Presentation on theme: "Adults and children estimated to be living with HIV as of end 2004 Total: 39.4 (35.9 – 44.3) million Western & Central Europe 610 000 [480 000 – 760 000]"— Presentation transcript:
Adults and children estimated to be living with HIV as of end 2004 Total: 39.4 (35.9 – 44.3) million Western & Central Europe 610 000 [480 000 – 760 000] North Africa & Middle East 540 000 [230 000 – 1.5 million] Sub-Saharan Africa 25.4 million [23.4 – 28.4 million] Eastern Europe & Central Asia 1.4 million [920 000 – 2.1 million] South & South-East Asia 7.1 million [4.4 – 10.6 million] Oceania 35 000 [25 000 – 48 000] North America 1.0 million [540 000 – 1.6 million] Caribbean 440 000 [270 000 – 780 000] Latin America 1.7 million [1.3 – 2.2 million] East Asia 1.1 million [560 000 – 1.8 million]
About 14 000 new HIV infections a day in 2004 l More than 95% are in low and middle income countries l Almost 2000 are in children under 15 years of age l About 12 000 are in persons aged 15 to 49 years, of whom: — almost 50% are women — about 50% are 15–24 year olds
Strategic goals in HIV prevention l Reduce the transmission l Lowering the risk of STI/HIV transmission – targeted interventions l Reduce the vulnerability l Prolonging and improving the quality of life – treatment and care of STI/HIV and related morbidity and disability l Reduce the impact l Promoting enabling health sector policies and institutional environments
Key issues in the region l Rapidly growing epidemic of HIV infections l 1300% increase 1996-2001 l Low numbers of reported AIDS cases l Epidemic of injecting drugs l 1% of the population inject drugs l IDU are > 2/3 of all new HIV cases l Epidemic of Sexually Transmitted Infections (STI) l Widespread high-risk sexual behavior l STI cofactor for HIV transmission l Poverty l Inability of the health sector to respond to the challenge
l Most proximal determinants of STI spread in any population are the three components of the rate of spread (R 0 ) model l R 0 = β c D l transmission efficiency per contact (infectivity, β), rate of contact between infected and susceptible individuals (c) and duration of infectiousness (D)
HIV Prevention: Main Lesson Learned l When the health status of populations most affected by inequity and alienations fails to improve despite the efforts of conventional public health approaches l Generally applied to those marginalized by poverty, ethnicity, geography, and different cultural or behavioural norms (like injecting drug use or sexual orientation) l People who engage in illicit or socially disapproved behaviours such as drug use and sex work. l HIV/AIDS epidemics are concentrated in specific populations that are often marginalized and vulnerable to a broad range of health and psychosocial difficulties apart from, or in addition to, HIV/AIDS.
Public Health Approach ProblemResponse Surveillance: What is the problem? Risk Factor Identification: What is the cause? Intervention Evaluation: What works? Implementation: How do you do it?
