Sir - Andrew Creese and colleaguesCreese A, Floyd K, Alban A, et al. Cost - effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Lancet 2002; 359: 1635 - 42. [Text] and Elliot Marseille and colleaguesMarseille E, Hofmann P, Kahn J. HIV prevention before HAART in sub - Saharan Africa. Lancet 2002; 359: 1851 - 56. [Text] argue that treatment of AIDS is not cost effective in some African settings. Their conclusions reflect a depressing backslide in the fight against the world's most disastrous pandemic. The vast needs and limited resources in developing countries, where tens of millions are infected, have led to endless debate but little action.

The international community has finally responded to a pandemic that alerts the world to the threats of emerging and recrudescing infectious diseases in an increasingly polarised world. There is now widespread recognition that it is a strategic and a moral imperative to make simple, effective, and affordable treatment available to as many people as possible. Richard HortonHorton R. The health (and wealth) of nations. Lancet 2002; 359: 993 - 94. [Text] notes the need to provide treatment for HIV/AIDS, and support such policies as the Doha Declaration, which affirms countries' rights to put their people's health before the market monopolies of pharmaceutical companies.

Intense opposition to pharmaceutical monopolies and increased market competition between brand and generic drugs have led to a fall in the yearly cost of triple therapy from US$15,000 to less than $300; WHO has sourced quality manufacturers of affordable antiretrovirals, and these drugs have finally been included in the Essential Drugs List.

But now, on the basis of flimsy economic data,1 WHO seems to recommend letting millions die without effective treatment. WHO is not an academic institution; it is a UN agency of substantial influence. Its mandate is health for all, and its job is to provide sound policy recommendations to save and improve lives.

Rather than accepting the price of drugs as immutable, WHO should be putting more energy into working with UNAIDS to bring the price of antiretrovirals within reach, calling for more funding and contesting those worldwide forces that keep billions of people in perpetual poverty. Treatment and prevention are inextricably linked; offering treatment strengthens prevention measures, and prevention is less effective without treatment.

Cost-effectiveness alone is a misguided way to justify one over the other. Social and economic benefits are vast: children saved from being orphaned, and longer life means people can contribute to society.Macroeconomics and health: investing in health for economic development - - report of the Commission on Macroeconomics and Health. Geneva: WHO, 2001. Cost-effectiveness analyses represent a narrow viewpoint from which relevant stakeholders are entirely excluded. Such analyses have never been an exclusive prescription for health-care choices in the developed world, and to advise the less-developed world to use them as such is iniquitous.

If they were applied consistently to all medical disorders, they would have been applied to the measures that could be taken to prevent 75% of preventable cardiovascular deaths in the worldBeaglehole R. Global cardiovascular disease prevention: time to get serious. Lancet 2001; 358: 661.. Narrow cost-effectiveness analyses of AIDS treatment in developing countries promote a medical ethic that would never be considered in the developed world, allowing people to die when drugs are available that can save them. Prevention improves public health, but cannot replace treatment of preventable diseases.

How are doctors in Africa to tell their patients they cannot treat them because it is not cost effective? We should be doing everything we can to prevent disease in the future while providing effective treatment for those who suffer today.