying to hang on during the transition. Real accountability waits for a later day. Democrats get democracy. Autocrats (mostly) retain their wealth and influence, but they cannot bid for power unless they play the democratic game. The Yale political scientist Robert Dahl coined a term for this type of bargain. He called it "mutual security." From the Spanish transition on, the generic bargain became known as a political pact.
Only a negotiated pact between Egypt's surviving authoritarian regime and its emergent democratic forces can steer the transition through the current treacherous straits to calmer and freer waters. For that to happen, Egypt's disparate democratic forces must unify in a broad negotiating front that unites the "outside" opposition of the youthful movements with the "inside" opposition of the "wise persons" and established parties who have so far dominated, on an ad hoc basis, the discussions with the old order.
Opposition unity will give Egypt's democrats strategic leverage; if negotiations stall due to regime intransigence, then the unified opposition can more credibly threaten to turn out people by the millions again in protest. But, if negotiations move forward to ensure the essential conditions for a democratic transition-an end to emergency rule; freedom of organization, expression, and assembly; judicial independence; and new and fair electoral administration-then a unified opposition can guarantee social peace and political stability. Opposition coherence enables clear negotiating priorities to level the playing field and ensure a democratic transition. It will also give the old order a clear set of interlocutors who can credibly commit to deliver popular support behind a difficult compromise agreement. No condition is more important for a successful transition.
The role for the United States and other international actors is not to dictate terms for the transition or structures for the new political order. That is not our place, and Egyptians of every political stripe will resent it. But international actors should offer training to political parties and technical and financial assistance to the new civil society organizations and state institutions needed to make democracy work. For the United States., this will mean millions of dollars in new assistance for democracy in Egypt-but that is a trifle compared to the $68 billion we have invested in dictatorship (even if it was to buy peace). No less importantly, other democracies (including leaders of recent democratic transitions) can encourage Egypt's opposition groups to coalesce and share lessons of the strategies and choices that have led to democratic outcomes. And the Obama administration can make it clear to Egypt's military rulers that nothing less than a real transition to democracy-with broad consultation, serious negotiations, and a new climate of freedom-will return Egypt to stability and a lasting partnership with the United States.
Film Screening: "To Russia With Love; The Great Radio War; Radio Free Europe and the Cold War"
Join us for a film screening (85 minute film) with A. Ross Johnson and R. Eugene Parta. Sponsored by The Europe Center at the Freeman Spogli Institute for International Studies, and the Center for Russian, East European and Eurasian Studies at Stanford University.
A workshop titled "Communicating to Unfree Societies: Cold War Legacies and Current Challenges" will take place the following day, February 23, from 1:30 to 4:45 PM in the Oksenberg Room of Encina Hall.
Building 320, Room 105 (Geology Corner, Main Quad)
Stanford University