HIV Prevention from a Development Perspective

1. HIV Prevention from a Development Perspective Irish Aid Development Education Conference Dublin City University 24th March 2006 mjkelly@jesuits.org.zm

2. Severity of the AIDS Crisis • HIV and AIDS have been with us for at least 25 years • During that time they have continued to expand at an accelerating rate in every continent • Prevalence is rising to heights never before thought possible (up to 40% of adults) • Prevention programmes have brought very limited success • Anti-retroviral treatment brings huge benefits (the Lazarus effect), but faces massive problems in reaching all who are in need

3. Global HIV Dynamics, 2005 New HIV Infections 4.9 million PLWHA 40.3 million PLWHA = People Living with HIV or AIDS AIDS deaths 3.1 million

4. HIV and AIDS Still Have the Upper Hand • The epidemic has progressed faster than anybody expected • 1996—about 20 million PLWHA • 2006—more than 40 million • The problem has doubled in just ten years • Straightforward prevention measures have very low coverage; e.g. for MTCT, <10% globally and <5% in African countries • Although there have been some achievements, the epidemic remains out of control

5. Why Has the Epidemic Got Out of Hand? • Leadership, vision and commitment at all levels not enough for what needs to be done • The silent epidemic — unnoticed, denied • Attention focuses on the immediate causes and manifestations but fails to address the contexts of poverty & gender • Insufficient attention to youth needs • Lack of sensitivity to and conflict with cultural and religious perceptions and values • Pervasive stigma and offensive discrimination

6. What Kind of Problem is HIV & AIDS in Africa? • Is it essentially a health problem that requires a biomedical response? • Is it a problem resulting from human behaviour practices? • Is it a problem of the underdeveloped conditions in which human behaviour takes place?

7. Do Sexual Practices Drive the AIDS Epidemic in Africa? • Extensive insinuations that sex drives the epidemic in Africa • Female prostitution and non-marital sex are said to be higher in Africa than elsewhere • Age of sexual debut is said to be lower • “Effective strategies addressing sexual transmission have the largest potential to turn the epidemic round” in SSA • How true is all of this?

8. Troublesome Questions • How does one account for the differences between Africa and Europe in the extent of mother-to-child transmission (if no treatment, 40% in Africa, 14% in Europe)? • Why did a major African-style AIDS epidemic not occur in Western Europe and North America? • If the statistical risk of hetero-sexual transmission of HIV is so low (3 per 10,000 contacts for the male partner), why is there so much of this transmission in Africa?

9. Age of Sexual Debut: Percentage of Girls aged 15–19 who Say they had Sex before their Fifteenth Birthday

10. Percentage of Men aged 15 – 19, Never Married, who say they have had Intercourse

11. Number of Lifetime Partners Reported by Men HIV Rate 23% 3% 20% 0.6% 4% 0.3% 0.4%

12. Basic Principles • HIV is an infectious disease • Like all other infectious diseases it needs conditions that facilitate its transmission • In the absence of these conditions, the rate of transmission will be low — there will be individual cases but they will not reach epidemic proportions • Individual transmission of HIV depends on • The characteristics of the virus • The characteristics of the transmitter • The characteristics of the recipient

13. Characteristics of the Virus • HIV types: HIV-1 and HIV-2 • Various sub-types – subtype C dominates in southern Africa • No convincing evidence to show that one subtype is more virulent than another • Differences in virus do not account for extent of HIV in southern Africa

14. Characteristics of the Individual • Anything that boosts the immune system strengthens against HIV infection • Anything that weakens the immune system increases susceptibility to HIV infection • Anything that increases the viral load increases the potency of an infected person to transmit infection • Poverty situations lead to weakened immune systems and increase the viral load of an infected individual • The poor are more susceptible to HIV infection • If already infected, the poor are more effective transmitters of HIV

15. What Really Drives Africa’s AIDS Epidemic? • There’s plenty of sex everywhere, but large-scale AIDS epidemics occur only among the poor • No infectious disease can spread rapidly in the absence of a supportive economic, social and environmental context—such as poverty • “The virus is nothing, the terrain is everything” (Pasteur) • In the absence of the poverty experienced in African countries, would a heterosexually transmitted HIV epidemic occur?

16. Unpacking Poverty Person Transmitting Person Receiving Virus Virus Poverty Related Conditions Increasing Viral Load Untreated STIs History of Malaria TB Malnutrition Micronutrient Deficiency Bilharzia Worm Infestation Poverty Related Conditions Depressing Immune System Untreated STIs History of Malaria TB Malnutrition Micronutrient Deficiency Bilharzia Worm Infestation

17. What Should be Done? • Intensifying HIV prevention should not be confined to dealing with the immediate causes of HIV transmission — sex, behaviour, blood and MTC • It should also extend in a major way to dealing with the underlying and structural causes that in the long term support the continuation of the epidemic • Provision of better/more public health, education, social protection, water & sanitation, infrastructure, jobs, recreation, governance, personal empowerment, transport efficiency, international cooperation, and others will all create conditions with less likelihood of HIV transmission

18. Mainstreaming HIV Prevention within Development • This is a development agenda which should be informed by an interplay of HIV prevention and development considerations • Medical and behavioural approaches could be integrated into this, but the driving principle would be the integral development of people so that they could have more, do more, be more, and be better able to keep themselves free from every kind of disease, including HIV

19. Responding to HIV and AIDS A Comprehensive Conceptual Framework

20. Food insecurity Increased gender inequity Human rights abuses Stigma & discrimination Orphans & children at risk Education problems Sickness, deaths, funerals Increased poverty HIV & AIDS Sex, Blood, Mother to Child Underlying Causes Structural Causes

21. Manifestations of the Impacts of HIV/AIDS: e.g., increased personal & household poverty; slower economic growth; depletion in skills & social capital; chronic food insecurity; overstretched health systems; debilitated education systems; single parent, female-headed & child-headed households; OVC growth; burdens on elderly; human rights problems; growing management & governance problems HIV Infection; Opportunistic Illnesses; ARVs? Premature Death Immediate Causes: sexual contacts; mother-to-child transmission; transfusions of infected blood; scarification or injecting practices Underlying Causes: permissiveness; ignorance; peer & social pressure; sexual abuse & violence; commercial/transactional sex; personal poverty; substance abuse; low health status; inadequate public health protection; cultural practices; migration Structural Causes: gender inequalities; poverty and inequalities in society; joblessness; legal systems; war and conflict; corruption; north-south relations; structural adjustment & IFI conditionalities; ecological abuse

22. Acknowledgement Much of the inspiration and some of the material for the foregoing has been drawn from AIDS and the Ecology of Poverty by Eileen Stillwaggon, published by Oxford University Press, New York