Why HIV/AIDS should be treated as exceptional: arguments from sub-Saharan Africa and Eastern Europe
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Why HIV/AIDS should be treated as exceptional: arguments from sub-Saharan Africa and Eastern Europe

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The idea that HIV and AIDS gets too much attention and funding emerged in 2008 with a call to end ‘AIDS...

The idea that HIV and AIDS gets too much attention and funding emerged in 2008 with a call to end ‘AIDS
exceptionalism.’ This article outlines a short history of AIDS exceptionalism — the idea that HIV and AIDS require
a response above and beyond ‘normal’ health interventions and is privileged in terms of attention and resources
when compared with other diseases — and the reasons for the backlash to this idea. We argue that in some settings
HIV and AIDS must be treated as exceptional. These are the hyperendemic countries of southern Africa, where HIV
epidemics have shown substantial and lasting demographic and social impact, and parts of Eastern Europe where
the epidemic is augmenting troubling demographic changes, such as declines in fertility rates and population
growth, and impacting society in nuanced ways. Also included are resource-poor settings, mostly in Africa, where
the combination of the high number of HIV infections and the cost of treatment have created issues concerning
donor dependency and sustainable responses. An HIV epidemic must be seen as a long-wave event, with complex
challenges to both HIV prevention and treatment responses. The article reviews the available data and literature to
provide evidence for our arguments. We conclude that the perception that AIDS exceptionalism is outdated ignores
the complexity of different HIV epidemics and obfuscates the challenges to effective responses.

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  • 1. This article was downloaded by: [UNIVERSITY OF KWAZULU-NATAL]On: 22 February 2012, At: 05:36Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: MortimerHouse, 37-41 Mortimer Street, London W1T 3JH, UK African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20 Why HIV/AIDS should be treated as exceptional: arguments from sub-Saharan Africa and Eastern Europe a b b b Julia Smith , Khaled Ahmed & Alan Whiteside a University of Bradford, Peace Studies, Bradford, West Yorkshire, BD7 1DP, United Kingdom b Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu- Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa Available online: 15 Dec 2011To cite this article: Julia Smith, Khaled Ahmed & Alan Whiteside (2011): Why HIV/AIDS should be treated as exceptional:arguments from sub-Saharan Africa and Eastern Europe, African Journal of AIDS Research, 10:sup1, 345-356To link to this article: http://dx.doi.org/10.2989/16085906.2011.637736PLEASE SCROLL DOWN FOR ARTICLEFull terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditionsThis article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form toanyone is expressly forbidden.The publisher does not give any warranty express or implied or make any representation that the contentswill be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug dosesshould be independently verified with primary sources. The publisher shall not be liable for any loss, actions,claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly orindirectly in connection with or arising out of the use of this material.
  • 2. African Journal of AIDS Research 2011, 10(supplement): 345–356 Copyright © NISC (Pty) Ltd AJAR Printed in South Africa — All rights reserved ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.637736 Why HIV/AIDS should be treated as exceptional: arguments from sub-Saharan Africa and Eastern Europe Julia Smith1,2, Khaled Ahmed2* and Alan Whiteside2 1 University of Bradford, Peace Studies, Bradford, West Yorkshire BD7 1DP, United Kingdom 2Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban 4000, South Africa *Corresponding author, e-mail: ka.ahmed7@gmail.comDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:36 22 February 2012 The idea that HIV and AIDS gets too much attention and funding emerged in 2008 with a call to end ‘AIDS exceptionalism.’ This article outlines a short history of AIDS exceptionalism — the idea that HIV and AIDS require a response above and beyond ‘normal’ health interventions and is privileged in terms of attention and resources when compared with other diseases — and the reasons for the backlash to this idea. We argue that in some settings HIV and AIDS must be treated as exceptional. These are the hyperendemic countries of southern Africa, where HIV epidemics have shown substantial and lasting demographic and social impact, and parts of Eastern Europe where the epidemic is augmenting troubling demographic changes, such as declines in fertility rates and population growth, and impacting society in nuanced ways. Also included are resource-poor settings, mostly in Africa, where the combination of the high number of HIV infections and the cost of treatment have created issues concerning donor dependency and sustainable responses. An HIV epidemic must be seen as a long-wave event, with complex challenges to both HIV prevention and treatment responses. The article reviews the available data and literature to provide evidence for our arguments. We conclude that the perception that AIDS exceptionalism is outdated ignores the complexity of different HIV epidemics and obfuscates the challenges to effective responses. Keywords: AIDS exceptionalism, demography, donor dependency, health interventions, health systems, hyperendemic disease, resource-poor settings Introduction argument is made for continuing to treat HIV and AIDS as exceptional in specific regions. This exceptionality thereby Since 1990, the global HIV epidemic has not been homoge- warrants the attention and resources that HIV and AIDS has nous. Its scale and impacts vary greatly. In Western Europe, received so far alongside other ongoing disease burdens. North America, most of Latin America, North Africa, Asia and We argue that in the hyperendemic countries of the Middle East, HIV infections are concentrated and stable, sub-Saharan Africa, HIV and AIDS is having lasting negative with low incidence and prevalence — meaning that less demographic and social impacts. The disease has become than 0.5% of adults are infected. In these regions the HIV a generalised epidemic — with Botswana, Lesotho, Malawi, epidemic is concentrated within specific population groups, Mozambique, Namibia, South Africa, Swaziland, Zambia such as among men who have sex with men, injection drug and Zimbabwe facing HIV prevalence levels between 11% users (IDUs) and sex workers (UNAIDS, 2010a). In much and 24%. HIV prevention continues to be a challenge in of the world, standard public health responses have been the region, both within behavioural and costly biomedical able to contain HIV outbreaks while treating people already approaches. Throughout the region, the number of people infected. However, the HIV epidemics of sub-Saharan requiring HIV-related treatment and the ability of national Africa and parts of Eastern Europe, notably Russia and the governments to bear these costs create exceptional risks Ukraine, are unique and require increased HIV-prevention in terms of sustainability and potential issues concerning efforts to advance the response. We argue that these HIV dependency and ‘international entitlement’ to ongoing epidemics are indeed ‘exceptional.’ foreign aid needed to maintain the current obligations to The term ‘AIDS exceptionalism’ is open to interpreta- supply HIV/AIDS treatment. tion. How it is perceived and what value judgements are In Eastern Europe, the argument for AIDS exception- used will vary greatly according to each individual and alism is based on the magnitude of an HIV epidemic that their experiences. We describe AIDS exceptionalism as was previously concentrated in a small population group the concept that the disease requires a response above (i.e. among male IDUs). The neglect of intervention strate- and beyond ‘normal’ health interventions. The term normal gies in Russia and ongoing discrimination in the Ukraine is used loosely since the majority of health interventions have failed to contain the epidemic. In Russia, the state are generally viewed as being important. In this article, the continues its reluctance to rollout evidence-based HIV African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
  • 3. 346 Smith, Ahmed and Whiteside prevention for drug users, even while the epidemic contrib- had perpetuated certain myths about the epidemic in order utes to worsening demographic dynamics and lowering the to ensure funding and jobs. Epstein (2007) suggested that rate of economic development. interventions had not been based on evidence of the drivers The article begins with a short review of the debate of the epidemic or from past experience. Pisani (2008) surrounding the perceived exceptionality of HIV and questioned funding priorities and warned that scientists had AIDS. This is followed by the main argument that the allowed themselves to be compromised by the money and concept of AIDS exceptionalism continues to be necessary politics surrounding the disease. All those authors argued in certain settings. We conclude with selected policy that, in many instances, HIV/AIDS programming had been recommendations. driven by ideological stances, not by evidence. Major criticism from England (2007a, 2007b and 2008) Review of the AIDS-exceptionalism debate highlighted that disease-specific funding and program- ming undermined other development initiatives — specifi- Mobilisation against HIV and AIDS was built on the gay cally health-system development — and that strengthening rights movement of the 1970s. The HIV pandemic then these would have better outcomes than targeting HIVDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:36 22 February 2012 led to a new style of response based on human rights and AIDS. Shiffman, Berlan & Hafner (2009) argued that and the shared responsibility of those most at risk (Gostin funding for strengthening health systems and reproductive & Lazzarini, 1997; United Nations, 1998). HIV and AIDS health had declined during the period 1998 to 2007, while attracted special attention from media, governments and funding for HIV/AIDS-specific programmes had increased scientists. The term AIDS exceptionalism was possibly first significantly. They did note that funding for other infectious coined in a 1991 article by Ronald Bayer (see Bayer, 1991), diseases also increased during the same period. Contrary since by the early 1990s an ‘exceptionalist alliance’ had to these assertions, Yu, Souteyrand, Banda, Kaufman & formed: “Depending on the countries this alliance included: Perriëns (2008) argued that the evidence was more mixed the gay community, liberal and left-wing parties, and large than concretely positive or negative, and they stressed that sections of the health-care and psychosocial professions” efforts should focus on strengthening existing synergies with (Rosenbrock, Dubois-Arber, Moers, Pinell, Schaeffer & primary healthcare. Setbon, 2000, p. 1610). This created a powerful and unique Recent criticism of HIV/AIDS responses has been voiced coalition of interests that brought HIV and AIDS into the by Bongaarts & Over (2010) who argue that funding should public and political arena, enforcing its positioning as a not be static, but rather proportional to the marginal returns health issue for both those directly affected and the general of reducing the disease. They also assert that recent public. progress (cf. UNAIDS, 2010a) should thus engender By the mid 1990s, as it became clear that in North a rebalancing of HIV/AIDS funding. Similar to England America and Western Europe HIV and AIDS was not as (2007a), they assert that funding for HIV/AIDS has been threatening as had been feared, there were calls for an end in excess of the actual disease burden. They highlight to the notion of its exceptionalism. General HIV epidemics the cost-ineffectiveness of ART programmes with respect had not materialised in the rich world; instead HIV and AIDS to other health interventions, such as fighting malaria, remained located in small, defined population groups. With reducing maternal mortality, and increasing childhood the introduction of combination antiretroviral (ARV) therapy immunisation. Bongaarts & Over (2010) also argue that in 1996 (notwithstanding its debilitating side-effects), HIV donor funding is utilised sub-optimally, and that donors disease developed into a chronic health condition that could should transition towards maintaining ART funding while be controlled via expensive drug therapy. By the end of the spending more on preventing new HIV infections (which is decade, AIDS exceptionalism in North America and Western much more cost-effective in the long-run). The counterargu- Europe had ended (Bayer, 1999). However, HIV/AIDS ment by Nattrass & Gonsalves (2010) is that Bongaarts & became increasingly ‘globalised’ as international actors Over (2010) have overestimated future costs (since prices began to view development challenges in impoverished are likely to decrease), underestimated the cost-effective- parts of the world as a humanitarian and security concern ness of ART (as indirect benefits are not factored in), and (Behrman, 2004; Barnett & Prins, 2006). The cost of overlooked the cost-savings from preventing opportun- providing antiretroviral treatment (ART) versus the scenario istic infections. Moreover, HIV and AIDS is represented of having millions of people already infected with HIV die by a global as well as strong African constituency of prematurely, opened space for mobilisation around the treatment activists to hold governments accountable in a disease. The success of this was evident from the