Presentation on theme: "Too little too late: responses to the HIV/AIDS pandemic"— Presentation transcript:
1Too little too late: responses to the HIV/AIDS pandemic Professor Hazel BarrettGeography DepartmentCoventry University
2A Global CrisisNumber of people living with HIV in 2005: Total millionWomen millionChildren 2.3 millionPeople newly infected with HIV in 2005: Total millionChildren 0.7 millionAIDS deaths in 2005: Total millionChildren (<15) million
3In every global region the number of people living with HIV is rising. Steepest rises have been in East Asia, Central Asia and Eastern Europe where there has been a 9-fold increase in the last decade.But the situation is most serious in sub-Saharan Africa.
4HIV/AIDS: Regional Statistics, 2005. (Source: UNAIDS, 2005) People living with HIVNew HIV infections 2005AIDS deaths 2005Adult HIV prevalence %Sub-Saharan Africa25.8 million3.2 million2.4 million7.2Asia8.2 million1.1 million521,0000.4Latin America1.8 million200,00066,0000.6North America & Western & Central Europe1.92 million65,00030,0000.5Eastern Europe Central Asia1.6 million270,00062,0000.9Middle East & North Africa510,00067,00058,0000.2Caribbean300,00024,0001.6Oceania74,0008,2003,600TOTAL40.3 million4.9 million3.1 million1.1
5The World Bank identifies three types of HIV/AIDS epidemic: NASCENT EPIDEMICAn HIV epidemic in a country in which less than 5% of individuals in high-risk groups are infected.CONCENTRATED EPIDEMICAn HIV epidemic in a country in which 5% or more of individuals in high-risk groups, but less than 5% of women attending urban ante-natal clinics are infected.GENERALISED EPIDEMICAn HIV epidemic in a country where more than 5% of individuals in high-risk groups as well as women attending urban ante-natal clinics are infected.(World Bank, 1997, 87)It is easier to control a nascent epidemic than a generalised one.
7SUB-SAHARAN AFRICASub-Saharan Africa, home to 10% of the world’s population has over 60% of global cases of HIV.Region is home to 25.8 million people living with HIV.In 2005 there were 3.2 million new infections and 2.4 million deaths from AIDS.It is home to over 75% of all women globally living with HIV.
8The prevalence rate and number of people living with HIV/AIDS in sub-Saharan Africa (UNAIDS, 2005)Year510152025301985198619871988198919901991199219931994199519961997199819992000200120022003MillionsNumberof peoplelivingwith HIVand AIDS% HIVprevalenceadult (15-49)Number of people living with HIV and AIDS% HIV prevalence, adult (15-49)
9In sub-Saharan Africa adult HIV prevalence has been stable in recent years at about 7.2%. ‘But stabilisation does not necessarily mean the epidemic is slowing. On the contrary, it can disguise the worst phases of an epidemic – when roughly equal numbers of people are being newly infected with HIV and are dying of AIDS.’ (UNAIDS, 2004)
10Southern Africa accounts for about 30% of global cases of HIV/AIDS, yet this region is home to only 2% of the world’s populationSouth Africa has the highest number of HIV/AIDS cases of any country, the figure exceeds 5 million people.Three countries have adult prevalence rates exceeding 30%:Botswana 39%Lesotho 31%Swaziland 39%20% − 39%10% − 20%5% − 10%1% − 5%0% − 1%trend data unavailableoutside region
11According to the UNAIDS 2003 report ‘The epidemic in sub-Saharan Africa remains rampant.’ ‘The AIDS epidemics coursing through this region are highly varied – both between and within sub-regions. It is therefore inaccurate to speak of a single, “African” epidemic.’ (UNAIDS, 2004)
12A generalised epidemic causing demographic devastation The main transmission route of the disease in sub-Saharan Africa is unsafe heterosexual intercourse.The peak age of AIDS cases in the region are:Males years oldFemales years oldMore women (60%) than men are infected.Recent studies show that on average 36 young women (15-24 years) are living with HIV for every 10 young men.In 2005 over 0.5 million children were infected with HIV as a result of mother-to-child transmission.
13The result has been the loss of a whole generation of young adults. They leave over 8 million orphans, some estimates put it at 12 million.
