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Investigating the empirical_evidence_for.1 Document Transcript

  • 1. Investigating the empirical evidence for understanding vulnerability and the associations between poverty, HIV infection and AIDS impact Stuart Gillespiea, Robert Greenerb, Alan Whitesidec and James Whitworthd AIDS 2007, 21 (suppl 7):S1–S4It is just over 25 years since the first cases of AIDS were were dead, killed in the First World War. It is only in thereported. Over this quarter-century, AIDS has become past decade that the last of these spinsters has died. Theone of most highly studied diseases in history. There impacts of AIDS will take even longer to work throughhave been significant medical advances in understanding the population.the consequences of HIV infection and treating AIDS, asis well documented in many journals, including AIDS. Second, HIV is diverse in its spread. Early fears that theThe complex and place-specific social, economic, virus would spread rapidly outside Africa have notbehavioural and psychological drivers of the spread of materialized. For example, the UNAIDS 2006 ‘ReportHIV remain less well delineated. The consequences of on the global AIDS epidemic’ estimated that there wereincreased illness and death in poor countries and commu- 5.7 million people living with HIV in India. In July 2007,nities are still unfolding. this was revised downward to 2.5 million, reflecting much less spread of the infection than had been feared [2].In 2000, HIV was placed firmly on the global development Similar downward revisions of estimates have been madeagenda by UN Security Council Resolution 1308, which in China. In a recent book, James Chin [3] argued thatstated: ‘the spread of HIV can have a uniquely devastating there are many populations in which heterosexualimpact on all sectors and levels of society’. A year later, in epidemics will not occur in the general population andJuly 2001, there was a UN General Assembly Special the epidemic will remain confined to specific risk groups.Session on HIV/AIDS. Since then our understanding of Chin’s examples of where the potential for HIVepidemicsthe epidemic and its potential impacts has deepened. This has been overstated are primarily from Asia, and insupplement, written by social scientists, looks at how particular China and the Philippines. This is not tosocioeconomic determinants drive HIV spread and how understate the individual tragedy of each infection, butAIDS illness and mortality is impacting on communities. rather to recognize that there are countries where AIDS will have a considerable impact and others where itsIt is helpful to locate the contents of this supplement in importance can be downgraded.the context of the history of the epidemic. There are threeoverarching points to be made in introduction. First, the It is not just globally that there is wide variation. Inepidemic is complex both in terms of what is driving it mainland sub-Saharan Africa HIV prevalence in adultsand the effects it has. It has been described as a ‘long wave ranges from 0.7% in Mauritania to 33.4 % in Swaziland.event’. It takes years for the epidemic to spread through The hardest-hit countries are all in southern Africa; thesesociety and generations for the full impact to be felt. A are shown in Fig. 1, the so-called ‘red’ countries. Adultrecent book highlights the nature of such long wave HIV prevalence exceeds 20% in four of these countries:events [1]. ‘Singled out: how two million women Swaziland, Lesotho, Botswana and Zimbabwe. Southsurvived without men after the First World War’ describes Africa, Namibia, Zambia, Mozambique, and Malawi allhow in the United Kingdom a generation of women were have adult prevalence rates in the range of 10–20% [2].unable to marry, as the men they would have partnered These countries are the focus of this supplement.From the aInternational Food Policy Research Institute, Geneva, Switzerland, the bJoint United Nations Programme on HIV/AIDS,Geneva, Switzerland, the cHealth Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, South Africa, andthe dWellcome Trust, London, United KingdomCorrespondence to Alan Whiteside, Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, BlockJ418 Westville, University Road Westville, Private Bag XS4001, Durban, 4000, South Africa.Fax: +27 (31) 260 25 87; e-mail: whitesid@ukzn.ac.za ISSN 0269-9370 Q 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins S1Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  • 2. S2 AIDS 2007, Vol 21 (suppl 7) deficiency virus (HIV) was identified as