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HIV Epidemiology : Progress, challenges and Human Rights implications. Yves SOUTEYRAND Rodney KORT Ani SHAKARISHVILI Thomas REHLE Txema GARCIA-CALLEJA.

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Hiv epidemiology progress challenges and human rights implications

HIV Epidemiology:Progress, challenges and Human Rights implications

Yves SOUTEYRAND

Rodney KORT

Ani SHAKARISHVILI

Thomas REHLE

Txema GARCIA-CALLEJA


"To understand a problem with clarity is already half way towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Amartya Sen,

Nobel Prize in Economics

AIDS Sutra, 2008


Outline
Outline towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Is the epidemic contained?

Trends in global epidemic

Dynamics of the epidemic

Epidemiology, response and Human Rights

Health information and Human Rights

Vulnerable and most-at-risk populations: Human Rights implications of HIV epidemiology


Thirty years into the epidemic
Thirty years into the epidemic towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

UNAIDS/WHO Epi update, 2009


Over 7 400 HIV infections/day in 2008 towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

  • About 1 200 children under 15 years of age

  • Each day 5 000 people die of AIDS

  • Each day 3 000 more people on Antiretroviral Therapy

  • 97% in low- and middle-income countries, 70% in Sub Saharan Africa

  • Down from 8 800 daily infectionsin 2001


Dynamics of the epidemic prevention works
Dynamics of the epidemic: towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"Prevention works

  • Declines in prevalence and risky sexual behaviors

    • Young people in 21 generalized epidemic countries: Prevalence declining in most countries (more than 25% reduction in 10 of them) along with risky sexual behaviors

      (Gouws et al, AIDS Conference 2010 – TUAC0204)

    • General population modelling in Zimbabwe: Between 460 000 and 860 000 infections averted due to reduction of high risk behaviours between 1999 and 2004 (Hallett et al, Epidemics, 2009)


PMTCT impact: infections averted among infants towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

70 000

60 000

50 000

40 000

Infant infections averted

30 000

20 000

10 000

0

1997

1999

2001

2003

2005

2007

1996

1998

2000

2002

2004

2006

2008

Estimate of the annual number of infant infections averted through

the provision of antiretroviral prophylaxis to HIV-positive pregnant women,

globally, 1996–2008, UNAIDS 2009


Art impact on the epidemic south africa
ART impact on the epidemic: South Africa towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Rehle et al. PLoS ONE, 2010


Impact of art on hiv incidence
Impact of ART on HIV incidence towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Growing evidence on impact of ART on decreasing transmission

Discordant couples in Africa (Donnell, 2010)

Decreasing HIV incidence at community level

Taiwan, China (Fang, 2004)

San Francisco (Das Douglass, 2010)

Vancouver (Wood/Montaner , 2010)

Models suggest large potential epidemic effect with Universal ART (Granich, 2008)


Outline1
Outline towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Is the epidemic contained?

Trends in global epidemic

Dynamics of the epidemic

Epidemiology, response and Human Rights

Health information and Human Rights

Vulnerable and most-at-risk populations: Human Rights implications of HIV epidemiology


Social determinants of health and health inequities
Social determinants of health and health inequities towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Socioeconomic

& political context

Governance

Policy

(Macroeconomic,

Social, Health)

Cultural and

societal norms

and values

Social position

Material circumstances

Social cohesion

Psychological factors

Behaviours

Biological factors

Distribution of health and well-being

EducationOccupationIncome

Gender

Ethnicity / Race

Health Care System

Source: Commission on Social Determinants of Health conceptual framework Amended from Solar & Irwin, 2007


How are epidemiology and human rights linked
How are Epidemiology and Human Rights linked? towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Human rights violations are a barrier to knowing your epidemic

Unethical HIV surveillance violates human rights

Human rights violations contribute to HIV transmission

Failure to act on epidemiological evidence worsen human rights challenges


Surveillance progress and gaps
Surveillance: progress and gaps towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Quality of HIV surveillance systems, 2009, WHO/UNAIDS

  • Weak surveillance systems in most countries with concentrated and low epidemics

  • Surveillance among MARPs insufficient in most countries with generalized epidemics

  • Stigma and discrimination challenge epidemiology


Ethics of hiv surveillance human rights considerations
Ethics of HIV surveillance: towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"Human Rights considerations

Appropriate framework

Informed and voluntary consent

Confidentiality protection

Community involvement

Responsiveness

"Without a commitment to using surveillance findings to benefit the vulnerable, the moral foundations of the activity vanish"

2010 WHO/UNAIDS guidelines on ethical issues on HIV surveillance, in press


Outline2
Outline towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Is the epidemic contained?