exponen- way previously unheard of. Holmes, Thirumurphy, Padian tial increase in funding. The amount of money available for & Goosby (2010) argued that just as the cost-savings of HIV/AIDS intervention rose from US$300 million in 1996, to HIV prevention accrued in later time periods, the economic US$13.7 billion by 2008 (UNAIDS, 2010a). benefits of preventing AIDS deaths should also be viewed Since then, there has been increasing debate over on a longer time scale. Unlike other diseases, HIV and whether the vast international attention and funding for HIV AIDS affect primarily the economically productive groups. and AIDS is warranted, what perverse impacts the HIV/ Hence, the ‘long-term wave’ of an HIV epidemic is rarely AIDS response may have had on health systems so far, and fully appreciated. Furthermore, contrary to the argument that how effective the responses have been. Chin (2006) said funding has been disproportionate to the burden of disease, that a generalised HIV epidemic would never occur in Asia De Lay & De Cock (2007) and Stuckler, King, Robinson & and that UNAIDS in collaboration with HIV/AIDS activists McKee (2008) suggest that spending on HIV prevention and
  • 4. African Journal of AIDS Research 2011, 10(supplement): 345–356 347 treating AIDS illnesses has not been over and above the respectively, and 20% and 30% in Uganda and Nigeria, funding needed. respectively. Furthermore, by 2030, 14% of deaths in sub-Saharan Africa will be attributable to AIDS. The United Regions where HIV and AIDS is exceptional Nations Population Division (2005) has estimated that in the seven worst affected countries, AIDS could reduce life We identify three locations where HIV and AIDS remain expectancy by 43% between 2010 and 2015. A high rate exceptional and should be treated as such: 1) hyperendemic of mortality among adults of reproductive age leaves older countries, 2) resource-poor nations with significant numbers people unattended without caregivers and also increases of HIV infections, and 3) some Eastern European countries. dependency ratios as there are fewer people to care for young children (Kautz, Bendavid, Bhattacharya & Miller, The hyperendemic countries of southern Africa 2010). Hyperendemic countries are those with adult HIV The HIV epidemic in southern Africa has become a force prevalence over 10% (among those aged 15–49 years). In unto itself, influencing contemporary social dynamics. Young southern Africa, these countries are: Botswana (24% HIV people might be delaying marriage owing to concerns aboutDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:36 22 February 2012 prevalence), Lesotho (23.6%), Malawi (11%), Mozambique HIV infection. Evidence has been found for reduced fertility (11.5%), Namibia (13.1%), South Africa (17.8%), Swaziland rates among women living with HIV, while households (25.9%), Zambia (13.5%) and Zimbabwe (14.3%) (UNAIDS, experiencing an adult’s AIDS death are at increased risk 2010a). In these cases, the disease is exceptional because of dissolution (Hosegood, 2009). In Swaziland, there are of the numbers of people infected, the ongoing challenges an estimated 113 000 orphaned and vulnerable children to HIV prevention, the consequent levels of mortality out of a population of 442 840 children aged 14 or below and morbidity, and the demographic and social impacts. (National Emergency Response Council on HIV and AIDS HIV-prevention efforts have made progress, although the [NERCHA], 2007). In the absence of effective HIV treatment overall numbers of HIV-infected people remain as high as in these numbers will grow. Orphanhood, either owing to the early 2000s, while HIV-treatment programmes present HIV-related illnesses or otherwise, has long-term implica- new challenges. tions for children’s health and education outcomes (Beegle, HIV prevalence in southern Africa rose sharply from the De Weerdt & Dercon, 2006). Areas with high HIV prevalence mid- to late 1980s and peaked in the late 1990s to early are correlated with slower progress through school, even 2000s. Since then prevalence levels have generally either for non-orphans (Fortson, 2011). Evans & Miguel (2007) decreased or stabilised at high levels. The sub-Saharan highlight the negative impact of these circumstances on the Africa estimate of adult HIV prevalence given in the recent acquisition of human capital; they find that parental deaths UNAIDS global report (UNAIDS, 2010a) indicates that HIV leads to lower levels of primary school attendance and that prevalence has fallen from 5.9% in 2001 to 5% in 2009; families are left to select children to whom to dedicate their meanwhile, the absolute number of people living with HIV scarce resources. This will impact societies in sub-Saharan has increased from approximately 20.3 million in 2001 to Africa for generations. 22.5 million in 2009. The rate of new HIV infections has HIV and AIDS has impacted on development gains and also fallen (from 2.2 million in 2001, to 1.8 million in 2009), undermines efforts to meet the Millennium Development although not at the speed anticipated. HIV-infection rates Goals (MDGs) (Poku, 2005; Barnett & Whiteside, 2006; display a great deal of heterogeneity across the continent, Chopra, Lawn, Sanders, Barron, Abdool Karim, Bradshaw while West African countries exhibit an average HIV et al., 2009; Stuckler, Basu & McKee, 2010). It presents prevalence of 2% (Kilmarx, 2009). challenges to all development sectors and has been Numerous factors have contributed to the spread of HIV, reversing previously made gains in African countries, partic- many stemming from a context of poverty and inequality ularly as concerns women and children (Boutayeb, 2009; and a history of social upheaval. Specific factors include: Nkomo, 2010). Hecht, Alban, Taylor, Post, Andersen & patterns of labour migration; the significant presence of Schwarz (2006, p. 445) write: other sexually transmitted diseases; malnutrition, which The severe health impacts of AIDS are well increases biological vulnerability; urbanisation and shifting documented. But HIV/AIDS also affects countries’ cultural norms; new economic activities, creating new fundamental economic and social development sexual networks; and gender inequality, with gender-based performance, and exerts detrimental effects on violence being significant in some high-prevalence countries many of the other MDGs. AIDS will make it difficult (Barnett & Whiteside, 2006; Denis & Becker, 2006). if not impossible for many countries to achieve their AIDS (and the opportunistic infections linked to HIV) MDG targets. is changing the structure of societies in hyperendemic This is partly because the majority of AIDS deaths occur countries. By 2015, 6 million South Africans may have within the economically active age range — those people succumbed to AIDS illnesses, representing 13% of the most essential for the region’s economic and social viability. current population (UNAIDS, 2008). Bongaarts, Pettetier The loss of teachers, coupled with absenteeism, is an issue & Gerland (2009) presented special tabulations using data for the education sector (Boler & Archer, 2008). In agricul- from a report by the United Nations Population Division ture, HIV and AIDS is lowering production (Gillespie & (2009). It forecast that by the year 2030 the percentage of Kadiyala, 2005; Naysmith, Whiteside & Walley, 2008) and AIDS deaths in the age group 15–59 years will be approx- contributing to a ‘new variant famine’ in Swaziland (De imately 70% and 90% in Botswana and South Africa, Waal & Whiteside, 2003; Naysmith, De Waal & Whiteside,
