Africa, the West and the Fight Against AIDS
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Africa, the West and the Fight Against AIDS

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Helen Epstein ...

Helen Epstein
Author of the new book The Invisible Cure: Africa, the West and the Fight against AIDS (Farrar, Straus & Giroux May 2007.) She is also a frequent contributor to The New York Review of Books, The New York Times Magazine and other publications. June 6, 2007

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  • Pretty good model for what’s happening in the rest of the world, but not adequate for what’s happening in E and S Africa.
  • Shown here are HIV prevalence rates over an approximately 15 year period from about a dozen sub-Saharan African cities. Despite many previous (and current) predictions to the contrary, for the most part HIV has remained relatively low and relatively flat in most of west Africa, with the exception of Ivory Coast (and Cameroon’s prevalence increased significantly during the 1990s). Although certainly a prevalence rate of 5-7%, as in Lagos for example, is a major problem, we still have not seen prevalence in west Africa reach anywhere near the levels observed in parts of southern and east Africa, even though most scientists believe that HIV probably emerged in west Africa, at least 70 years ago (probably in the Cameroon/Gabon rain forest region). A number of factors may be involved (such as, at least in some African countries, a certain degree of non-sexual transmission stemming from contaminated blood, reuse of syringes, etc.), yet many epidemiologists increasingly believe that male circumcision is particularly key to explaining many of the regional disparities in SSA (and in south and southeast Asia as well). In the extensive UNAIDS 4-site study, for example, there were no significant differences in sexual behavior -- or even prevalence of most STDs – between the high-HIV-prevalence sites in east and southern Africa, compared to the much lower prevalence west African sites. If anything (as we shall similarly see for our ABC Study), reported sexual behavior was markedly riskier in Yaonde, Cameroon than in Kisumu, Kenya or in Ndola, Zambia, yet even so HIV prevalence was much higher in the latter two sites. Few men were circumcised in those sites, whereas nearly all men were circumcised in Cameroon and Benin (the other lower-prevalence site in the study). In most of west Africa, male circumcision is the rule (with some parts of Ivory Coast and Burkina Faso being the main exceptions). In the east and southern African sites, we see that, in contrast, HIV prevalence rose dramatically during the late 1980s and throughout most of the 1990s, with the now famous exception of Uganda (Kampala pictured here in red), where prevalence evidently began plateauing after 1987 and then began to decline sharply after 1993. Various modelers and other researchers believe that, for various epidemiological reasons, HIV incidence (the rate of new infections) would have had to begin declining, perhaps rather sharply, sometime in the late 1980s.
  • Most of the Phase 1 Report focuses on a comparative analysis of behavior and behavior change (or lack of change) across the five African countries in the ABC Study. (Thailand was the other country studied.) As shown here, in the two countries for which there is evidence of HIV prevalence decline in key populations (i.e., among many populations in Uganda, and probably among young women in Lusaka, Zambia during the 1990s), there was also a significant decline in premarital sex, whereas there was little change in levels of premarital sexual behavior in the three countries where HIV prevalence had not declined during the 1990s (Cameroon, Kenya, Zimbabwe). In Uganda, levels fell between the 1989 and 1995 surveys; however, the level of premarital sex in young women actually rose somewhat between the 1995 and 2000 surveys. Note: the ABC Study Director, Doug Kirby, suggested at a July 2003 Youth Research Meeting in DC that, based on recent study data from focus groups, key informant interviews, etc., this may have been due in part to the possible “substitution” or “disinhibitory” effect of the greater impact of condom promotion in recent years in Uganda. This does not mean that condom promotion has necessarily been unbeneficial in Uganda overall, but perhaps raises the question, as some other recent data from places such as Rakai has similarly done so, about how best to promote condoms, especially so as not to inadvertently negate “A” and “B” outcomes (and vice-versa), as Kirby emphasized in his talk.
  • Also, Zero grazing in the Diocese of Kampala. Also, a very compassionate response, like that seen in gay community in 80s. Lots of talking about AIDS, in very personal ways, a huge number of spontaneous “care” groups, that weren’t necessarily formal, also women’s rights groups, etc etc. Co-wives and concubines…It was like this national obsession for a few years…
  • These data are from a question which used to be a standard one included in the DHS AIDS module.
  • How do you get people to do this? Everyone says behavior change is impossible…sneers at this. But I don’t know, I think we need to ask Africans what they think. Obviously, the Ugandans DID think it would work….
