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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 po...
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...
Who has HIV? (Zambia)
Frequency of concurrent and suspected concurrent relationships.
Redrawn from Carael M. “Sexual Behavior” Chapter 4 in
Clel...
Concurrency Slides
By Stewart Parkinson
Effects of Concurrency
HIV Negative Male
HIV Positive Viremic Male
HIV Positive Non-Viremic Male
HIV Negative Female
HIV P...
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...
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
...
Teenage pregnancy in Uganda
Percentage who have had children or who are currently pregnant
From USAID funded Demographic a...
Condoms?
Since the beginning of the HIV/AIDS epidemic, a considerable amount of
programmatic effort has focused on condom ...
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...
C is for condomize
1
Shelton, et al (2004)
“Ever” use of condoms
among adults increased
from 15 to 30 percent in
men, and ...
“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
W...
B is for be faithful
Uganda coined (from
agricultural tradition) the “zero-
grazing” approach to
prevention
1
Shelton, et ...
Types of Reported Behavior Change in
Uganda: DHS 1995
Never-Married People’s Behavior Change to Avoid AIDS
Delayed First
S...
Types of Reported Behavior Change in
Uganda: DHS 1995
Married People’s Behavior Change to Avoid AIDS
Restricted Sex to
One...
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 amo...
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 ...
The importance of evidence-based practice
How does what is being done…
•Mass-mediated
advertising targeting
young men
•“Mi...
IMPLICATIONS FOR PREVENTION?
• AFRICAN PEOPLE NEED TO KNOW WHERE THEIR RISKS ARE COMING FROM
—IE NOT JUST FROM “PROMISCUOU...
Africa, the West and the Fight Against AIDS
Africa, the West and the Fight Against AIDS
Africa, the West and the Fight Against AIDS
Africa, the West and the Fight Against AIDS
Africa, the West and the Fight Against AIDS
Africa, the West and the Fight Against AIDS
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
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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Africa, the West and the Fight Against AIDS

  1. 1. Africa, the West, and the Fight against AIDS By Helen Epstein June 6, 2007 UCLA School of Public Health
  2. 2. The countries in Africa most affected by AIDS
  3. 3. 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.
  4. 4. Adult Prevalence Projections, to 2030
  5. 5. “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.
  6. 6. Who has HIV? (Zambia)
  7. 7. 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
  8. 8. Concurrency Slides By Stewart Parkinson
  9. 9. 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
  10. 10. Concurrency December
  11. 11. Concurrency January
  12. 12. Concurrency February
  13. 13. Concurrency March
  14. 14. Concurrency April
  15. 15. Concurrency May
  16. 16. Concurrency June
  17. 17. Concurrency July
  18. 18. Concurrency August
  19. 19. Serial Monogamy December
  20. 20. Serial Monogamy January
  21. 21. Serial Monogamy February
  22. 22. Serial Monogamy March
  23. 23. Serial Monogamy April
  24. 24. Serial Monogamy May
  25. 25. Serial Monogamy June
  26. 26. Serial Monogamy July
  27. 27. Serial Monogamy August
  28. 28. WHERE DID MARTINA MORRIS GET THE IDEA THAT LONG TERM CONCURRENCY WAS DRIVING THE HIV EPIDEMIC IN AFRICA? • UGANDAN DOCTORS……
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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:
  35. 35. “CONSISTENT” CONDOM USE PROTECTS, BUT NOT TOTALLY…. (PROBABLY BECAUSE THE USE IS NOT AS CONSISTENT AS IT SHOULD BE.)
  36. 36. 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
  37. 37. 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 :
  38. 38. 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
  39. 39. 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
  40. 40. Early successes: Uganda and “zero grazing”
  41. 41. 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
  42. 42. Early successes: Thailand and “100% condoms”
  43. 43. 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?
  44. 44. 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…
  45. 45. 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.

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