HIV/AIDS : Global Overview

1. Interactive Workshop by the Commonwealth Pharmacists Association HIV/AIDS, Maternal Health, Child Health and TB Chennai, India 11 – 12 March 2010 HIV/AIDS : Global Overview

2. Global estimates for adults and children, 2008 • People living with HIV33.4 million[31.1 – 35.8 million] • New HIV infections in 20082.7 million [ 2.4 – 3.0 million] • Deaths due to AIDS in 20082.0 million[1.7 – 2.4 million]

3. HIV/AIDS in the Commonwealth • Population: 1.8 billion - 28% of the world’s total. • Two thirds (2/3) of all people living with HIV/AIDS. • 25 million of the 33.4 million people living with HIV/AIDS worldwide. • 4 million of the 6 million people in need of ARV • Three the countries with increasing number of infected and affected people are South Africa, Nigeria and India, all in the Commonwealth.

4. Sub-Saharan Africa • The most heavily affected. • Accounted for 72% of the world’s AIDS-related deaths in 2008. • Impact on life expectancy in heavily affected countries • Huge impact on women.

5. Asia • In 2008, 4.7 million people in Asia were living with HIV. • Regionally, the epidemic has remained somewhat stable since 2000. • India accounts for roughly half of Asia’s HIV prevalence.

6. Key messages from the epidemiology • There is geographic variation between and within countries and regions. • The epidemic is evolving. • There is evidence of successes in HIV prevention • Improved access to treatment is having an impact. • There is increased evidence of risk among key populations.

7. Lessons learned • The need to understand individual epidemics and national responses. • Focussing on the vulnerabilities particularly Persons Living With HIV and AIDS.

8. Why is the epidemic still spreading? • The major cause is the slow uptake and progress of HIV/AIDS prevention, treatment and care services. • HIV/AIDS stigma and discrimination is a direct cause.

9. Maternal Health

10. Maternal Health: Scope of Problem • 180–200 million pregnancies per year • 75 million unwanted pregnancies • 50 million induced abortions • 20 million unsafe abortions (same as above) • 600,000 maternal deaths (1 per minute) • 1 maternal death = 30 maternal morbidities

11. Neonatal Health: Scope of Problem • 3 million neonatal deaths (first week of life) • 3 million stillbirths

12. Maternal Death Watch Every Minute... • 380 women become pregnant • 190 women face unplanned or unwanted pregnancy • 110 women experience a pregnancy related complication • 40 women have an unsafe abortion • 1 woman dies from a pregnancy-related complication

13. Global Causes of Maternal Mortality

14. But WHY Do These Women Die?Three Delays Model • Delay in decision to seek care • Lack of understanding of complications • Acceptance of maternal death • Low status of women • Socio-cultural barriers to seeking care • Delay in reaching care • Mountains, islands, rivers — poor organization • Delay in receiving care • Supplies, personnel • Poorly trained personnel with punitive attitude • Finances

15. Maternal Health Services • Good quality maternal health services are not universally available and accessible • > 35% receive no antenatal care • ~ 50% of deliveries unattended by skilled provider • ~ 70% receive no postpartum care during 1st 6 weeks following delivery

16. Interventions to Reduce Maternal Mortality Historical Review • Traditional birth attendants • Antenatal care • Risk screening Current Approach • Emergency Obstetrics Care • Skilled attendant at delivery • Active Management of 3rd stage of labour.

17. Maternal Mortality ReductionSri Lanka 1940–1985 • Introduction of system of health facilities • Expansion of midwifery skills • Decreased use of home delivery and delivery by untrained birth attendants • Spread of family planning

18. The higher the proportion of deliveries attended by skilled attendant in a country, the lower the country’s maternal mortality ratio Maternal deaths per 1000000 live births % skilled attendant at delivery

19. Introduction to the Countdown Countdown to 2015 is a collaborative effort to track progress in Maternal, Newborn and Child Survival in HIGH mortality countries involving a range of instituions and individuals. It highlights the progress, obstacles and solutions to achieve MDG4 (Child Survival) and MDG5 (Maternal and Newborn).

20. The countdown prioritizes 68 countries which together account for 97% of Maternal, Newborn and Child deaths worldwide each year. Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008

22. MDG 5 – Universal access to reproductive health and a 75% reduction in Maternal Mortality between 1990 and 2015. VI. Three steps to save lives of Women and their Newborn • Three (3) Progress Strategy: • All women must have access to reproductive health care including contraception to enable them to control the number and spacing of their children. • All pregnant women must have access to skilled care at the time of birth, including timely access to quality emergency obstetric care if needed. • All women and newborn must have access to post-natal care soon after delivery.