  • In Uganda’s generalized epidemic , Efforts to encourage people to limit their sexual partners played a central role in Uganda’s early approach to HIV prevention, and appear to have contributed to significant declines in HIV infection rates in the last 1980s and early 1990s. Interestingly , there seemed to be little change in teenage pregnancy rates from 1989-1995, the period in which incidence seemed to decline most dramatically. A recent paper presented at the 2005 retrovirus conference concluded that deaths contributed significantly to declines in HIV prevalence in Rakai, in the study period of 1994-2002 -- following the period in which Uganda experienced its dramatic declines in HIV incidence According to this new paper, the rates of new infections remained fairly stable in Rakai after the dramatic declines of the late ’80s and early ’90s. This later period was characterized by increases in reported condom use , but also by increases in the proportion of people reporting more than one sexual partner .  There also may have been slight decreases in the median age of sexual initiation among males . Some argue that the programmatic emphasis migrated away from “B” and towards “C” during this later period, and that consistent emphasis on all three of the “ABCs” of prevention might have resulted in continued declines in HIV incidence. The most recent DHS, which included a linked HIV biomarker, found that adult prevalence in Uganda is now 7% (the UNAIDS estimate is 4.1%), and that 39% of sexually active men and 18% of sexually active women reported sex with a non-marital, non-cohabitating partner in the past year. 41% of women and 50% of men reported condom use at last sex with a non-marital, non-cohabitiating partner.
  • By promoting the correct and consistent use of condoms in brothel settings, and by emphasizing the risks associated with casual sexual partnerships, Thailand was able to reverse a rising tide of new infections occurring via prostitution.
  • I personally think these bilboards sent the wrong message. They basically say, just go ahead and screw around, just use condoms. But by associating disease with “disreputable” behavior, womanizing, even violence and rape, reinforced the stigma and denial that have made the response to AIDS so desultory, so steeped in shame throughout much of southern Africa. Not Soddom and Gomorrha. Sex holds an important place in cosmology, and silence around it reinforced by centuries of racist stereotypes about black sexuality. Those stereo types were used to justify colonialism, idea being that black were less evolved, more subject to basic “drives” and therefore couldn’t govern these selves. So ads like this only emphasized the point. You are seeing a more compassionate response now, but it took a long time, and lot of people suffered in the meatime.
  • Here’s another one. I have nothing against condoms, and nothing against teen sex, if a young girl wants to go around wth an older man, that’s her business. But if your business is preventing HIV in southern Africa, I just think the risks are too great to be fooling around like this. I know it sounds puritanical and preachy, but would YOU really want your kid running around with condoms, thinking she’s safe, in a 30% HIV epidemic? Obviously everyone needs access to condom and information about how to use them. And that should be, I think, taught in schools, and health clinics and such, in a sober neutral manner. But when it comes to mass advertising, I really think you’d want to have another type of message out there that doesn’t glamorixze what is in fact insanely dangerous behavior. It reminds me of those cigarette ads from the sixties-Come to marlboro country, you’ve come a long way baby, etc. That tried to make what is an incredibly dangerous habit, seems sexy and fun.Or even worse, they gave people a false sense of security.. ”for a milder flavor smoke burpos….” It also seems to me a little racist, but African-Americans can tel me if they agree. I mean would this be an apprpriate poster to put up in a black neighborhood in the US? Would that be considered a little offensive? The corresponding Ugandan message during the early 90s was different, it was a poster, unfortunately I don’t have it, but it depicted a big fat man standing next to a car counting a handful of banknotes, and three teenage girls in school uniform and one of whom is making for the man, but the others are holding her back. And the slogan is: protect your friends! Don’t let them go with sugar daddys! And the norms around that did change. Not that there aren’t still sugar daddys in uganda, but its less common and more frowned upon than it used to be.
  • TOO MANY HIV PREVENTION PROGRAMS HAVE DIVIDED PEOPLE: HIV POS FROM HIV NEG, MORAL FROM IMMORAL, YOUNGER PEOPLE FROM ELDERS, MEN FROM WOMEN. WHAT WE NEED ARE MORE PROGRAMS THAT BRING PEOPLE TOGETHER: WOMEN’S RIGHTS, MICROFINANCE, ORPHAN CARE, HOME BASED CARE, ETC.

Africa, the West and the Fight Against AIDS Africa, the West and the Fight Against AIDS Presentation Transcript

  • Africa, the West, and the Fight against AIDS By Helen Epstein June 6, 2007 UCLA School of Public Health
  • The countries in Africa most affected by AIDS
  • Adult HIV Prevalence Worldwide Source: UNAIDS 2004: 2004 Report on the Global AIDS Epidemic This map does not reflect a position by the UN on the legal status of any country or territory or the delimitations of any frontiers.
  • Adult Prevalence Projections, to 2030
  • “HIGH RISK GROUP” MODEL • ACCORDING TO “HRG” MODEL, THE EXTENT OF SPREAD OF HIV IN A POPULATION WILL DEPEND ON: • FRACTION OF PEOPLE IN “HRG”s (CSWs, MIGRANT LABORERS, ETC) AND • THE DEGREE OF “MIXING” BETWEEN HIGH AND LOWER RISK GROUPS.