14‘The rapid spread of HIV in sub-Saharan Africa is one of the greatest failures in the history of public health.’ (Potts & Walsh, 2003, 1389)
15Responses to the Pandemic Period 1: Up to mid 1990s: Lots of words…Characterised by Health Belief Model [a medical problem]Period 2: Mid 1990s to 2000: Not much action…Characterised by Primary Behaviour Change (informed by Health Belief Model) [a behavioural problem]Period 3: 2000 to date: Better late than never…Period of paradigm ‘drift’, recognition that social, community and structural factors are important, but biomedical and behavioural approaches still dominant [a development issue]
16Period 1: Lots of words…. Period up to mid-1990s 1982 AIDS first identifiedNov 1983 WHO meeting to discuss global AIDS situation1983 WHO Global Programme on AIDS1986 Clinical trials of AZT1988 World Summit of Ministers of Health in London1 Dec 1988 First World AIDS Day1991 Red Ribbon adopted as symbol
17Background New disease No cure High cost of treatment Limited resourcesDenial and stigma
18Response Health Belief Model Based on the assumption that behaviour is shaped by the conscious decisions of rational individuals.Response very much medically and epidemiologically driven.Education and knowledge are regarded as ‘the key to effective prevention’ (UNESCO, 2005, 6)
19Biomedical and health belief response to HIV/AIDS epidemics
20But infections continued to rise…questions asked… Appropriateness for sexual behaviourA Western approachOnus on the individualNo understanding of the risk taking environment
21Period 2: Not much action… Period mid 1990s to 20001996 UNAIDS set upUN agencies combined forces UNESCO, UNICEF, UNDP, UNFPA, WHO,WB, UNODC (1999), ILO (2001), WFP (2003), UNHCR (2004)Multi-sectoral approach
22Background Increase in HIV infection and deaths from AIDS Epidemic evolvesHigh cost of ARVFew resourcesKnowledge increasingLow useage of condoms
23Response Primary Behaviour Change Assumes that human beings are rational and key behaviours are under individual control.Stresses: abstinence, reducing number of partners, using condomsABC approach‘International responses to HIV and AIDS have changed from a narrow health sector approach to a multi-sectoral focus.’ (SIPPA, 2005, 11)
24Sexual behaviour and biomedical determinants and responses to HIV/AIDS
25Health Belief Model and Primary Behaviour Change responses to HIV/AIDS
26But infections continued to rise…questions asked… Why are people still continuing to take risksResearch showing that individual agency is constrained by social, economic and structural factors, such as poverty, mobility and migration patterns and gender inequality (Parker, 2000).
27Period 3: Better late than never… Period 2000 to date2000 Tackling HIV/AIDS becomes a Millennium Development Goal2001 UN General Assembly Special Session on HIV/AIDS2001 Global Fund to fight AIDS, malaria and TB set up2003 ‘3 by 5 campaign2005 UN World Summit.
28Background Emphasis moved from prevention to treatment and care Cost of HAART reducedIncreased international fundingRenewed international commitment to tackle HIV/AIDSRecognition that HIV/AIDS is a development issue.
29The cost of Highly Active Antiretroviral Therapy (HAART) Early US$ 10,000-12,000 pp paEnd of 2000 US$ pp paMay 2003 WHO recommended brand named drugs US$ 675 pp paMay 2003 WHO recommended generic drugs US$ 300 pp pa
30Price of ARV therapy in Uganda (UNAIDS, 2005) 2 0004 0006 0008 00010 00012 00014 000Price US$Jun00OctFeb01AprDecNovJulMar03Sep98AugJanMay10Launch of AcceleratingAccess Initiative (AAI)Negotiatiations with R & D Pharma within AAIGeneric companies’ offer of price reduction to UgandaFurther price reductions by AAI companiesFurther discussion with generic companiesNegotiations by William J. ClintonFoundation with 4 generic companies6007008009001 0001 1001 200500400300200100
31‘3 by 5’ CampaignIn 2003 UNAIDS committed itself to providing ARV to 3 million HIV suffers in the poorest countries by 2005.According to UNAIDS the campaign is ‘the declaration of an emergency.’
32In December 2003 South Africa announced it would make available free HAART treatment to all citizens who were HIV+.Uganda has pledged to give HAART to all HIV+people from January 2004 starting with pregnant women.
33In Uganda ARV therapy is available to 40% of those in need, in Botswana and Namibia the coverage is 25%. In a further 13 countries coverage is 10%.
34Numbers of people receiving and needing ARV therapy in December 2005, by WHO region. (Source: WHO, 2006)WHO RegionEstimated no. of people receiving ARV December 2005Estimated no of people under 49 years needing ARV 2005ARV coverage, December 2005African Region810,0004,700,00017%Region of the Americas315,000465,00068%European Region21,000160,00013%Eastern Mediterranean Region4,00075,0005%South-East Asia RegionWestern Pacific region140,00040,000970,000150,00014%27%TOTAL1,330,0006,500,00020%
35At the end of 2004, 310,000 people were receiving ARV in the region and by June 2005 this had reached 500,000.By December ,000 people (17%) of those needing ARV were receiving it.According to UNAIDS US$3.8 billion is needed in 2005 to achieve the target, yet only US$1.55 billion has been donated.
36ARV is not a cureIt can prolong the life of an HIV suffer and provide a reasonable quality of life, enabling suffers to work and care for their families.By reducing the viral load in the genital tract the spread of the disease might be slowed.But there are issues of patient compliance especially in deprived communities.Fears of drug resistant strains of the virus developing.