Impediments to HIV prevention in low prevalence/emerging epidemic countries l Low priority l We’re different –’Risk behaviour does nor happen here so there’s no need to respond’ l Lack of capacity l Tendency to focus on politically popular but epidemiologically inefficient groups, e.g. general population l Vicious circle of lack of data→ no response→ lack of data…
Prevention Framework Enabling Environment Service and Commodities Empowerment for Prevention Decrease in Risky Behavior Modify Biologic Factors Decrease in HIV Incidence
Factors Affecting HIV Prevention Individual micro- level factors Structural intermediate- level factors Structural macro- level factors Individual level knowledge of HIV risk and prevention Area-based treatment center and neighborhood characteristics; poverty and deprivation Socio-economic status of populations Individual characteristics targeted in prevention programs Personal vulnerabilities such as knowledge and skills Structural level laws, policies, standard operating procedures; environmental conditions and resources of individuals Economic conditions or policies Programmatic vulnerabilities such as education and services Economic underdevelopment, gender inequality Societal vulnerabilities such as discrimination of HIV-positive Class, race, gender, sexuality inequalities
Social capital l By Putnam: “the core idea of social capital is that social networks have value” – includes trust, reciprocity, cooperation among members of social networks l As a variable contains community organisational life, involvement in public affairs, social trust, informal sociability l Numerous linkages between social capital and health: influences healthy behaviours by establisinh societal norms supportive to that behaviours; fosters accessibility to healthcare services; fosters mutual trust and respect l Structural interventions are based in part on social capital approach
Structural Interventions l Interventions that operate at the environmental or structural level and alter the context for individual action l Three kinds of contextual factors that determine health: availability (of behaviours, tools, materials), acceptability (health is determined by values, culture and beliefs), accessibility (health function of social, economic and political power) Examples: 100% condom brothels Legalizing Drug-substitution Treatment Decrease condom prices
l In the recent years, the approach to HIV/AIDS has broadened to focus not only on individual risk- taking behaviour, but also on societal factors that influence risky behaviour: from risky behaviours to risky environments
Effective HIV programs Characteristics (1) 1. Designed according to needs 2. Affordable and easy to access 3. Culturally competent, and include members of the target population in program planning and implementation 4. Clearly defined target group (s), interventions and program components, and objectives 5. Non- judgmental, moralistic, or attempt to instil fear
Effective HIV programs. Characteristics (2) 6. Enough duration and intensity 7. Consistent and reinforced messages 8. Offered as part of a continuum of health care 9. Address other basic needs of the targeted population (e.g., housing, food) in order for HIV prevention to be considered a priority 10. Regularly monitored to assure implementation is according to plan and that outcomes are being met
Need to Return to Public Health Principles l Discard concept of exceptionalism l Primary responsibility to protect the uninfected l Promote (risk-free) testing l Prevention of transmission
Intervention Strategies l Educational approaches l Behavioral (theory-based) l Harm reduction l Community intervention
Past and current STI Control Past l Total State Control: Active case detection, in-patient treatment, obsolete drug regimens, lack of confidentiality (in former Soviet Union countries) Current l Loss of State Control: Shift from public to private providers, fee for service, lack of reporting, indi-vidual responsibility and community participation, supportive legal and social environment
Neki podaci iz Hrvatske – istrazivanje spolnog ponasanja na nacionalnom uzorku, 18 – 24 godine, 2004. % zena I muskaraca koji su tocno prepoznali klamidiju I HPV kao uzrocnike spolno prenosivih bolesti
Key Elements for Successful Interventions l Mobilization of political will and commitment l Good surveillance l Learn and adapt from past experiences l Unified national planning l Rapid implementation l Focused intervention especially to marginalized groups l Access to intervention tools e.g. condoms, testing l Community involvement l Reduce stigmatization and discrimination
Gaps and Questions l Size of key populations at risk? l Levels of risk – population-based surveys lacking in at-risk populations l Reach of prevention programmes – coverage remains the great unknown l Quality issues in existing surveillance systems l We need to do more convincing analyses and use them to mobilise responses and resources l Little cross-disciplinary research l What is the capacity of the current social conditions to generate more explosive HIV epidemic?
l Need for a shift from a narrow epidemiological perspective to a comprehensive approach that should include qualitative and quantitative work on behaviours and vulnerability factors l This should lead to a focus not only on interventions aimed at ”persuading” individuals to adopt certain behaviours, but on those “enabling” them to do so, or at least easing the way
Criteria for Evaluating HIV prevention Programmes 1) Relevance l perception as relevant by target groups l cultural and contextual relevance 2) Efficiency – well coordinated planning and implementation – reach (coverage) 3) Impact – impact on reported rates of STD and HIV – impact on HIV-related knowledge, beliefs and attitudes – impact on safer sex practices and safer forms of drug use 4) Sustainability – generalizability to other contexts – cost-effectiveness 5) Ethical soundness