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HSS4331 – International Health Theory. HIV/AIDS. Nov 9, 2009. Today…. HIV/AIDS Africa. Today…. I will present to you what most researchers think about the HIV/AIDS pandemic

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HSS4331 – International Health Theory


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today
Today….
  • HIV/AIDS
  • Africa
today1
Today….
  • I will present to you what most researchers think about the HIV/AIDS pandemic
  • Next week, we will have a guest lecture by HIV/Africa specialist Dr Ed Mills who will present a slightly different –and maybe controversial-- viewpoint
hiv aids
HIV/AIDS
  • The basics
    • “Acquired Immune Deficiency Syndrome”
    • Caused by “Human Immunodeficiency Virus”
    • Evidence of infection before 1970
    • Current pandemic started in late 1970s, early 1980
    • AIDS defined in 1982
    • First identified in gay community in USA
      • Originally called “GRID” – gay-related immune deficiency
transmitted via
Transmitted via…
  • Sex
  • Needle sharing
  • Blood transfusions
  • Mother-to-infant
  • Any other activity that allows meaningful contact of body fluids
timeline
Timeline…
  • 1983: Pasteur Institute in France discovers HIV – “Human Immunodeficiency Virus”
    • If not treated, those with HIV will develop AIDS in 8-10 years
  • 1995: protease inhibitors dramatically increase survival of HIV patients with access
alternative theory
Alternative Theory
  • A minority of scientists question the link between HIV and AIDS
  • http://www.orgonelab.org/hiv_aids.htm
treatment
Treatment
  • “Cocktail”
    • “highly active anti-retroviral therapy” – HAART
    • ARV = anti retroviral therapy
    • Serious side effects
    • Regimens can be complicated
    • Can be very expensive
slide9

Affordability of ARV drugs

-gone down from $10,000/year to $200/year

Last year, the European Commission ruled that EU countries are free to make available generic versions of patented drugs for export to poor countries which lack their own manufacturing facilities.

Trade Related Intellectual Property Rights (TRIPS)

death
Death
  • People don’t “die from AIDS”
  • AIDS allows “opportunistic infections”
    • Leading cause of death of AIDS patients is bacterial infection
      • Tuberculosis
    • Fungal infections
    • Pneumonia
co infection with tb
Co-infection with TB
  • 1/3 of the world is currently infected with TB, though most are not “active” cases
    • 5-10% will develop active TB disease
    • Only 25% have access to treatment
  • TB accounts for 13% of all AIDS deaths
  • HIV is the strongest known risk factor for a TB carrier to progress to full TB disease
co infection with stds
Co-infection with STDs
  • In the presence of an STD, chance of acquiring HIV increases 5X
  • Puts sex workers at even greater risk
diagnosis
Diagnosis
  • Bloodtest
    • Looking for HIV antiobodies
  • Cheek swab
    • Not saliva, but “oral mucosal transudate”, a fluid produced by cheek cells
  • “Visual”
    • In 1985, WHO developed the “Bangui Definition” for use in countries without antibody testing technology
    • Sometimes more informal… “Slim disease”
bangui definition
Bangui Definition
  • Exclusion criteria
    • Pronounced malnutrition
    • Cancer
    • Immunosuppressive treatment
  • Inclusion criteria with the corresponding score
    • Weight loss exceeding 10% of body weight 4
    • Protracted asthenia 4
    • Continuous or repeated attacks of fever for more than a month 3
    • Diarrhoea lasting for more than a month 3
    • Cough 2
    • Pneumopathy 2
    • Oropharyngeal candidiasis 4
    • Chronic or relapsing cutaneous herpes 4
    • Generalized pruritic dermatosis 4
    • Herpes zoster (relapsing) 4
    • Generalized adenopathy 2
    • Neurological signs 2
    • Generalized Kaposi's sarcoma 12
  • The diagnosis of AIDS is established when the score is 12 or more.
cd4 count
CD4 Count
  • A proxy measurement of the strength of a patient’s immune system
  • CD4 count goes down as HIV infection progresses
  • Used in coordination with…

Viral Load Test

  • The amount of HIV virus in the blood, lymph, spleen, and other body parts
  • Viral load goes up as HIV infection progresses
hiv aids around the world
HIV/AIDS Around the World

To get current data, go to:

http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp

slide22

*detection bias?