  • Who has HIV? (Zambia)
  • Frequency of concurrent and suspected concurrent relationships. Redrawn from Carael M. “Sexual Behavior” Chapter 4 in Cleland and Ferry 1995 n/a n/a 36 n/a 13 n/a 55 39 18 9 22 11 3 3 2 0.2 2 1 3 0.2 7 0.4 0 10 20 30 40 50 60 CAR Cote d'Ivoire Kenya Lesotho Tanzania Lusaka Manila Singapore Sri Lanka Thailand Rio de Janeiro F do M do 4 20 n/a 48 n/a 20 15 35 4 25 4 23 1 2 n/a n/a n/a n/a 0.3 4 1 4 0 10 20 30 40 50 60 CAR Cote d'Ivoire Kenya Lesotho Tanzania Lusaka Manila Singapore Sri Lanka Thailand Rio de Janeiro F think M think
  • Concurrency Slides By Stewart Parkinson
  • Effects of Concurrency HIV Negative Male HIV Positive Viremic Male HIV Positive Non-Viremic Male HIV Negative Female HIV Positive Viremic Female HIV Positive Non-Viremic Female
  • Concurrency December
  • Concurrency January
  • Concurrency February
  • Concurrency March
  • Concurrency April
  • Concurrency May
  • Concurrency June
  • Concurrency July
  • Concurrency August
  • Serial Monogamy December
  • Serial Monogamy January
  • Serial Monogamy February
  • Serial Monogamy March
  • Serial Monogamy April
  • Serial Monogamy May
  • Serial Monogamy June
  • Serial Monogamy July
  • Serial Monogamy August
  • WHERE DID MARTINA MORRIS GET THE IDEA THAT LONG TERM CONCURRENCY WAS DRIVING THE HIV EPIDEMIC IN AFRICA? • UGANDAN DOCTORS……
  • HIV Seroprevalence for Pregnant Women Selected Urban Areas of Africa: 1985-2000 Note: Includes infection from HIV-1 and/or HIV-2. Source: U.S. Census Bureau, HIV/AIDS Surveillance Data Base, 2000. & & & & & & & & , , , , , , ∗ ∗ ∗ ∗ ∗ ∗ ∗ ∗ ∗ ∗ ∗ + + + + # # # # # # # # # # # # ∀ ∀∀ ∀ ∀ ∀ ∀ ∀ ∀ ∀ ∀ ∀ ∀ ∀ ! ! ! ! ! ! ! ! ! ! 1985 1987 1989 1991 1993 1995 1997 1999 2001 0 5 10 15 20 25 30 35 40 45 50 HIV Seroprevalence (%) Kampala Nairobi Abidjan Harare Kwazulu/ Natal Lagos Yaounde Francistown Blantyre Lusaka Dakar
  • Premarital sex: % of never married women 15- 24 years old who had sex in the past year 48 33 18 52 35 39 13 3534 22 15 32 2627 0 10 20 30 40 50 60 70 Uganda Zambia Cameroon Kenya Zimbabwe early-1990s mid-1990s late 1990s ORC Macro Early 90s/late 80s Mid 90s Late 90s/early 2000s Uganda Zambia Cameroon Kenya Zimbabwe 35 22 27 39 34 26 48 52 33 35 32 18 13 15
  • Teenage pregnancy in Uganda Percentage who have had children or who are currently pregnant From USAID funded Demographic and Health Surveys 23.2 43.3 44.1 17year olds 12.9 22.1 20.8 16 year olds 54.0 64.7 58.3 18 year olds 61.23.32000/1 70.87.71995 59.48.71988 19 year olds15 year olds
  • Condoms? Since the beginning of the HIV/AIDS epidemic, a considerable amount of programmatic effort has focused on condom promotion… Reported condom use last higher-risk sex for ages 15-24 (UNAIDS, 2001 & BAIS 2001) Given that Botswana has for some time featured some of the highest rates of (self-reported) condom use in the world, why isn’t Botswana hailed alongside of Uganda as a major success story? 0 10 20 30 40 50 60 70 80 90 Botswana Uganda Zimbabwe Rwanda Senegal Kenya Malawi Male Female Percent
  • The condom quandary HIV Prevalence in Pregnant Women VS PSI Condom Sales 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% 50.00% 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Year Prevalence 0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000 CondomSales Urban Rural PSI Condom sales HIV Prevalence
  • C is for condomize 1 Shelton, et al (2004) “Ever” use of condoms among adults increased from 15 to 30 percent in men, and from 7 to 20 percent for women, from 1989 to 19951 Botswana may have the highest levels of reported condom use in Sub-Saharan Africa 0 20 40 60 80 100 Women Men Women 37.8 Men 58.9 Condom Use Last Higher-Risk Sex (UNAIDS 2000, ages 15-24) Uganda: 0 20 40 60 80 100 Women Men Women 75.3 Men 88.3 Condom Use Last Higher-Risk Sex (BAIS 2001, ages 15-24) Botswana:
  • “CONSISTENT” CONDOM USE PROTECTS, BUT NOT TOTALLY…. (PROBABLY BECAUSE THE USE IS NOT AS CONSISTENT AS IT SHOULD BE.)