  • 5. 348 Smith, Ahmed and Whiteside 2009). Pre-existing conditions of food insecurity are being The World Health Organization recommends that male exacerbated by the presence of fewer adults to tend to farm circumcision be incorporated into HIV-prevention strategies, work and other productive labour activities owing to AIDS as several case studies have shown it to be effective with deaths and people’s need to care for HIV-affected individ- relatively few side-effects (Hargreave, 2010; Templeton, uals. The ‘effective’ or ‘real’ dependency ratio has become 2010). There are concerns however about potential larger, decimating traditional community support networks. sexual disinhibition, where condom-use is reduced owing The sale of vital agricultural equipment assets and other to the false belief that circumcision fully protects from HIV items to pay for healthcare and funeral costs reduces the infection. The full impact on males’ sexual practices has yet economic assets of households. The HIV epidemic has, to be explored (Templeton, 2010). and will continue to have, negative impacts on economic Evidence concerning the relationship between highly growth (Boutayeb, 2009; Lovasz & Schipp, 2010; Nkomo, active antiretroviral therapy (HAART) and reductions in 2010; Weil, 2010). For instance, a recent estimate of the new HIV infections has been championed by international HIV epidemic’s impacts in South Africa suggests that HIV agencies as a way to both foster HIV prevention and access and AIDS reduces GDP growth by 1.42% per year (Thurlow, to treatment. Increased HAART coverage has been foundDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:36 22 February 2012 Gow & George, 2009). to decrease viral load and reduce new infections through The socioeconomic dynamics associated with an HIV vertical, sexual and blood-borne HIV transmission (Cohen epidemic are long-wave in nature, which, for us, makes HIV & Gay, 2010; Donnell, Baeten, Kiarie, Thomas, Stevens, and AIDS unique. They manifest over periods of time, with Cohen et al., 2010; Montaner, Lima, Barrios, Yip, Wood, several already having tangible impacts. Kerr et al., 2010). Treatment-as-prevention is an integral component of UNAIDS Treatment 2.0 strategy (UNAIDS, HIV prevention in sub-Saharan Africa 2010b). Although the indirect benefits of ART are encour- There is still a need to strengthen HIV-prevention aging, the feasibility of such an approach is question- programmes across sub-Saharan Africa, particularly able given current progress in ART rollout. Prevention of in southern Africa’s hyperendemic countries, where mother-to-child HIV transmission (PMTCT) in hyperen- HIV is a major public health matter (Kapiga, Hayes & demic countries has been promising, with several countries Buvé, 2010). HIV-prevention strategies for youths have reaching more than 80% coverage (UNAIDS, 2010a). Even not been adequately tailored towards the needs and so, there are continuing needs in terms of strengthening pressures facing this group, and there remain difficul- family planning and maternal and newborn healthcare in the ties in implementing interventions (Michielsen, Chersich, sub-Saharan African region. Luchters, De Koker, Van Rosem & Temmerman, 2010). Young women continue to be at greater risk for contracting Resource-poor countries HIV than any other group, which is fuelled in part by gender-based inequalities (Delpech & Gahagan, 2009). The challenge of ongoing treatment and funding Since gender-based inequalities tend to be structural they dependency are difficult to challenge (Jewkes, Dunkle, Nduna & Shai, The second rationale for considering HIV and AIDS as 2010; Silverman, 2010). Intergenerational sexual relation- exceptional is the challenge of providing ongoing treatment. ships, driven by transactional sex, continue to leave young Here the argument for exceptionalism can be extended women especially vulnerable to HIV infection (Jewkes et beyond the hyperendemic countries to include resource- al., 2010). poor countries with a medium burden of HIV disease A large number of heterosexually transmitted HIV (i.e. with between 3% and 9% HIV prevalence). AIDS is infections occur among HIV-discordant couples, where only an expensive disease to treat, and low-income African one partner was originally infected. Dunkle, Stephenson, countries face many resource constraints. This makes it Karita, Chomba, Kayitenkore, Vwalika et al. (2008) report unlikely that they can provide ongoing treatment for all who that 55–93% of heterosexually transmitted HIV infections need it without critically impeding other important develop- occur in this way. The apparent safety of a stable partner, ment and health goals. where both may be monogamous, highlights the difficul- In 2009, the weighted, mean price of the six most ties of HIV prevention via ‘condomise’ campaigns where frequently used first-line ART combinations was US$137 per both individuals in this situation may not see the need for a person per year in low-income countries. This increased to condom, except to prevent pregnancy. HIV-testing centres US$141 in lower-middle-income countries, and US$202 in have only relatively recently catered for couples’ testing upper-middle-income countries (World Health Organization (UNAIDS, 2010a). [WHO], 2010). In 2009, the costs of the most frequently Recent developments in ARV microbicides (see Abdool used second-line regimens for those three country-income Karim, Abdool Karim, Frohlich, Grobler, Baxter, Mansoor classifications were US$853, US$1 378 and US$3 638, et al., 2010) have been championed as protecting women respectively. (especially young women) and empowering them in Treatment provision has been scaled-up across the situations they have poor control over (Abdool Karim, continent. In 2009, 3 911 000 people were receiving Sibeko & Baxter, 2010). Several years remain before treatment, the vast majority in eastern and southern microbicides are fully commercially available, and current parts of Africa (WHO, 2010). After the revision of WHO research suggests that efficacy with this method peaks at guidelines to initiate treatment when an individual’s CD4 50% (Abdool Karim et al., 2010). cell count is ≤350 cells/mm, the absolute number of