New AIDS Cases Per Year

Per 100,000 Population

35

Caribbean

30

25

20

North America

15

10

Latin America

5

0

2000

90

91

92

93

94

95

96

slide23

Estimated number of adult and child deaths

due to AIDS globally, 1990–2007

3.0

Millions

2.5

2.0

1.5

1.0

0.5

0

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Year

This bar indicates the range around the estimate

5.3

slide26

Estimated number of people living with HIV and adult HIV prevalence

Global HIV epidemic, 1990‒2005*

HIV epidemic in sub-Saharan Africa, 1985‒2005*

Number of people

living with HIV (millions)

% HIV prevalence,

adult (15‒49)

Number of people

living with HIV (millions)

% HIV prevalence,

adult (15‒49)

50

5.0

30

15.0

12.5

25

40

4.0

20

10.0

30

3.0

7.5

15

20

2.0

5.0

10

10

1.0

2.5

5

0

0.0

0

0.0

1990

1995

2000

2005

1985

1990

1995

2000

2005

*Even though the HIV prevalence rates have stabilized in sub-Saharan Africa, the actual number of people infected continues to grow because of population growth. Applying the same prevalence rate to a growing population will result in increasing numbers of people living with HIV.

Number of people living with HIV

% HIV prevalence, adult (15-49)

This bar indicates the range around the estimate

2.2

slide27

Regional HIV and AIDS statistics and features, 2006

Adults & children living with HIV

Adults & children newly infected with HIV

Adult (15‒49) prevalence [%]

Adult & child

deaths due to AIDS

Sub-Saharan Africa

24.7 million

[21.8 – 27.7 million]

2.8 million

[2.4 – 3.2 million]

5.9%

[5.2% – 6.7%]

2.1 million

[1.8 – 2.4 million]

Middle East & North Africa

460 000

[270 000 – 760 000]

68 000

[41 000 – 220 000]

0.2%

[0.1% – 0.3%]

36 000

[20 000 – 60 000]

South and South-East Asia

7.8 million

[5.2 – 12.0 million]

860 000

[550 000 – 2.3 million]

0.6%

[0.4% – 1.0%]

590 000

[390 000 – 850 000]

East Asia

750 000

[460 000 – 1.2 million]

100 000

[56 000 – 300 000]

0.1%

[<0.2%]

43 000

[26 000 – 64 000]

Latin America

1.7 million

[1.3 – 2.5 million]

140 000

[100 000 – 410 000]

0.5%

[0.4% – 1.2%]

65 000

[51 000 – 84 000]

Caribbean

250 000

[190 000 – 320 000]

27 000

[20 000 – 41 000]

1.2%

[0.9% – 1.7%]

19 000

[14 000 – 25 000]

Eastern Europe & Central Asia

1.7 million

[1.2 – 2.6 million]

270 000

[170 000 – 820 000]

0.9%

[0.6% – 1.4%]

84 000

[58 000 – 120 000]

Western & Central Europe

740 000

[580 000 – 970 000]

22 000

[18 000 – 33 000]

0.3%

[0.2% – 0.4%]

12 000

[ <15 000]

North America

1.4 million

[880 000 – 2.2 million]

43 000

[34 000 – 65 000]

0.8%

[0.6% – 1.1%]

18 000

[11 000 – 26 000]

Oceania

81 000

[50 000 – 170 000]

7100

[ 3400 – 54 000]

0.4%

[0.2% – 0.9%]

4000

[2300 – 6600]

TOTAL

39.5 million [34.1 – 47.1 million]

4.3 million[3.6 – 6.6 million]

1.0%

[0.9% - 1.2%]

2.9 million [2.5 – 3.5 million]

Table 1b

slide30

70

Sub-Saharan Africa

60

GLOBAL

50

Percent

female

(%)

Caribbean

40

Asia

30

Latin America

20

Eastern Europe

& Central Asia

10

0

1990

‘91

‘92

‘93

‘94

‘95

‘96

‘97

‘98

‘99

2000

‘01

‘02

‘03

‘04

‘05

‘06

2007

Percent of adults (15+) living with HIV who are female

1990–2007

2.4

slide32

Proportions of HIV infections in different population groups

by region, 2005

Eastern Europe and

Central Asia

Latin

America

South and South-East

Asia*

MSM 26%

CSW clients 41%

CSW 4%

MSM 4%

CSW 5%

CSW

clients 13%

CSW

clients 7%

CSW 8%

IDU 67%

IDU 19%

MSM 5%

All others

38%

All others

17%

All others 24%

IDU 22%

IDU: Injecting Drug Users

MSM: Men having sex with men

CSW: Commercial Sex Workers

* India was omitted from this analysis because the scale of its HIV epidemic (which is largely heterosexual) masks

the extent to which other at-risk populations feature in the region’s epidemics.