the cause. The number of cases rose rapidly across the United States and was quickly identified in Europe, Australia, New Zealand and Latin America. In central Africa, health workers were observing new illnesses such as Kaposi’s sarcoma (a cancer) in Zambia, cryptococcosis (an unusual fungal infection) in Kinshasa, and there were reports of ‘slim disease’ and unexpectedly high rates of death in Lake Victoria fishing villages in Uganda [6–8]. These illnesses were occurring in heterosexual adults, not just gay men, individuals with haemophilia, blood transfusion recipients, and intravenous drug users, who formed the main groups at risk in developed countries. By 1982, cases were being seen in the partners and infants of those infected [8,9]. The initial response of public health specialists, epide- miologists and scientists was to try to identify what was causing the disease and to understand how it was spreading. This would inform prevention strategies and Fig. 1. Map of adult HIV prevalence in Africa. 20–34%; medical interventions. Early responses were therefore 10–< 20%; 5–< 10%; 1–< 5%; < 1%. predominantly scientific and technical in nature. Third, social science faces problems in addressing the It soon became apparent, however, that this was not phenomenon of HIVand its consequences. The epidemic enough, and attention shifted to understanding why is only 25 years old, which means that it, and its effects, are people were being exposed. This led to early knowledge still unfolding. Social science relies on assessing what has attitude and practice surveys, which sought to understand happened. This is done through surveys and panel data, high-risk behaviours [3] p.73. This emphasis on and sometimes the picture is at odds with what we expect. prevention gained momentum because medical scientists For example in the 1980s it was suggested, on the basis of had not yet discovered drugs that could cure, or even slow, models, that AIDS would cause economies to grow more the progress of the disease. Initial optimism for developing slowly than otherwise would be the case. In 2007, at the an effective vaccine soon faded and is now seen to be individual country level, this does not seem to have many years, if not decades, away. occurred. Uganda had the worst epidemic in the world during the early 1990s yet managed consistent economic Internationally, the World Health Organization (WHO) growth estimated at 6.5% per annum from 1991 to 2002. took the lead in response to HIV in 1986; teams visited Botswana’s growth rate over the same period was 5.6%. most developing countries to establish short and South Africa has seen steady growth since 1999. Yet it is medium-term AIDS programmes, which then evolved only through longitudinal and cross-sectional studies that into national AIDS programmes [10]. International we can hope to understand the impact of the disease. responses to HIV were, however, limited and character- Longitudinal panel data give a picture of what has ized by denial, underestimation, and oversimplification. happened in a population over the period for which the HIV was not placed high on the agenda of any other data are collected. An alternative is to gather cross- United Nations agency. Although life expectancy was sectional data: if we can understand what has happened in plummeting in certain African countries, for example, Uganda will it help predict what might happen in the United Nations Development Programme waited Lesotho? The one thing we have not been good at is until 1997 to take this into account in calculating its predicting the future, although UNAIDS made a brave human development index [11]. attempt at this through its ‘AIDS in Africa: three scenarios to 2025’ report launched in March 2005 [4]. By the 1990s there was a new perspective developing, as interest in the individual, social, and economic milieux that lead to vulnerability to HIV infection began to grow. Academics and programme officers increasingly recog- A brief history of 25 years of response nized that social justice, poverty and equity issues were driving the uneven spread of the virus within and 1981–1996 between communities and societies [12–15]. The AIDS epidemic was recognized in 1981, initally among gay men in New York and San Francisco [5]. It was 1996–2007 officially named ‘acquired immune deficiency syndrome’ In 1996, there were major changes in response to HIV, (AIDS) in July 1982, and in 1983 the human immuno- reflecting and reflected in the scholarship of the time. In Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  • 3. Editorial