  • 6. African Journal of AIDS Research 2011, 10(supplement): 345–356 349 people eligible for treatment increased. In 2009, only 37% on already tight resource envelopes. Yet Hecht, Stover, of all adults and children eligible for ART (at this higher Bollinger, Muhib, Case & De Ferranti (2010, p. e455) note criterion) had access (UNAIDS, 2010a). Currently, only two that HIV/AIDS spending in 2008 placed severe pressure African countries, Botswana and Rwanda, have achieved on available domestic resources and that this is unlikely 80% or above ART coverage. The revision to the WHO to abate in the near future. In their analysis of high-burden treatment guidelines is valid and much needed; however, (>5% HIV prevalence) low-income countries (the selected it does pose financial challenges considering already African countries included Cameroon, Kenya, Nigeria and tight resources. It is estimated that early therapy for Uganda), they write that with continued scale-up, “HIV/ patients with a CD4 cell count <350 cells/mm will increase AIDS spending in 2031 is estimated at 1–3% of the GDP worldwide ART coverage needs from 40% to 85% of all of HBLI [high-burden low-income] countries, and 23–65% people living with HIV, thereby increasing costs by 57% of expected health expenditures, suggesting that these (Stover, Bollinger & Avila, 2009). countries will be dependent on outside financing for HIV/ Once treatment programmes are initiated they must be AIDS for several decades to come.” Furthermore, the maintained and medication must be taken for life. People chronic lack of healthcare workers across the region (KoberDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:36 22 February 2012 will, after varying periods of time, need to switch to more & Van Damme, 2006; Wadee & Khan, 2007) severely expensive second-line treatment. Thus, questions arise impedes efforts to improve and scale-up current efforts. as to what is sustainable and appropriate. Many African In order for services to improve, these costs would also countries with mid-to-high HIV prevalence face major have to increase. Such programmes attempt a precar- budgetary constraints in meeting the costs of treatment ious balance between urgent need and the necessities of provision. Figure 1 provides an idea of the vast costs of planning carefully with limited resources. HIV/AIDS programmes up to the year 2025: 14 of these There is an additional concern about ongoing depend- countries have an HIV prevalence level greater than 5%; ence on foreign aid. Hecht et al. (2010) highlight how this 22 have a prevalence of 2% or more. And 22 are classi- dependency creates risks for recipient countries since much fied by the World Bank as heavily indebted poor countries of the decision-making (and thereby power and influence) (The World Bank, 2010). Because there is a growing need remains in Geneva and Washington, D.C. (the two main for countries with high disease burdens to rely on foreign bases for several prominent international health, develop- donors in order to provide treatment, the role of long-term ment and HIV/AIDS agencies). This translates into a loss sustained international funding becomes crucial. of full ownership over domestic health programmes and a Reliance on foreign aid for life-prolonging treatment for a dependence on external resources to maintain a healthy critical mass of individuals has risks. Haacker (2009) finds and productive society. From the perspective of the donors, that countries in receipt of large external financing also continued increases in aid for HIV/AIDS treatment also maintain a vulnerable fiscal position owing to the inherent highlights another problematic dependency issue. Over uncertainty of foreign aid. A withdrawal or reduction in (2007 and 2008) describes the moral responsibility that aid would be akin to a large fiscal shock. Haacker (2009) the United States faces in maintaining the successes in continues by arguing that calculations reported in the increasing treatment access versus funding other global paper on the future global need (2007–2025) will require needs. Over (2008, p. 19) points out that ‘entitlement’ to US an annual 6% increase in aid from donors, however this foreign aid for HIV/AIDS treatment might, in the extreme, surpasses medium-term growth forecasts for the main create a “post-modern colonial relationship between the donors from advanced economies (International Monetary US and these countries”; he suggests that PEPFAR, for Fund, 2011). Domestic funding will have to increase greatly example, should limit the expansion of new entitlements if foreign funding becomes inadequate, adding pressure (enrolling new patients) and focus more on HIV prevention. 18 15 Other costs US$ (Billions) 12 Other care and treatment 9 Second-line treatment 6 3 First-line treatment 2007 2010 2015 2020 2025 YEAR Figure 1: Projected costs of HIV/AIDS programmes in 34 African countries, 2007–2025
  • 7. 350 Smith, Ahmed and Whiteside Eastern Europe Cherkassova et al. (2007), 86% of the participants currently During the late 1990s and early 2000s, the Eastern sharing needles were infected with HIV. European HIV epidemic created a stir among researchers, policymakers and public health specialists (Webster, Missed opportunities to contain the HIV epidemic in Eastern 2003). The region was going through a transition from the Europe Soviet system to a market economy, which caused concur- As the HIV epidemic in Eastern Europe is largely concen- rent decreases in standards of living and state support. trated within a specific population group, there is the High levels of poverty and unemployment among young potential for a focused and sustained HIV-prevention people, as well as feelings of confusion and hopelessness response to reverse the infection rates. Mathers, given the struggle to cope with the transition, fuelled drug Degenhardt, Phillips, Wiessing, Hickman, Strathdee et al. use (Barnett, Seeley & Grellier, 2004; Hurley, 2010). In this (2008, p. 1745) write: “There is a clear mandate to invest environment of increased vulnerability and susceptibility to in HIV-prevention activities such as needle and syringe HIV infection, HIV prevalence rose exponentially, especially programmes and opioid substitution treatment and to among young males (Barnett, Whiteside, Khodakevich, provide treatment and care for those who are living withDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:36 22 February 2012 Kruglov & Steshenko, 2000). Barnett et al. (2000) warned HIV/AIDS.” Yet this is not happening. of increased HIV incidence and a possible bridging of Needle exchange, safer injection sites and other infections from IDUs to the general population. harm-reduction strategies have been proven to work in other UNAIDS (2010a) estimates there were between 1 140 000 contexts (see Kerr, Small, Buchner, Zhang, Kathy, Montaner and 1 610 000 adults and children living with HIV or AIDS in & Wood, 2010; Vlahov, Robertson & Strathdee, 2010), Russia and the Ukraine in 2009. The two countries account though only 10% of