1. Too little too late: responses to the HIV/AIDS pandemic
Professor Hazel Barrett
Geography Department
Coventry University

2. A Global Crisis
Number of people living with HIV in 2005: Total million
Women million
Children 2.3 million
People newly infected with HIV in 2005: Total million
Children 0.7 million
AIDS deaths in 2005: Total million
Children (<15) million

3. In 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.

4. HIV/AIDS: Regional Statistics, 2005. (Source: UNAIDS, 2005)
People living with HIV
New HIV infections 2005
AIDS deaths 2005
Adult HIV prevalence %
Sub-Saharan Africa
25.8 million
3.2 million
2.4 million
7.2
Asia
8.2 million
1.1 million
521,000
0.4
Latin America
1.8 million
200,000
66,000
0.6
North America & Western & Central Europe
1.92 million
65,000
30,000
0.5
Eastern Europe Central Asia
1.6 million
270,000
62,000
0.9
Middle East & North Africa
510,000
67,000
58,000
0.2
Caribbean
300,000
24,000
1.6
Oceania
74,000
8,200
3,600
TOTAL
40.3 million
4.9 million
3.1 million
1.1

5. The World Bank identifies three types of HIV/AIDS epidemic:
NASCENT EPIDEMIC
An HIV epidemic in a country in which less than 5% of individuals in high-risk groups are infected.
CONCENTRATED EPIDEMIC
An 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 EPIDEMIC
An 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.

7. SUB-SAHARAN AFRICA
Sub-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.

8. The prevalence rate and number of people living with HIV/AIDS in sub-Saharan Africa (UNAIDS, 2005)
Year 5 10 15 20 25 30
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Millions
Number
of people
living
with HIV
and AIDS
% HIV
prevalence
adult (15-49)
Number of people living with HIV and AIDS
% HIV prevalence, adult (15-49)

9. In 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)

10. Southern Africa accounts for about 30% of global cases of HIV/AIDS, yet this region is home to only 2% of the world’s population
South 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 unavailable
outside region

11. According 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)

12. A 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 old
Females years old
More 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.

13. The 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)

15. Responses 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]

16. Period 1: Lots of words…. Period up to mid-1990s
1982 AIDS first identified
Nov 1983 WHO meeting to discuss global AIDS situation
1983 WHO Global Programme on AIDS
1986 Clinical trials of AZT
1988 World Summit of Ministers of Health in London
1 Dec 1988 First World AIDS Day
1991 Red Ribbon adopted as symbol

17. Background New disease No cure High cost of treatment
Limited resources
Denial and stigma

18. Response 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)

19. Biomedical and health belief response to HIV/AIDS epidemics

20. But infections continued to rise…questions asked…
Appropriateness for sexual behaviour
A Western approach
Onus on the individual
No understanding of the risk taking environment

21. Period 2: Not much action…
Period mid 1990s to 2000
1996 UNAIDS set up
UN agencies combined forces UNESCO, UNICEF, UNDP, UNFPA, WHO,WB, UNODC (1999), ILO (2001), WFP (2003), UNHCR (2004)
Multi-sectoral approach

22. Background Increase in HIV infection and deaths from AIDS
Epidemic evolves
High cost of ARV
Few resources
Knowledge increasing
Low useage of condoms

23. Response Primary Behaviour Change
Assumes that human beings are rational and key behaviours are under individual control.
Stresses: abstinence, reducing number of partners, using condoms
ABC approach
‘International responses to HIV and AIDS have changed from a narrow health sector approach to a multi-sectoral focus.’ (SIPPA, 2005, 11)

24. Sexual behaviour and biomedical determinants and responses to HIV/AIDS

25. Health Belief Model and Primary Behaviour Change responses to HIV/AIDS

26. But infections continued to rise…questions asked…
Why are people still continuing to take risks
Research showing that individual agency is constrained by social, economic and structural factors, such as poverty, mobility and migration patterns and gender inequality (Parker, 2000).