Whiteside et al. S3the 1994 book ‘AIDS in Africa’ of 33 chapters only three inequity, long-term concurrent partnerships, the lack ofwere on preventive strategies and four on socioeconomic male circumcision, and the prevalence of co-infectionsimpact, the rest were scientific or epidemiological [16]. are factors that have been identified and need furtherBy 1996, when the second edition of ‘AIDS in the world’ examination. There are no easy solutions to curbing thewas published, of 41 chapters only approximately 18 were spread of the epidemic. There are countries, outsidepure science [17]. southern Africa, where the epidemic appears to be under control: Uganda brought early hope to Africa by showingIn 1996, the new UN agency charged with coordinating how high levels of political commitment and com-the response to the epidemic, UNAIDS, began operations munity-led responses can work to stabilize HIVin Geneva. This was significant as it acknowledged that prevalence. In other locations, such as Tanzania, infectionthe international health body the WHO was not able to rates peaked at a lower level than those currently seen inrespond to the epidemic in all its facets, and there needed most of southern Africa.to be international coordination for an exceptionaldisease. At the XIth International AIDS Conference in The focus of this supplement is on bringing together andVancouver, the arrival of new drugs in developed understanding the data on the socioeconomic dimensionscountries to treat AIDS was announced, and mortality of the epidemic. It came out of a meeting sponsored byamong those being treated plummeted. UNAIDS and hosted by the Health Economics and HIV/AIDS Research Division of the University ofAt the XIIIth International AIDS Conference in KwaZulu-Natal held in Durban from 16 to 18 OctoberDurban, South Africa, in July 2000, Nelson Mandela, 2006. The aim of the symposium was to bring togetherclosed the conference with a call for drugs to be made people, especially those involved in field research, to shareaccessible to all. Since then, the response to AIDS has knowledge and experience and to address gaps in ourbeen dominated by new initiatives for making treatment understanding of the spread of HIV and impact of AIDS.accessible, especially in developing countries. The price In particular, we were looking for community-of drugs has fallen dramatically with the manufacture of based longitudinal studies currently being carried outgeneric drugs.1 In 2001, United Nation’s Secretary in Africa.General, Kofi Annan, called for spending on AIDS to beincreased 10-fold in developing countries, and the The outputs of this meeting were to be a review of theGlobal Fund for AIDS, TB and Malaria was established. main longitudinal socioeconomic data collections inThe same year, President George W. Bush announced Africa with a bearing on HIV, the publication of thethe Presidential Emergency Plan for AIDS Relief participants’ best papers, and an opportunity to network(PEPFAR) targeting 15 developing countries. In 2003, and share ideas.the WHO and UNAIDS proclaimed the ‘3 by 5’ plan, totreat 3 million people in poor countries by the end The meeting was a qualified success in that papers wereof 2005. presented and we have this interesting and thought- provoking supplement. There are, however, a numberOver the decade from 1996 to 2006, more financial of caveats, and these cut to the heart of the issues weresources than ever before were made available for the are dealing with. South African research and papersresponse to AIDS, with emphasis increasingly on making dominate. Of the 10 papers we publish, seven are fromtreatment available in developing countries. In 1996, South Africa, two compare data from across the continentthere was approximately US$300 million for HIV/AIDS and one is from Zimbabwe. This is also true of thein low and middle-income countries; by 2006, this authors, the vast majority are either South African orincreased to US$8.3 billion. It is noteworthy that this based in the developed world. Clearly, there are real issuesresponse, largely a result of treatment becoming with developing capacity in African countries. The globalavailable and affordable, led to a ‘remedicalization’ of emphasis is on delivery not research, but, as thisHIV/AIDS. supplement shows, quality data and good science are essential.It is not clear why southern Africa has been so hard hit byHIV. Socioeconomic variables, cultural factors and sexual Of the ten papers, there is a good thematic spread withbehaviour all play a role. Poverty, income inequality, sex