IDUs in Eastern Europe have access for nearly 90% of all new HIV infections in the region and to a syringe-exchange programme (Mathers, Degenhardt, have shown consistent increases in HIV incidence each Ali, Wiessing, Hickman, Mattick et al., 2010). The latent year (Van de Laar, Likatavicius, Stengaard & Donoghoe, response to HIV prevention for IDUs and the continued 2008). National HIV prevalence in Russia within the age neglect from the Russian government has exacerbated the group 15–49 has increased from 0.5% in 2001, to 1% in HIV epidemic. HIV infections have switched from being 2009 (UNAIDS, 2010a). National HIV prevalence is 1.1% in predominantly a phenomenon among male IDUs, which the Ukraine, while medical HIV diagnoses there have more could have been contained, to being predominantly hetero- than doubled since 2001 (UNAIDS, 2010a). sexually transmitted. The epidemic in Eastern Europe is generally concen- Hence, this ‘lost opportunity’ has made the HIV epidemic trated within the IDU population, their sex partners, and sex in Eastern Europe unique and deserving of an exceptional workers (UNAIDS, 2010a). The main mode of HIV transmis- response. Evidence of a ‘bridging’ of HIV infections between sion has changed from exposure to contaminated injections demographic groups and accordingly a change in the to heterosexual contact (European Centre for Disease major mode of transmission was highlighted by Burchell, Control and Prevention [ECDC], 2010) owing to the interplay Calzavara, Orekhovsky & Ladnaya (2008). Furthermore, between IDU (mostly males) and the sex work industry Ancker (2008) writes that cases of HIV contracted through (UNAIDS, 2010a). Data from ECDC (2010) indicate that this heterosexual transmission outnumbered those transmitted switch occurred in mid-2007, where the number of hetero- through IDUs in 43 of 89 regions in Russia. sexually acquired HIV infections overtook HIV incidence Social and political barriers impede the potential for in the IDU population. Heterosexual intercourse now effective HIV-prevention programmes. In Russia, the accounts for 46% of new HIV infections and has increased greatest barrier towards the full-scale implementation of by 128% since 2004 (ECDC, 2010). Contaminated injecting harm-reduction programmes is the government. Rhodes, equipment nonetheless continues to be a significant driver Sarang, Vickerman & Hickman (2010) argue that govern- of the epidemic in the region (Delpech & Gahagan, 2009), ment resistance to evidence-based HIV-prevention methods accounting for about 39% of new HIV infections (ECDC, is a contributing factor to the continued spread of HIV. 2010). With an increase in HIV infections among women, Studies on syringe exchange programmes in Russia have the risk of vertical transmission also increases. Thus, in found that they dramatically reduce the sharing of needles the Russian Federation and Ukraine, in 2005, 16 000 among IDUs; additionally there is evidence to suggest that infants were born to HIV-positive mothers; in 2006, 7% of IDUs with access to syringe exchange programmes report HIV-positive mothers transmitted the virus to their babies more frequent condom use (Rhodes, Sarang, Bobrik, (Burruano & Kruglov, 2009). Bobkov & Platt, 2004). What is striking is the relative size of the IDU population in Despite the available evidence, at the Eastern Europe and each country, and their associated level of HIV prevalence, Central Asia AIDS Conference in Moscow in 2009, Russia’s even when compared to other countries with similar IDU Chief Public Health Officer declared that the govern- populations. Table 1 lists countries with IDU subpopulations ment was ‘emphatically against’ the use of drug-replace- ≥1% of the national population. Russia and the Ukraine ment therapy (International AIDS Society, 2009). Rhodes each display high (mid-level) estimates of the numbers of et al. (2010) quotes from a meeting held between high IDUs (1.78% and 1% of the total populations, respectively), powers in the Russian government (i.e. president, prime with significantly high HIV prevalence among IDUs (37.15% minister, health minister, and director of the Federal Drug and 41.8% of the total populations, respectively). In the Control Service); it highlighted the government’s policy study by Kissin, Zapata, Yorick, Vinogradova, Volkova, against substitution therapy and the perception that
  • 8. African Journal of AIDS Research 2011, 10(supplement): 345–356 351 Table 1: Extent of injection drug use/users (IDU/IDUs) and estimated HIV prevalence Mid-level estimate of IDU Countries with IDUs totalling Mid-level estimate of the numbers Mid-level estimate of HIV prevalence among 15–64-year-olds >1% of the total population of IDUs prevalence among IDUs (%) (%) Azerbaijan 5.21 300 000 13 Georgia 4.19 127 833 1.63 Mauritius 2.07 17 500 Insufficient data Russia 1.78 1 825 000 37.15 Estonia 1.51 13 801 72.1 Malaysia 1.33 205 000 10.3 Puerto Rico 1.15 29 130 12.9 Australia 1.09 149 591 1.5 Ukraine 1.0 375 000 41.8 Canada 1.0 286 987 13.4Downloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:36 22 February 2012 Kazakhstan 0.96 100 000 9.2 South Africa 0.87 262 975 12.4 Data adapted from Mathers et al. (2008): the authors used a mix of data sources (peer-reviewed research articles, United Nations data sets, etc.) to create estimates which were then independently reviewed. introducing harm-reduction strategies stimulates social Ideologically driven responses to the HIV epidemic in tolerance for drug addicts. Methadone clinics are legally Eastern Europe, especially in Russia, create a perverse restricted because it violates Russia’s national criminal situation where funding for HIV prevention is available but code (Rhodes et al., 2010) and there is no state funding the relevant political will is not. The result is an exceptional for needle-exchange programmes. Though not illegal, such HIV epidemic that is preventable. programmes are thought of as promoting drug use. The efforts of NGOs to implement such programmes have been HIV prevention in Eastern Europe truncated owing to resistance from officials (Barnett et al., The speed of HIV transmission is unlikely to abate given 2004), and syringe programmes do not reach the majority inadequate harm-reduction and HIV-prevention tools for of IDUs and lack institutional support (Rhodes et al., 2004; IDUs (Delpech & Gahagan, 2009). Social condemnation and Rhodes et al., 2010). ongoing discrimination is likely to continue to drive young Resistance by the Russian government has a deeper drug users underground (Merkinaite, Grund & Frimpong, social context. It is not the evidence that is questioned. For 2010), thereby making it more difficult for outreach example, the available evidence indicates that “increasing the programmes to reach the most vulnerable. To respond coverage of opioid substitution treatment from 0% to 10%, effectively to the injecting-drug-centred HIV epidemic in 25%, or 50% could decrease [HIV] incidence by 21% (90% Eastern Europe, Merkinaite et al. (2010, p. 112) suggest a confidence interval [CI]: 14–34), 34% (CI: 23–51), or 55% need to “develop a clear understanding of young peoples’ (CI: 40–71), respectively” (Rhodes et al., 2010). Other factors drug-taking, risk and protective behaviours, the motives, constraining harm-reduction strategies for IDUs are a lack of values and beliefs that may drive their drug use, as well information on the effectiveness of such strategies, percep- as their concerns, aspirations and expectations of society tions that they will be culturally unacceptable, the reluctance and its institutions.” Harm-reduction strategies can possibly of IDUs to use the services owing to fear of persecution, and be adapted to religious and social contexts. Any long-term the influence of the Russian church (Tkatchenko-Schmidt, HIV-prevention strategy will need to address the structural Renton, Gevorgyan, Davydenko & Atun, 2008). social and economic impoverishment that drives drug use. In recent years, the Ukrainian government has taken a Alongside IDUs, women and youths are at increased less conservative stance. The state funds opioid substitution risk of HIV. The proportion of women living with HIV therapy and recognises the importance of HIV prevention among newly registered cases of HIV rose from 13% among criminalised groups. The country has taken signif- in 1995, to 44% in 2006; and in the Ukraine it rose from icant steps in protecting drug users from HIV (UNAIDS, 37.2% to 41.9% (Burruano & Kruglov, 2009). There are 2010a) and has worked alongside the International HIV/ well-established linkages between drug use and the sex AIDS Alliance, an NGO with a presence in the Ukraine, who work industry: at least 30% of sex workers surveyed in advocate for marginalised groups. But problems continue Russia reported having ever injected drugs (UNAIDS, to arise between government policy and the lived reality: 2008). The annual number of new HIV infections in Russia the police have been known to harass doctors and clinics has declined from its peak in 2001 (UNAIDS, 2008). for ‘drug dealing’ and drug users continue to be stigmatised Youths continue to be a vulnerable group, however, yet (Hurley, 2010). The effectiveness of clinic-run HIV-prevention are neglected in HIV-prevention programmes (Merkinaite projects has been impeded because of a fear of accessing et al., 2010). There are clear links between drug use and services among the intended targets (drug users and sex exchanging sex for money, shelter, drugs, food and other workers, who are both perceived as criminal groups) and goods. In a study of HIV seroprevalence among street because of the clinic costs incurred by the clients. youths aged 15–19 in St Petersburg, over one-third (37%)
  • 9. 352 Smith, Ahmed and Whiteside were HIV-infected (Kissin et al., 2007). Ukrainian youths insurance funds by individuals and by the state. A United living or working on the street are similarly at greater risk Nations report warns: “In some regions of Russia, especially of HIV. Harm-reduction and HIV-prevention initiatives have in oil and gas producing regions, drug use is acquiring the tended to respond to ‘older’ injection drug users; few tend status of a mass phenomenon” (United Nations Population to target young people’s recreational use (Merkinaite et al., Division, 2005, p. 27). In the context of high HIV prevalence 2010). Meanwhile, stigmatisation from society and harass- among IDUs, this ‘phenomenon’ may greatly impact ment from police problematise HIV-intervention programmes industry. Sharp (2002) used a sector-based macroeconomic (Busza, Balakireva, Teltschik, Bondar, Sereda, Meynell & model to show how Russia’s extractive industries could be Sakovych, 2010). highly vulnerable to HIV and AIDS owing to productivity losses caused by illness, absenteeism and death. Like the The demographic impacts of HIV in Eastern Europe mining industries in South Africa, Russian companies are In the absence of access to HIV treatment and care, AIDS developing HIV-prevention and mitigation programmes to mortality has increased. The number of persons diagnosed avert this. in 2006 with AIDS (not HIV infections) went up by 54%Downloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:36 22 February 2012 compared to the previous year, and the number of deaths Conclusions from AIDS rose by 39%. The number of AIDS deaths in Russia in the first five months of 2007 exceeded the annual There are HIV epidemics that should continue to be total for 2006 (Feshbach, 2008). regarded as exceptional. Sub-Saharan Africa and In Eastern Europe, HIV and AIDS exacerbates an already Eastern Europe are distinctly unique, but they do share troubling demographic situation, with a low total fertility rate some common characteristics. We briefly summarise and declining population. Eastern Europe is experiencing a the demographic impacts and treatment challenges that negative population growth rate (–0.2% in 2010) (Population motivate the case for an exceptional response to HIV and Reference Bureau, 2010). The majority of countries that AIDS, and offer policy recommendations. will see the largest population declines in 2050 will be in In hyperendemic countries the sheer scale of the HIV Eastern Europe, with the Ukraine seeing –28% contraction, epidemic and its impacts make HIV and AIDS exceptional. and Russia –22% (Population Reference Bureau, 2008). It is causing high rates of mortality and morbidity among Emigration will cease to be the leading cause of popula- reproductive adults, leaving greater numbers of the young tion decline in the near future. High adult mortality as well and old to care for themselves in a context of increasing as falling total fertility rates are driving the decline (Menon, vulnerability and poverty. The demographic impact of the Ozaltin, Poniakina, Frogner & Oliynyk, 2009). From 1987 HIV epidemic is crippling communities. HIV infections in to 1999, Russia saw a 50% drop in births, and by 2015 it is sub-Saharan Africa appear to have reached a plateau. To estimated that there will be just four workers for every three prevent a generation lost to HIV-related illnesses, current non-workers, with most of the non-working-age population efforts to provide treatment need to be expanded. being elderly (Menon et al., 2009). The cost of ART makes it difficult for countries with high HIV and AIDS contribute to these demographics by HIV prevalence but limited health financing to fund their increasing premature mortality among those of reproductive own HIV-treatment programmes within existing resource ages. A projection by the World Bank (2006, p. ix) for the envelopes. Ongoing bottlenecks in supplies pose further Ukraine suggests that by 2014 the share of AIDS deaths challenges to scaling-up treatment. Furthermore, there are will be 4.8%, 7.9%, or 8.6% under an optimistic, medium, concerns about the long-term sustainability