Too little too late: responses to the HIV/AIDS pandemic

Professor Hazel Barrett

Geography Department

Coventry University

A Global CrisisNumber of people living with HIV in 2005: Total 40.3 million

Women 17.5 millionChildren 2.3 million

People newly infected with HIV in 2005: Total 4.9 millionChildren 0.7 million

AIDS deaths in 2005: Total 3.1 millionChildren (<15) 0.57 million

• 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.

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 30,000 24,000 1.6

Oceania 74,000 8,200 3,600 0.5

TOTAL 40.3 million 4.9 million 3.1 million 1.1

The 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.

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.

Year

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1985198619871988198919901991199219931994199519961997199819992000200120022003

Mill

ions

Number of people living with HIV and AIDS

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% HIVprevalence adult (15-49)

Number of people living with HIV and AIDS

% HIV prevalence, adult (15-49)

The prevalence rate and number of people living with HIV/AIDS in sub-

Saharan Africa 1985-2003 (UNAIDS, 2005)

• 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)

• 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

• 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)

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 25-34 years oldFemales 20-29 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.

• 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.

‘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)

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]

Period 1: Lots of words….

• Period up to mid-1990s1982 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

Background

• New disease

• No cure

• High cost of treatment

• Limited resources

• Denial and stigma

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)

Biomedical and health belief response to HIV/AIDS epidemics

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

Period 2: Not much action…

• Period mid 1990s to 20001996UNAIDS set up

UN agencies combined forces UNESCO, UNICEF, UNDP, UNFPA, WHO,WB, UNODC (1999), ILO (2001), WFP (2003), UNHCR (2004)

Multi-sectoral approach

Background

• Increase in HIV infection and deaths from AIDS

• Epidemic evolves

• High cost of ARV

• Few resources

• Knowledge increasing

• Low useage of condoms

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)

Sexual behaviour and biomedical

determinants and responses to HIV/AIDS

Health Belief Model and Primary Behaviour Change responses to

HIV/AIDS

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).

Period 3: Better late than never…

• Period 2000 to date2000Tackling 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.

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.

The cost of Highly Active Antiretroviral Therapy (HAART)

• Early 2000 US$ 10,000-12,000 pp pa

• End of 2000 US$ 800-500 pp pa

• May 2003 WHO recommended brand named drugs US$ 675 pp pa

• May 2003 WHO recommended generic drugs US$ 300 pp pa

2 000

4 000

6 000

8 000

10 000

12 000

14 000

0

Pri

ce U

S$

Jun00

Oct00

Feb01

Apr01

Dec00

Nov00

Jul01

Mar03

Sep98

Aug98

Jul98

Oct03

Jun98

Sep03

Jan01

May01

Aug01

Mar10

Jun01

Launch of Acceleratin

g

Access Initia

tive (A

AI)

Negotiatia

tions with

R & D Pharma with

in AAI

Generic companies’ o

ffer of p

rice re

duction to

Uganda

Further p

rice re

ductions by AAI companies

Further d

iscussion with generic

companies

Negotiatio

ns by Willia

m J. Clinton

Foundation with

4 generic companies

Mar01

Apr01

Oct03

Jun01

May01

Feb01

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Dec00

Nov00

Jul01

600700800900

1 0001 1001 200

500

Pri

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400300200100

0

Price of ARV therapy in Uganda(UNAIDS, 2005)

• 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.’

‘3 by 5’ Campaign

• 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.

• 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%.

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%

• 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 2005 810,000 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.

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.

0

500

1,000

1,500

2,000

2,500

3,000

1996 1997 1998 1999 2000 2001 2002

Domestic

Private

UN System

Bilateral

US

$ m

illion

s

International commitment is shown by increased funding since 2000

(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)

US35.2% ($577m)

UK27.6%

($452m)

The main bi-lateral donors in 2004 (UNAIDS, 2005)

EC11%

Italy9%

Germany7%

U.K.6%

OtherGovt’s

7% Japan5%

Netherlands 3%

Canada 2%Corporate/Private* 2%

France14%

U.S.33%

EC19%

Italy10%

Germany 2%U.K. 6%

OtherGovt’s10%

Japan 8%

Netherlands 2%

Canada 2%

Corporate/Private* 5%

France 6%

U.S.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

Yet promises are not always translated into action (UNAIDS,

2005)

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

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 2003. 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)

• 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.

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).

‘…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.

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)

The wider picture of the factors that facilitate HIV transmission

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)

• ‘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)

ReferencesBarnett, 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), 155-167.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, 85-99.

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.

Potts, M & Walsh, J, 2003, Tackling India’s HIV epidemic: lessons from Africa. British Medical journal, 326, 1389-1392.

SIPAA, 2005, Building bridges with SIPAA:lessons from an African response to HIV and AIDS. www. sipaa.org.

UNAIDS, 2003, AIDS epidemic update December 2003. www.unaids.org.

UNAIDS, 2004, AIDS epidemic update December 2004. www.unaids.org.

UNAIDS, 2005, AIDS epidemic update December 2005. www.unaids.org.

UNESCO, 2005, UNESCO’s response to HIV and AIDS. www.unesco.org.

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. www.who.org.