Trends in global epidemic

Dynamics of the epidemic

Epidemiology, response and Human Rights

Health information and Human Rights

Vulnerable and most-at-risk populations: Human Rights implications of HIV epidemiology


Epidemic among migrants in Western Europe towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past"

Spain2008(10 regions)

The Netherlands 2010 (modelled; sexual transmission only)

France 2008

Other9%

Other11%

LatinAmerica16%

Caribbean26%

Netherlands21%

Spain63%

Africa12%

Africa37%

France52%

Africa53%

InVS, 2009

Xiridou, RIVM, 2010

SPNS, 2010

Distribution of new HIV cases by country/region of origin


Epidemic among migrants in western europe human rights challenges
Epidemic among migrants in Western Europe: Human Rights challenges

  • Gaps in information prevent adequate response

  • Tensions between immigration, interior and health policies are counterproductive to effective service provision

  • Economic crisis exacerbate negative attitudes towards migrants

    (ECDC report on Migrant Health: access to HIV prevention, treatment and care, 2009)


Modes of transmission in sub-Saharan African countries challenges

Distribution of new infections by sources of riskModes of transmission in South, East and West Africa, 2008–2009


Men who have sex with men msm epidemics and response
Men who have sex with men (MSM) epidemics and response challenges

Recent steady increases in rate of HIV infections among MSM in North America, Western Europe and Australia (2009 UNAIDS/WHO Epi Update)

MSM have 19.3 times greater risk of being infected with HIV than the general population (Baral et al, PLoS Medicine, 2007)

High HIV prevalence among MSM in African countries: 19.7% in Botswana, 21.4% in Malawi, 12.4% in Namibia (Baral et al, PLoS ONE, 2007)


MSM epidemics: law and the response challenges

  • Homosexuality criminalized in 80 countries (Global Forum on MSM and HIV)

  • High prevalence of homophobic attitudes (Baral et al, PLoS ONE, 2007)

  • For most countries prevention for MSM has not started or is underfunded (Beyrer, Clin Infect Dis 2010)

HIV Prevalence and Criminalization of Homosexuality in the Caribbean

Global Forum on MSM and HIV, May 2010


Injecting drug users idus epidemics and response
Injecting Drug Users (IDUs) epidemics and response challenges

In Eastern Europe and Central Asia, among 100 IDUs living with HIV, one is receiving ART

In 40% of countries, laws reduce accessibility of HIV services for people who inject drugs

Extrajudicial systems of closed detention of IDUs in 11 Asian countries

(Mathers et al, Lancet 2010; Cohen et al, Plos Medicine, 2008)


Modeled impact of structural changes on epidemic
Modeled impact of structural changes on epidemic challenges

HIV infections among IDUs averted by structural changes

4–19% decrease in incidence

3–9% decrease in incidence

2–5% decrease in incidence

662 infections averted

343infections averted

209

Elimination of police beatings (Ukraine)

Strathdee et al., HIV Risks Among Injection Drug Using Populations:

Past, Present, and Projections for the Future (Lancet 2010)


Idus epidemic and response in ukraine a success story
IDUs epidemic and response in Ukraine: challengesa success story?

Decrease in HIV prevalence among recent Injecting Drug Users

(median sentinel surveillance in 8 cities, Ukraine - International HIV/AIDS Alliance, 2009)


Conclusion
Conclusion challenges

Strong health information and vital registration systems are essential for informing the nature and scope of the epidemic

Human Rights abuses continue to blind our knowledge of the epidemic and to challenge our ability to respond

Concerted efforts have decreased new infections and deaths – challenge is to expand the response to reach populations facing human rights abuses

Universal access to prevention and treatment cannot be achieved without universal access to Human Rights


" challengesWe, Head of States, … reaffirm that the full realization of all human rights and fundamental freedoms for all is an essential element in the global response to the HIV/AIDS pandemic"

United Nations High-Level Meeting on AIDS,

New York, June 2006


Acknowledgements
Acknowledgements challenges

WHO

Gottfried Hirnschall

Andrew Ball

Michel Beusenberg

Keith Sabin

Jean Michel Tassie

Cyril Pervilhac

Chika Hayashi

Carla Obermeyer

Theresa Babovic

Vincent Habiyambere

Francoise Renaud-Théry

Boni Dongmo Nguimfack

Gundo Weiler

Reuben Granich

Kim Dickson

Jos Perriens

Ying Lo-Ru

Tunga Namjilsuren

Rodney Kort, Ani Shakarishvili, Thomas Rehle, Txema Garcia-Calleja

And

Alain Volny-Anne

Véronique Collard

Parijat Baijal

Jean Paul Moatti

Bruno Spire

But not least

Ludovic Coutière

Isabelle de Vincenzi

Helena Nygren Krug

Florence Rusciano

UNAIDS

Peter Ghys

Eleanor Gouws

Mary Mahy

Jason Sirgudson

Robert Greener

And

Jhoney Barcarolo

Kevin DeCock

Michel Carael

Maria Xiridou

Chris Beyrer

Steffanie Strathdee

Robert Booth

Timothy Hallett


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