Download Document

HIV Prevention from a
Development Perspective
Irish Aid Development Education
Conference
Dublin City University
24th March 2006
[email protected]
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
2
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
3
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
4
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
5
What Kind of Problem is HIV &
AIDS in Africa?
1. Is it essentially a health problem
that requires a biomedical response?
2. Is it a problem resulting from
human behaviour practices?
3. Is it a problem of the
underdeveloped conditions in which
human behaviour takes place?
6
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?
7
Troublesome Questions
1. 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)?
2. Why did a major African-style AIDS
epidemic not occur in Western Europe and
North America?
3. 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?
8
Age of Sexual Debut: Percentage of
Girls aged 15–19 who Say they had
Sex before their Fifteenth Birthday
40
USA
35
Finland
30
25
20
Malawi
Ethiopia
15
10
5Zimbabwe
0
South Africa
Uganda
Kenya
Zambia
Percentage of Men aged 15 – 19,
Never Married, who say they have
had Intercourse
70
60
50
40
30
20
10
U
K
az
il
Br
U
SA
ai
ti
H
ni
a
nz
a
al
i
M
ha
na
G
Ta
Zi
m
ba
bw
e
0
Number of Lifetime Partners
Reported by Men
12
10
8
6
4
2
0
HIV
Rate
Ndola
23%
Cotonou Kisumu
3%
20%
USA
0.6%
Yaonde
4%
Peru
0.3%
France
0.4%
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
12
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
13
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
14
effective transmitters of HIV
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?
15
Unpacking Poverty
Person
Transmitting
Virus
Virus
Poverty Related Conditions
Increasing Viral Load
Untreated STIs
History of Malaria
TB
Malnutrition
Micronutrient Deficiency
Bilharzia
Worm Infestation
Person
Receiving
Poverty Related Conditions
Depressing Immune System
Untreated STIs
History of Malaria
TB
Malnutrition
Micronutrient Deficiency
Bilharzia
16
Worm Infestation
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
17
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
18
Responding to HIV and AIDS
A Comprehensive Conceptual
Framework
Food insecurity
Increased gender
inequity
Human
rights abuses
Stigma & discrimination
Orphans &
children at
risk
Education problems
Increased poverty
Sickness, deaths, funerals
HIV
&
AIDS
Underlying
Causes
Sex, Blood, Mother to Child
Structural
Causes
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
21
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