摘要：The primary goal of HIV prevention is to prevent as many infections as possible. This requires allocating HIV-prevention resources according to costeffectiveness principles: those activities that prevent more infections per dollar are favored over those that prevent fewer. This is not current practice in the United States, where prevention resources from the federal government to the states flow in proportion to reported AIDS cases. Although such allocations might be considered equitable, more infections could be prevented for the same expenditures were cost-effectiveness principles invoked. The downside of pure cost-effective allocations is that they violate common norms of equity. In this article, we argue for a middle ground that promotes both equity and efficiency in allocating federal HIV-prevention resources. WHAT IS THE PRIMARY GOAL of HIV prevention? The obvious answer is, To prevent new HIV infections. What then should be the primary objective of a national HIV-prevention strategy? As argued in the recent Institute of Medicine (IOM) report 1 : to prevent as many new HIV infections as possible with the resources available for HIV prevention. How can this goal be achieved? By allocating HIVprevention resources to those activities that are most cost-effective. Many view the allocation of HIV-prevention resources principally as a political issue. Community-based organizations, advocacy groups, state health departments, and other stakeholders clamor for their fair share of the federal HIVprevention pie. Indeed, the existing federal allocation processes (for example, HIV-prevention community planning) and funding outcomes (for example, funding proportional to AIDS cases) are consistent with the view that fair division, and not cost-effectiveness, is the predominant concern in allocating HIV-prevention resources. We do not deny that equity and fairness are important considerations that must be factored into any resource allocation process. However, it is not often realized that the choices of which, and at what levels, HIV interventions will be funded have important consequences for the overall success of the national HIVprevention effort. Changing the way that available HIV-prevention dollars are allocated across different activities can have an even greater impact than increasing the overall level of spending on prevention. Viewed in this light, it is clear that the nation pays a price─measured in infections that could be averted but are not─for maintaining our current approach to resource allocation for HIV prevention.