37International commitment is shown by increased funding since 2000 (UNAIDS, 2005) 5001,0001,5002,0002,5003,0001996199719981999200020012002DomesticPrivateUN SystemBilateralUS$ millions
39Yet promises are not always translated into action (UNAIDS, 2005) EC11%Italy9%Germany7%U.K.6%OtherGovt’sJapan5%Netherlands 3%Canada 2%Corporate/Private* 2%France14%U.S.33%19%10%Germany 2%U.K. 6%8%Netherlands 2%Corporate/Private* 5%France 6%30%Total pledges:US$ 4,966 millionTotal contributions received:US$ 2,104 million*Foundations and Non-for-profit organizations, Corporations, and Individuals, Groups and Events
40Some questions…and a paradigm drift… ARVS are welcome but might divert resources from prevention programmes and could result in complacencyInfection and death from HIV and AIDS continue to rise.Despite good levels of knowledge people continue to engage in risky sexual behaviour
41Some countries in East Africa, such as Ethiopia, Kenya, Uganda and Zimbabwe show signs of decline in infection levels.The steepest drop has been in Uganda, where national prevalence rates have fallen from 13% in early 1990s to 4.1% at end of This it is suggested has been the result of behavioural change, in particular an increased use of condoms.But it is too early to claim that these declines herald a definitive reversal of the epidemic in these countries, recent research suggests infections are once again increasing.But ‘East Africa continues to provide the most hopeful indications that serious AIDS epidemics can be reversed.’ (UNAIDS, 2005, 25)
42People need knowledge to enable them to be able to make choices about their life styles. But this alone can’t guarantee behavioural change.There are many intervening factors that prevent individuals adopting safer behaviour.
43Paradigm drift‘Evidence is mounting that global models of HIV/AIDS prevention, designed by Western experts, have been largely ineffective in Africa.’ (Green, 2003) He continues by saying AIDS is a ‘behavioural problem with behavioural solutions.’ but this is questioned by Farmer. He states that it is becoming clear that ‘AIDS is also surely, a social problem with social solutions.’ (Farmer, 2003).
44‘…a generalised HIV/AIDS epidemic does not just happen ‘…a generalised HIV/AIDS epidemic does not just happen. There are social, economic and cultural reasons why such events occur.’ ‘In certain circumstances risk environments develop and these increase susceptibility.’ (Barnett & Whiteside, 2003, 96 & 97)Hemrich & Topouzis (2000) state that AIDS is rooted in problems of poverty, food and livelihood insecurity, socio-cultural inequalities and poor support services and infrastructure.
45Campbell ( 2003) argues that there is a need to focus on the psycho-social and community level determinants of sexuality. We need to pay attention to the social change that needs to take place to support the likelihood of healthier sexual behaviour. She states that ‘Sexual behaviour, and the possibility of sexual behavioural change, are determined by an interlocking series of multi-level processes, ranging from the intra-psychological to the macro-social.’ (p. 183)
46The wider picture of the factors that facilitate HIV transmission
47Too Little…Too Late…‘AIDS responses have grown and improved considerably over the past decade. But they still do not match the scale or the pace of a steadily worsening epidemic.’ (UNAIDS, 2005,5)‘…the AIDS epidemic continues to outstrip global efforts to contain it.’ (UNAIDS, 2005,6)‘…responses to the epidemic came too late and were not commensurate to the magnitude and urgency of the challenge.’ (UNESCO, 2005, 5)
48‘Bringing AIDS under control will require tackling with greater resolve the underlying factors that fuel these epidemics – including societal inequalities and injustices.’ (UNAIDS, 2005, 5)For Basu (2004) AIDS ‘is a symptom as much as it is a disease.’ (p. 158)
49ReferencesBarnett, T & Whiteside, A, 2003, AIDS in the twenty-first century: disease and globalisation. Palgrave Macmillan, Basingstoke.Basu, S, 2004, AIDS, empire and public health behaviourism. International Journal of Health Services, 34 (1),Campbell, C, 2003, ‘Letting them die’: why HIV/AIDS prevention programmes fail. International African Institute, Oxford.Farmer, P, 2003, AIDS: a biosocial problem with social solutions. Anthropology News 44 (6).Green, E.C, 2003, New challenges to the AIDS prevention paradigm. Anthropology News, 44 (6)Hemrich, G & Topouzis, D, 2000, Multi-sectoral responses to HIV/AIDS: constraints and opportunities for technical cooperation. Journal of International development, 12,Parker, R.G, Easton, D & Klein, C.H, 2000, Structural barriers and facilitators in HIV prevention: a review of international research. AIDS, 14 (1), S22-S32.
50Potts, M & Walsh, J, 2003, Tackling India’s HIV epidemic: lessons from Africa. British Medical journal, 326,SIPAA, 2005, Building bridges with SIPAA:lessons from an African response to HIV and AIDS. www. sipaa.org.UNAIDS, 2003, AIDS epidemic update DecemberUNAIDS, 2004, AIDS epidemic update DecemberUNAIDS, 2005, AIDS epidemic update DecemberUNESCO, 2005, UNESCO’s response to HIV and AIDS.World Bank, 1997, Confronting AIDS: public priorities in a global epidemic. OUP, Oxford.WHO, 2006, Progress on global access to HIV antiretroviral therapy: a report on “3 by 5” and beyond.