four papers focusing on drivers, four on impacts and two on both. What do the papers tell us? Put simply, the causes and consequences of the epidemic are complex and policy1 Presentation by Peter Graaf of the HIV/AIDS Department of the needs to take this into account.WHO to an ‘Informal technical consultation on the relevance andmodalities of implementation of an observatory for HIV commodities Although poor individuals and households are likely to bein Africa’ organized by Health Economics and HIV/AIDS ResearchDivision (HEARD), University of KwaZulu Natal, the World Health hit harder by the downstream impacts of AIDS than theirOrganization, and Swedish/Norwegian HIV/AIDS Team on 25 June less poor counterparts, their chances of being exposed to2007. HIV in the first place are not necessarily greater thanCopyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  • 4. S4 AIDS 2007, Vol 21 (suppl 7) wealthier individuals or households. It is too simplistic to References refer to AIDS as a ‘disease of poverty’. As an infectious disease, it is appropriate that the primary core response 1. Nicholson V. Singled out: how two million women survived to HIV focuses on public health prevention strategies and without men after the First World War. London: Viking; 2007. 2. UNAIDS. 2006 Report on the Global AIDS epidemic. 2006. on medical treatment and care. But if we are to make Available at: http://www.unaids.org/en/HIV_data/2006Global- further strides in combating the epidemic we need broad- Report/default.asp. Accessed: September 2007. based prevention, that is, prevention that deals with the 3. Chin J. The AIDS pandemic: the collision of epidemiology with political correctness. Oxford: Radcliffe Publishing; 2006. contextual environment and the underlying socio- 4. UNAIDS. AIDS in Africa: three scenarios to 2025. Geneva: economic, behavioural and psychological drivers of the UNAIDS; 2005. epidemic. Like the virus, these strategies need to cut 5. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. across all socioeconomic strata of society. 6. Bayley A. Aggressive Kaposi’s sarcoma in Zambia. Lancet 1984; ii:1318–1320. On the downstream side, although AIDS impoverishes 7. Hooper E. The river: a journey back to the source of HIV and households, its effects are not uniform. Again, appropriate AIDS. London: Allen Lane/The Penguin Press; 1999. Copyright Edward Hooper 2000. responses need to take account of the context-specificity 8. Iliffe J. The African AIDS epidemic: a history. Oxford: James and dynamic nature of the stresses, shocks and local Currey; 2006. responses brought by AIDS, so that mitigation measures 9. Shilts R. And the band played on: people politics and the AIDS epidemic. London: Viking; 1988. are appropriately designed. 10. Mann J, Tarantola D, editors. Government national AIDS pro- grams, Chap. 30. In: AIDS in the world II. Oxford: Oxford University Press; 1996. Finally, as is always the case with a publication, there are 11. Whiteside A, Barnett T, George G, Van Niekerk A. Through a people who need to be thanked. In Durban, Marisa glass, darkly: data and uncertainty in the AIDS debate. In: Casale took charge of organizing the meeting. UNAIDS Developing world bioethics, issue 3. Oxford: Blackwell Publish- ers Ltd.; 2003. sponsored both the meeting and publication. Alan 12. Whiteside A. AIDS – socio-economic causes and conse- Whiteside’s time was largely supported through a DFID quences. Occasional paper no 28. Economic Research Unit, Research Partners Consortium grant. Stuart Gillespie’s University of Natal, Durban; 1993. 13. Gruskin S, Hendriks A, Tomasevski K. Human rights and the time was supported by the RENEWAL programme response to HIV/AIDS. In: AIDS in the world II. Edited by Mann through support from Irish Aid and the Swedish J, Tarantola D. Oxford: Oxford University Press; 1996. International Development Cooperation Agency, and 14. Loewenson R, Whiteside A. Social and economic issues of HIV/ by UNAIDS. We also acknowledge the extensive inputs AIDS in southern Africa: a review of current research. SAfAIDS 1997;. of Suneetha Kadiyala of the International Food Policy 15. Barnett T, Whiteside A. HIV/AIDS and development: case studies Research Institute throughout the preparation of this and a conceptual framework. Eur J Dev Res 1999; 11:200–234. supplement. 16. Essex M, Mboup S, Kanki PJ, Kalengayi MR. AIDS in Africa. New York: Raven Press; 1994. 17. Mann J, Tarantola D, editors. AIDS in the world II. Oxford: Conflicts of interest: None. Oxford University; 1996. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.