23. Why Are They Dying? Continuum of Care is missing Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008

24. Conclusions • We looked at the magnitude of: HIV/AIDS Maternal Health • We discussed some key strategies. • The next steps is to explore the roles and responsibilities of Pharmacists in implementing the strategies.

26. Why HIV/AIDS is highly stigmatised? • Perceived as lethal & incurable • Perceived to be the responsibility of the affected.

27. The consequences • Prevention-reduced access to service • Treatment- fear of disclosure of status to staff, not waiting to be seen at the clinic. • Research-concerns of loss of confidentiality • Not wanting to identify as a member of a stigmatized group • Care-unwilling to provide care for the sick family members. • Mental Health- high rates of depression and suicide.

28. What is stigma and discrimination? Effective action requires understanding of: • What is HIV/AIDS related stigma and discrimination. • How do the 2 relate • Where do they occur & what is their impact

29. Stigma • Quality/Qualities that discredit - the individual or community. • A process of devaluation- unworthiness. • Does not naturally exist - It is created through social construction

30. Stigma • Reinforces earlier prejudices: Builds upon, plays into – especially gender, sexuality and race. • Power and control relations: Produces/reproduces • Social inequality: creates and is reinforced

31. Discrimination • An act or omission, that harms or denies services or entitlements based on their HIV status. • Distinction made based on known or presumed HIV/AIDS status that results in unfair and unjust treatment.

32. Stigma & Discrimination: The Link In practice - a trickle cause & effect: • Vicious circle • One leads to the other • They reinforce and legitimize each other

33. Vicious circle

34. Addressing Stigma & DiscriminationSome key principles of success • Multi-pronged action • Sustained over time. • Inter-dependent • Mutually reinforcing • Consequences: Responses in one setting impact another setting • Address structural issues: Values and expectations of communities and society

35. General Approaches • Stigma: solidarity, tolerance, understanding, respect at community level. • Discrimination & human rights violations: • Laws and policies: to protect against discrimination • Advocacy: promotion and protection the rights of people living with HIV/AIDS and marginalised groups. • Accountability: Enforcement of the law & ensuring redress

36. Stigma Reduction Strategies • Involvementof People Living With HIV/AIDS. • Counselling and support to HIV/AIDS-affected families, including children, through ‘succession planning’ • Creating a supportive and confidential space for the discussion of sensitive topics - HIV/AIDS hotline. • Mobilising community leaders to encourage greater openness around sexuality and HIV-related issues within communities by building on positive social norms. • Raising awareness through the media.

37. Stigma Reduction Strategies • AIDS Integrated Programme • Mobilising religious leaders • AIDS education • Addressing broader inequalities

38. Anti-discrimination strategies These tend to address institutional settings. These include: • Mobilising workplaces to implement non-discriminatory policies. • Promoting understanding about HIV/AIDS through education of managers and employees. • Improving the quality of care in health services for patients living with HIV/AIDS.

39. Anti-discrimination strategies • Instituting legal action to challenge violations of human rights. • Promoting understanding among people living with HIV/AIDS of their rights. • Advocating for increased access to HIV/AIDS treatment.

40. Indicators of Success: Community Settings • Increased willingness of relatives and community members to care for HIV-positive people • Increased willingness of community members to volunteer in HIV/AIDS prevention and care programmes • Increased disclosure of seropositivity by people living with HIV/AIDS, and their increased involvement in, and leadership of, prevention, care and advocacy efforts • Reduction in self-stigma and increased confidence among people living with HIV/AIDS; and • A more open expression of positive attitudes within communities towards people living with, and affected by, HIV/AIDS.

41. Indicators of success: Health Care Settings • Increased uptake of HIV counselling and testing • Increased access to and uptake of treatment • Reduced numbers of complaints by people living with HIV/AIDS and their families • Improved quality of care of HIV-positive patients, resulting in enhanced quality of life • Increased willingness on the part of health workers to deal with people living with HIV/AIDS

42. Indicators of success at workplace • Reduction in complaints of discrimination • Increase in volunteers within workplaces for specific HIV/AIDS programmes • Increased ability to be open about status by HIV-positive employees • Increased willingness of employees to work alongside people known to be living with HIV/AIDS • Enhanced uptake of treatment services offered by workplaces.

43. Gaps • Responses are inadequate : programmes are not addressing underlying structural (social, economic, political) determinants of HIV/AIDS related stigma and discrimination • Private settings not addressed:Discrimination that frequently occurs in contexts and settings not covered by policies or legislation, such as within families and everyday social encounter.

44. Sex workers, injecting drug users, other marginalized groups are seen as responsible for are seen as HIV/AIDS People living with HIV/AIDS Gap- Circle of stigmatisation and marginalisation