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

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 40.3 million Women 17.5 million Children 2.3 million People newly infected with HIV in 2005: Total 4.9 million Children 0.7 million AIDS deaths in 2005: Total 3.1 million Children (<15) 0.57 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)

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. 30 30 Millions Number of people living with HIV and AIDS 25 25 % HIV prevalence, adult (15-49) 20 20 Number of people living with HIV and AIDS % HIV prevalence adult (15-49) 15 15 10 10 5 5 0 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year The prevalence rate and number of people living with HIV/AIDS in sub-Saharan Africa 1985-2003 (UNAIDS, 2005)

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. 20% − 39% 10% − 20% 5% − 10% 1% − 5% 0% − 1% trend data unavailable outside region • 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%

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 25-34 years old Females 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.

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 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

30. 14 000 12 000 Launch of Accelerating Access Initiative (AAI) 10 000 8 000 Price US$ Generic companies’ offer of price reduction to Uganda Negotiatiations with R & D Pharma within AAI Further price reductions by AAI companies 6 000 Negotiations by William J. Clinton Foundation with 4 generic companies Further discussion with generic companies 4 000 2 000 0 Jun 98 Jul 98 Aug 98 Sep 98 Jun 00 Oct 00 Nov 00 Dec 00 Jan 01 Feb 01 Mar 10 Apr 01 May 01 Jun 01 Jul 01 Aug 01 Mar 03 Sep 03 Oct 03 1 200 1 100 1 000 900 800 700 600 Price US$ 500 400 300 200 100 0 Nov 00 Dec 00 Jan 01 Feb 01 Mar 01 Apr 01 May 01 Jun 01 Jul 01 Oct 03 Price of ARV therapy in Uganda(UNAIDS, 2005)

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)

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 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.

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. 3,000 US$ millions 2,500 Domestic 2,000 Private 1,500 UN System 1,000 Bilateral 500 0 1996 1997 1998 1999 2000 2001 2002 International commitment is shown by increased funding since 2000 (UNAIDS, 2005)

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

39. France 14% EC 11% France 6% EC 19% Italy 9% Italy 10% U.S. 33% U.S. 30% Germany 2% Germany 7% U.K. 6% Other Govt’s 10% Japan 8% Netherlands 2% U.K. 6% Canada 2% Other Govt’s 7% Japan 5% Corporate/Private* 5% Netherlands 3% Corporate/Private* 2% Canada 2% 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 Yet promises are not always translated into action (UNAIDS, 2005)

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 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)

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. 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), 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.

50. 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.