of this aid, of or pessimistic scenario. HIV and AIDS will be responsible the ability of donors to increase funding, and the possibility for over one-third (41%) of deaths within the age group of inconsistent aid leading to drug resistance and increased 15–49, with 60% of deaths in this age group being females mortality. An argument in favour of not increasing funding for (Figure 2), and there will be 300 000–500 000 fewer people HIV and AIDS has been already been put forward. because of AIDS (The World Bank, 2006). In Eastern Europe the case for AIDS exceptionalism Ancker (2008) summarises several studies modelling is attributed to the concentration of the epidemic within the demographic impact of AIDS in Russia. A study by specific high-risk population groups. The fear that HIV and Eberstadt (2002) forecasts that Russia’s working-age AIDS would reach wider society has been realised in Russia population could decline by 3–11 million by 2025. A study and the Ukraine. The HIV epidemic grew during a period of for the United Nations Development Programme (Barnett et rapid economic, social and political transition and is located al., 2004) projects that Russia’s population could shrink by primarily among youths. It is expected to contribute to a an additional 20 million people by 2045 as a result of AIDS troubling population decline which is expected to have major mortality. While such projections are likely to change as new impacts on economic activity. To date, political will has been data emerges, the reality is that Russia and the Ukraine either lacking or insufficient to address this alarming trend. have significant IDU populations, high HIV prevalence in HIV-prevention efforts in hyperendemic regions have this group, and declining general populations. seen progress, especially in medical-based interventions, It is predicted that these demographic changes will affect although bottlenecks have impeded further progress. economic development. For example, AIDS deaths currently Structural issues, particularly with respect to tackling gender result in an additional 1–2% contraction in the Ukrainian inequalities, continue to be a barrier. There is a need labour force (The World Bank, 2006). Declines in the to tackle the structural drivers of the HIV epidemic — by workforce result in fewer contributions to health and social addressing the criss-crossing and interlinked contributors to
  • 10. African Journal of AIDS Research 2011, 10(supplement): 345–356 353 Total 60 Male Female 50 PERCENT (%) 40 30 20 10 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Downloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:36 22 February 2012 YEAR Figure 2: Forecasted share of AIDS deaths among adults (ages 15–49 years) in the Ukraine, 2004–2014 it — especially gender-based inequities, poverty dynamics, responding effectively. Exceptional epidemics continue to stigma, discrimination, the criminalisation of sex workers, require exceptional responses. and treatment access (Delpech & Gahagan, 2009). Introducing substitution therapy for drug users in Eastern Acknowledgements — Some of the ideas discussed in this article Europe requires ongoing dialogue with governments that came about from work carried out by Alan Whiteside on behalf of to date have been reluctant to introduce such policies and the ‘aids2031’ consortium. The authors contributed equally to the undertake efforts to bring about meaningful change. HIV current work. prevention will require state-level support and understanding of the socio-historical context driving drug use. References Policy recommendations Abdool Karim, Q., Abdool Karim, S.S., Frohlich, J.A., Grobler, A.C., The Russian government’s conservative stance on Baxter, C., Mansoor, L.E., Kharsany, A.B.M., Sibeko, S., Mlisana, K.P., Omar, Z., Gengiah, T.N., Maarschalk, S., Arulappan, N., harm-reduction therapy and needle-exchange programmes Mlotshwa, M., Morris, L. & Taylor, D. (2010) Effectiveness and has blocked access to strategies that could reduce safety of tenofovir gel, an antiretroviral microbicide, for the the incidence of injection drug use (IDU) and new HIV prevention of HIV infection in women. Science 329(5996), pp. infections. We propose that greater engagement with 1168–1174. public health actors in Russia, by local and internationally Abdool Karim, Q., Sibeko, S. & Baxter, C. (2010) Preventing HIV based civil society organisations, as well as with interna- infection in women: a global health imperative. Clinical Infectious tional agencies, can open dialogue for change. Evidence- Diseases 50(supplement 3), pp. S122–S129. based HIV/AIDS-intervention programmes that highlight the Ancker, S. (2008) Demographic impact of HIV/AIDS in Russia: cost-effectiveness of acting now rather than later are likely projections, analysis and policy implications. China and Eurasia to be more successful than scolding the government. Forum Quarterly 6(4), pp. 49–79. Barnett, T. & Prins, G. (2006) HIV/AIDS and security: fact, fiction Continued focus on the Millennium Development Goals in and evidence — a report to UNAIDS. International Affairs 82(2), sub-Saharan Africa will make some progress in mitigating pp. 359–368. the social, educational and health-related impacts of HIV Barnett, T., Seeley, J. & Grellier, R. (2004) HIV/AIDS in Eastern and AIDS. The long-term challenge will be to increase the Europe and the Commonwealth of Independent States. availability of domestic funds for HIV and AIDS treatment. Reversing the Epidemic: Facts and Policy Options. New York, This should be a central focus not just for HIV and AIDS, United Nations Development Programme (UNDP). but for overall health. Barnett, T. & Whiteside, A. (2006) AIDS in the Twenty-First Century: In the absence of an HIV vaccine or more-affordable Disease and Globalization (2nd Edition). London, Palgrave treatment, the demographic, social, economic and political Macmillan. consequences of HIV and AIDS will have a formidable hold Barnett, T., Whiteside, A., Khodakevich, L., Kruglov, Y. & Steshenko, V. (2000) The HIV/AIDS epidemic in Ukraine: its potential social in some regions and countries (where this hasn’t already and economic impact. Social Science and Medicine 51(9), pp. occurred). Development gains of the 20th century will be 1387–1403. eroded and targets for the Millennium Development Goals Bayer, R. (1991) Sounding board: Public health policy and the AIDS will be missed. This picture of the HIV/AIDS landscape is epidemic: An end to HIV exceptionalism? New England Journal not new, but it is being viewed less directly — the response of Medicine 324(21), pp. 1500–1505. therefore has to be reinvigorated. The idea that ‘AIDS Bayer, R. (1999) Clinical progress and the future of HIV exceptionalism’ is outdated ignores the complexity of exceptionalism. Archives of Internal Medicine 159(10), pp. different HIV epidemics and obfuscates the challenges to 1042–1048.
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