  • Consistent condom use by type of partner, Zambia 2003 0 10 20 30 40 50 60 70 80 90 With Sex Workers With Regular Partner With wives Truck drivers Uniformed Personnel Minibus Drivers
  • B is for be faithful Uganda coined (from agricultural tradition) the “zero- grazing” approach to prevention 1 Shelton, et al (in press) 3 BAIS (2001) 2 Reported higher risk sex in the past 12-months2 0 10 20 30 40 50 60 70 80 90 100 15-49 year olds 15-49 year olds 28.4 14.1 Men Women Uganda: Reported higher risk sex in the past 12-months3 0 10 20 30 40 50 60 70 80 90 100 15-49 year olds 15-49 year olds 64.5 53.6 Men Women Botswana: 0 10 20 30 40 1989 1995 1989 35 16 15 1995 15 6 3 Men with one or more "casual" partners in past year Women with one of more "casual" partners in past year Men with three or more "non-regular" partners in the past year Uganda1 :
  • Types of Reported Behavior Change in Uganda: DHS 1995 Never-Married People’s Behavior Change to Avoid AIDS Delayed First Sex or Stopped Sex Restricted Sex to One Partner Began Using Condoms Did Not Change Behavior Percent of Men: 29 27 17 15 Percent of Women: 38 29 3 27
  • Types of Reported Behavior Change in Uganda: DHS 1995 Married People’s Behavior Change to Avoid AIDS Restricted Sex to One Partner Began Using Condoms Did Not Change Behavior Percent of Men: 66 5 11 Percent of Women: 58 1 38
  • Early successes: Uganda and “zero grazing”
  • From Warren Winkelstein Jr et al, “The San Francisco Men’s Health Study: Continued Decline in HIV Seroconversion Rates among Homosexual/Bisexual Men.” AJPH November 1988 vol 78, pp. 1472-4
  • Early successes: Thailand and “100% condoms”
  • The HIV rate is beginning to decline in several African countries, including Kenya, Zimbabwe and I think maybe Malawi and Zambia. But—why did it take so long? And why is the HIV rate still so high in southern Africa?
  • The importance of evidence-based practice How does what is being done… •Mass-mediated advertising targeting young men •“Miss Lovers Plus” beauty pageant •Youth-oriented jam sessions •Etc…
  • IMPLICATIONS FOR PREVENTION? • AFRICAN PEOPLE NEED TO KNOW WHERE THEIR RISKS ARE COMING FROM —IE NOT JUST FROM “PROMISCUOUS PEOPLE.” • MY HYPOTHESIS IN INVISIBLE CURE IS THAT AN UNDERSTANDING OF CONCURRENCY NETWORKS COULD HELP REDUCE THE STIGMA AND DENIAL SURROUNDING THE EPIDEMIC IN MUCH OF SOUTHERN AFRICA, AS IT DID IN UGANDA, AND THIS COULD FOSTER A MORE PRAGMATIC RESPONSE TO THE EPIDEMIC.. • UGANDANS DID KNOW EARLY ON THAT HIV WAS SPREADING THROUGH CONCURRENT LONG TERM RELATIONSHIPS ALTHOUGH THEY DIDN’T USE THE WORLD “CONCURRENCY.” UGANDAN GOVERNMENT CAMPAIGNS MADE IT CLEAR THAT EVERYONE WAS AT RISK, NOT JUST SEX WORKERS AND PROMISCUOUS, ‘IMMORAL’ PEOPLE. THIS HELPED ROUSE A MORE COMPASSIONATE, OPEN REPONSE TO THE AFFLICTED, AND A GENERAL RECOGNITION THAT AIDS WAS NEITHER AN ACT OF GOD OR A PUNISHMENT FOR SIN, BUT A TERRIBLE DISEASE THAT NO ONE DESERVES. • TOO MANY HIV PREVENTION PROGRAMS HAVE DIVIDED PEOPLE: HIV POS FROM HIV NEG, MORAL FROM IMMORAL, YOUNGER PEOPLE FROM ELDERS, MEN FROM WOMEN. WHAT WE NEED ARE MORE PROGRAMS THAT BRING PEOPLE TOGETHER: WOMEN’S RIGHTS PROGRAMS, MICROFINANCE PROGRAMS, ORPHAN CARE PROGRAMS, HOME BASED CARE PROGRAMS, ETC.