27. Period 3: Better late than never…
Period 2000 to date
2000 Tackling HIV/AIDS becomes a Millennium Development Goal
2001 UN General Assembly Special Session on HIV/AIDS
2001 Global Fund to fight AIDS, malaria and TB set up
2003 ‘3 by 5 campaign
2005 UN World Summit.

28. Background Emphasis moved from prevention to treatment and care
Cost of HAART reduced
Increased international funding
Renewed international commitment to tackle HIV/AIDS
Recognition that HIV/AIDS is a development issue.

29. The cost of Highly Active Antiretroviral Therapy (HAART)
Early US$ 10,000-12,000 pp pa
End of 2000 US$ pp pa
May 2003 WHO recommended brand named drugs US$ 675 pp pa
May 2003 WHO recommended generic drugs US$ 300 pp pa

30. Price of ARV therapy in Uganda (UNAIDS, 2005)
2 000
4 000
6 000
8 000
10 000
12 000
14 000
Price US$
Jun 00
Oct
Feb 01
Apr
Dec
Nov
Jul
Mar 03
Sep 98
Aug
Jan
May 10
Launch of Accelerating
Access Initiative (AAI)
Negotiatiations with R & D Pharma within AAI
Generic companies’ offer of price reduction to Uganda
Further price reductions by AAI companies
Further discussion with generic companies
Negotiations by William J. Clinton
Foundation with 4 generic companies
600
700
800
900
1 000
1 100
1 200
500
400
300
200
100

31. ‘3 by 5’ Campaign
In 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.’

32. In 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.

33. In 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%.

34. Numbers of people receiving and needing ARV therapy in December 2005, by WHO region. (Source: WHO, 2006)
WHO Region
Estimated no. of people receiving ARV December 2005
Estimated no of people under 49 years needing ARV 2005
ARV coverage, December 2005
African Region
810,000
4,700,000
17%
Region of the Americas
315,000
465,000
68%
European Region
21,000
160,000
13%
Eastern Mediterranean Region
4,000
75,000 5%
South-East Asia Region
Western Pacific region
140,000
40,000
970,000
150,000
14%
27%
TOTAL
1,330,000
6,500,000
20%

35. At 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.

36. ARV is not a cure
It 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.

37. International commitment is shown by increased funding since 2000 (UNAIDS, 2005)
500
1,000
1,500
2,000
2,500
3,000
1996
1997
1998
1999
2000
2001
2002
Domestic
Private
UN System
Bilateral
US$ millions

38. The main bi-lateral donors in 2004 (UNAIDS, 2005)
EC 4.0% ($65m)
Netherlands 4.0% ($65m)
Norway 3.1% ($51m)
Ireland 2.4% ($40m)
Australia 2.4% ($39m)
Italy 1.5% ($25m)
France 1.5% ($25m)
Other 2.4% ($40m)
Canada 4.0% ($66m)
Japan 5.2% ($85m)
Germany 6.5% ($107m) US
35.2% ($577m) UK
27.6% ($452m)

39. Yet promises are not always translated into action (UNAIDS, 2005)EC
11%
Italy 9%
Germany 7%
U.K. 6%
Other
Govt’s
Japan 5%
Netherlands 3%
Canada 2%
Corporate/Private* 2%
France
14%
U.S.
33%
19%
10%
Germany 2%
U.K. 6% 8%
Netherlands 2%
Corporate/Private* 5%
France 6%
30%
Total pledges:
US$ 4,966 million
Total contributions received:
US$ 2,104 million
*Foundations and Non-for-profit organizations, Corporations, and Individuals, Groups and Events

40. Some questions…and a paradigm drift…
ARVS are welcome but might divert resources from prevention programmes and could result in complacency
Infection and death from HIV and AIDS continue to rise.
Despite good levels of knowledge people continue to engage in risky sexual behaviour

41. Some 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)

42. People 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.

43. Paradigm 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.

45. Campbell ( 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)

46. The wider picture of the factors that facilitate HIV transmission

47. Too 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)

49. References
Barnett, 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.

50. Potts, 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 December
UNAIDS, 2004, AIDS epidemic update December
UNAIDS, 2005, AIDS epidemic update December
UNESCO, 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.