1. Public Health Practice I: HIV/AIDS Consequences for Socio- Economic Development Thomas Novotny The World Bank

2. Outline of Presentation 1.The Global HIV/AIDS Pandemic 2.HIV/AIDS in Europe and Central Asia 3.Potential economic impact 4.Policy approaches 5.The Balkans, Moldova & Central Asia 6.Conclusion

3. + 1 300% +60% + 160% + 100% + 30% + 40% + 20% Global HIV Pandemic UNAIDS

4. Adult (15-49) HIV prevalence rate 0.6% (range: 0.4-0.9%) Adults (15-49) living with HIV 1 300 000 (range: 850 000- 1 900 000) Adults and children (0- 49) living with HIV 1 300 000 (range: 860 000- 1 900 000) Women (15-49) living with HIV 440 000 (range: 280 000- 650 000 ) AIDS deaths (adults and children) in 2003 49 000 (range: 32 000- 71 000) HIV/AIDS Estimates in ECA (2003) UNAIDS 2003

5. Epidemic Outlook Eastern Europe and Central Asia confront 4 overlapping epidemics  Drug Use  HIV/AIDS  Sexually Transmitted Infections  Tuberculosis Epidemic drivers act regionally and can best be addressed at regional level  Trafficking in people and drugs  Economic and political migration  Sex Work  Prisons Godinho J, Renton A, Vinogradov V, Novotny T, Gotsadze G, Rivers MJ, Bravo M (2004)

7. Explosive Epidemics of HIV among IDU 0 20 40 60 80 19831985 1987198919911993 1995 HIV prevalence (%) Year Edinburgh Bangkok Myanamar Manipur Odessa 19971999 2001 Samara RF Renton A 2004

8. STI/IDU/HIV Interactions High STI Prevalence Low STI Prevalence Successful IDU harm reduction No IDU harm reduction 1 0 explosive IDU epidemic 2 0 larger sexually transmitted epidemic Contained IDU epidemic Smaller and slower 2 0 sexually transmitted epidemic 1 0 explosive IDU epidemic Smaller and slower 2 0 sexually transmitted epidemic Contained IDU epidemic Very small and slow 2 0 sexually transmitted epidemic Renton A 2004

9. Epidemiological Factors Prevalence of TB in PLWH MDR-TB Prevalence in PLWH Duration of infectiousness in PLWH STI and other co-morbidities TB INFECTION ACTIVE TB CURE RECURRENCE DEATH TB TRANSMISSION Role of HIV/AIDS in Fueling the TB epidemic Interventions to avert the TB epidemic fueled by HIV/AIDS TB Preventive Treatment Intensified case-finding Decreased delay in case detection and DOTS BCG TB Preventive Treatment Access to Second-line drugs Lack of access to HAART STI Treatment Harm Reduction for IUD Condom Use Socio-structural Factors Over-crowded prisons Poverty related commercial sex Sale and transfusion of contaminated blood

10. HIV/AIDS Role in Poverty Loss of income Catastrophic cost of care Increased dependency ratio Loss of productivity (companies) Loss of social capital (countries) Reduced national income? Contributors to Poverty HIV Infection AIDS

11. Epidemic Drivers Economic & Political migration Poverty/ Income Differential s Unemploym ent Drug Traffickin g Low levels of population awareness and knowledge of HIV & STI Explosion of Injecting Drug Use Explosion of Commercial Sex Work Epidemics of STIs Low Level HIV Epidemic Concentrated HIV Epidemic Generalized HIV Epidemic Renton 2004

12. Potential Economic Impact in Russia Economic growth rates could decline by 0.5-1.0 percent annually Health expenditures could increase up to 50 percent Costs of treatment would not be sustainable The dependency ratio could rise Household size & composition could change Transfer of intellectual capital and social skills from one generation to another could be lost Ruhl C, Pokrovsky V, Vinogradov V 2002

13. Policy Approaches Decriminalize risk behavior Improve medical treatment Social support to PLWHA Legislative authority for NGOs to work with vulnerable groups Reproductive health & HIV/AIDS Education  IDU, CSW, MSM, Migrants  Narcology, HAART, STIs, TB  Social protection, palliative care  Harm Reduction, outreach  Schools,policymakers, general public

14. Information Needs Sentinel surveillance of high risk groups –Behavioral –Serologic Respondent-driven sampling Venue-based testing Voluntary testing and counseling Data used for decision making Harm reduction Education programs Supply chain for drugs, supplies, condoms Prison health system National AIDS Programs Monitoring Evaluation

15. Non-financial Factors  Political will and perception  Social constraints and stigmatization  Community, Gender, and Values  Institutional capacity to implement effective interventions  Regulatory and legal issues  Donors Coordination

16. Funding Needs Funding would have to increase from $300 million in 2001 to $1.5 billion in 2007  40% for prevention  55% for care and treatment  5% for policy, administration, research & evaluation For treatment of HIV/AIDS & TB, funding would have to increase  For ARVT, from $60 million in 2002 to more than $600 million by 2007  For TB control, from <1 billion in 2001 to $1.9 billion by 2007 UNAIDS and The World Bank 2003

17. HIV/AIDS in ECA Countries  Opportunity for prevention is now  Cross-border externalities important in addressing most vulnerable groups  Future burden on health systems and economic productivity may be enormous  Sentinel surveillance in high risk groups and vulnerable populations is needed  Harm reduction application and decriminalization are needed  Public information and professional education are essential

18. Youth Vulnerability 80% of infected persons are less than 30 years of age in ECA Primary carriers are boys and young men CSW and trafficking in girls and young women IDU, heavy alcohol use, and lack of access to reproductive health education and safe sex Iatrogenic cases in Romania

19. Mobile Populations Sailors, truckers (37% have unsafe sex while traveling) Peacekeepers Commercial Sex Workers (CSW) Trafficked women and children Roma and other ethnic minorities (8 million in ECA) Displaced people Tourists

20. Harm Reduction in Prisons

22. Is Harm Reduction working in Moldova? Laticevschi D 2004 New Cases

23. HIV/AIDS in Central Asia

24. Why should we take HIV/AIDS seriously in ECA Steep growth of HIV cases in the Region Established relation between Injecting drug use, STI and TB Share of youth over 40% of the population Low levels of knowledge about the epidemics

25. Red: high risk oblasts, major drug routes Green: human trafficking routes Drug and migration routes Renton A, Gzirishvili D, Gotsadze G, Godinho J 2004

26. Results Prevention Needs US$208 million Treatment Costs US$??? million per year + Existing Resources: 2002 to 2010 US$75 million Given needs outweigh resources what is best way to spend the money? Cercone 2004 J 2004

27. AIDS Challenges in ECA  Target most vulnerable groups with appropriate approaches  Improve Public Health functions  Increase opportunities for youth to participate in the knowledge economy