Figure 2

why msm
Why “MSM”?
  • Sexuality is culturally defined
  • Men having sex with men do not necessarily self-identify as homosexual
  • Sociologically:
    • MSM refers to the sexual relationship between two men
    • Homosexuality refers to broader relationships between men, beyond the sexual
truck drivers
Truck Drivers
  • Yes, truck drivers
  • The spread of HIV in Africa is linked to the movement of labour between rural and urban centres
  • Geographical link between HIV clusters and road networks
  • Truck drivers have high-risk behaviour of sleeping with prostitutes and a tendency to spread the infection along trade routes
impact of aids on sub saharan africa
Impact of AIDS on Sub-Saharan Africa
  • 2/3 of all people with HIV live in this region
    • 75% of all AIDS deaths occur here
  • (region comprises only 10% of world population)
  • Each year, >2 million people died of AIDS in this region
  • In this region, direct medical treatment related to AIDS (not including ARV) = US$30 per person per year
    • Overall public health spending is <US$10 per person per year*

* UNAIDS 2002 Report on the Global AIDS Epidemic

impact
Impact…
  • Hospitals
    • People with HIV occupy half of all hospital beds
    • Shortage means only people in later stages are admitted, resulting in lessened treatment success
  • Health Care Workers
    • Large numbers are HIV or AIDS positive
    • Dwindling numbers
    • Providing ARVs requires more training

*UNAIDS, 2006 Report on the Global AIDS Epidemic,

chapter 4: The impact of AIDS on people and societies

household impact
Household Impact
  • Wage earners killed off -> impoverished families
  • Young forced into prostitution -> increased disease transmission
  • AIDS has erased much of the anti-poverty progress made over the past 6 decades
  • Basic necessities not being provided
  • There are entire communities with no adults left -> households led by small childen
    • No transfer of knowledge from adults to children
food production
Food Production
  • Not enough labour to work fields
    • In Malawi, Botswana, Zimbabe, agricultural output will drop 14%-20% by 2020 due to AIDS
  • The use of ARV requires proper nutrition
    • Vicious cycle:
      • AIDS -> poor food production -> poor nutrition -> more AIDS
slide40

Number of people receiving antiretroviral drugs

in low- and middle-income countries, 2002−2007

3.0

2.8

North Africa and

the Middle East

Millions

2.6

2.4

2.2

Eastern Europe and

Central Asia

2.0

1.8

1.6

East, South and

South-East Asia

1.4

1.2

Latin America and

the Caribbean

1.0

0.8

0.6

Sub-Saharan

Africa

0.4

0.2

0.0

end-

2002

end-

2003

end-

2004

end-

2005

end-

2006

end-

2007

Year

Source: Data provided by UNAIDS & WHO, 2008.

5.2

gender disparity
Gender Disparity
  • The impact of AIDS in Africa is felt disproportionately by women
  • In many circles, AIDS is no longer a “gay disease”, but a “woman’s disease”, since >50% of all cases are borne by heterosexual women
  • Women function as family care givers, and are now the sole providers
    • Leading to neglect in care-giving
aids virgin myth
AIDS “Virgin Myth”
  • It is believed that an HIV-infected man will be cured if he has unprotected sex with a virginal female
  • -> epidemic of child rape
  • -> emerging epidemic of rape of the disabled
  • Global movement to re-educate those at risk
    • South African group “Love Life”
    • www.lovelife.org.za
circumcision
Circumcision
  • Some studies suggest that male circumcision can reduce HIV transmission (via sex) by >50%
  • Presently, there are vocal advocates to make circumcision mandatory in high risk communities
  • Global teams offering free, safe circumcisions in Swaziland, Botswana and elsewhere
nice summary
Nice Summary
  • Of some of the AIDS impacts is found here:
    • http://www.avert.org/aidsimpact.htm
orphans a lost generation
Orphans: A Lost Generation
  • Numbers are large and growing
  • Social support systems are overwhelmed
  • Risk of a lost generation:
    • little or no education
    • poor socialization
    • social upheaval
    • economic underclass
slide46

Debt

-Kenya pays 17X more on debt repayment than on HIV control

economic growth impact of hiv 1990 97
Economic Growth Impact of HIV (1990-97)

(Data from 80 developing countries)

0

-0.2

-0.4

-0.6

-0.8

Reduction in growth rate GDP

per capita (%, per year)

-1

-1.2

-1.4

-1.6

0

5

10

15

20

25

30

35

HIV Prevalence Rate (%)

Source: R. Bonnel (2000) Economic Analysis ofHIV/AIDS, ADF2000 Background paper, World Bank

slide48

“There are two refrains which I’ve regularly (and painfully) heard over the last three years traveling in Africa, always coming from young [African] women with their children in tow: ‘What will happen to my children when I die?’ and ‘You have drugs to treat people in your country; why can’t I have drugs to stay alive in my country?’

-Stephen Lewis

slide49

Even if we made ARVs dirt cheap, would this solve the problem?

  • Bill Clinton: "90% of HIV positive people in the developing world are unaware of their [disease] status.“
  • Bill Gates: "The capacity to treat [AIDS] is not so much gated by access to drugs as it is by the availability of trained personnel."