hiv and development challenges for...

25 October, 2007UNAIDS

‘HIV and development challenges for Africa’Catherine Hankins,

Associate Director & Chief Scientific Adviser to UNAIDS

Session: Challenges of globalisation, regional integration and development of Africa10th Anniversary of the Centre for the Study of Globalisation and Regionalisation

Centre at Warwick University

Warwick, September 17, 2007

Hankins

Warwick Univ.Sept 172007

HankinsUNAIDS

HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation

HIV and development challenges for Africa

• There is no one African epidemic: know your epidemic and act on it

• Upstream effects: structural drivers in Africa: poverty versus income equality: which is more powerful?

• Downstream impact: long wave impacts on poverty, GDP, human capital, social capital

• Responding to the interaction between HIV and poverty


HankinsUNAIDS


Global HIV epidemic, 1990‒2005* HIV epidemic in sub-Saharan Africa, 1985‒2005*

Number of people living with HIV% HIV prevalence, adult (15-49)

% HIV prevalence, adult (15‒49)

Number of peopleliving with HIV (millions)

0

10

20

30

40

50

1990 1995 2000 20050.0

1.0

2.0

3.0

4.0

5.0

1985 1990 1995 2000 20050

5

10

15

20

25

30

0.0

2.5

5.0

7.5

12.5

15.0

% HIV prevalence, adult (15‒49)

Number of peopleliving with HIV (millions)

Estimated number of people living with HIV and adult HIV Estimated number of people living with HIV and adult HIV prevalenceprevalence

This bar indicates the range around the estimate

*Even though the HIV prevalence rates have stabilized in sub-Saharan Africa, the actual number of people infected continues to grow because of population growth. Applying the same prevalence rate to a growing population will result in increasing numbers of people living with HIV.

10.0

2.2


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1990 1992 1994 1996 1998 2000 2002 2004 2006

Sub-Saharan Africa

Caribbean

GLOBAL

Latin America

Asia

E Europe and C Asia

PercentFemale (%)

70

60

50

40

30

20

10

0

Percent of adults (15+) living with HIV who are female, 1990‒2006

Figure 1


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HIV prevalence (%) in adults in Africa, 2005HIV prevalence (%) in adults in Africa, 2005

2.5


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HIV prevalence (%) by gender and urban/rural residence, HIV prevalence (%) by gender and urban/rural residence, selected subselected sub--Saharan African countries, 2001Saharan African countries, 2001‒‒20052005

0

10

20

30

%15‒49 years old,by gender

Lesotho South Africa

Zambia Kenya Uganda URTanzania

BurkinaFaso

Ghana Guinea Senegal

Urban Rural

Women Men

Women Men

0

10

20

30

%

15‒24 years old,by gender

0

10

20

30

%

15‒49 years old,by urban/rural residence

South East West

Sources: Demographic and Health Survey reports (Lesotho, Zambia, Kenya, Burkina Faso, Ghana, Guinea and Senegal) (2001–2005). Nelson Mandela Foundation (South Africa) (2005). Ministry of Health (Uganda). Tanzania Commission for AIDS (UR Tanzania) (2005).

2.7

Illustrative ResultsResources Needed for Prevention

02,0004,0006,0008,000

10,00012,00014,00016,000

2006 2010 2015

Mill

ions

of

US$

Univ Precautions

Male circumcision

Safe injections

PEP

Blood safety

PMTCT

STI treatment

Condoms

Social marketing

Other vuln. pops.

Prevention for PLHA

Workplace

IDU

MSM

CSW

Youth out of school

Youth in school

VCT

Comm. Mobilization

Mass media

Targets reached in 2010

Disconnect between dynamics of the epidemic and action: example from a West African country

General population prevalence 1.8%; antenatal clinic data stable 10 yearsPeak age is 35-39 years (low prevalence in youth)Sex worker HIV prevalence 78% and 82% in 2 largest cities75% of new infections in men in the capital city are clients of sex workersStrategic plan presupposes a highly generalised epidemic with widest possible engagement of society and a broad range of interventionsOnly 0.8% of AIDS investments are focused on sex work


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•• Upstream effects: structural drivers in Upstream effects: structural drivers in Africa: poverty versus income equality: Africa: poverty versus income equality: which is more powerful?which is more powerful?




HankinsUNAIDS


HIV & Poverty - Africa

0%

5%

10%

15%

20%

25%

0 10 20 30 40 50 60 70 80Percentage below $1 per day

HIV

Pre

vale

nce

BotswanaLesotho

NamibiaZimbabwe

Zambia

Malawi

Mozambique

Sierra Leone

Tanzania

Central African Republic

Ethiopia

Côte d'Ivoire Uganda

Kenya

Rwanda

South Africa

Mali

NigeriaCameroon

NigerMadagascar

GambiaBurundi

Ghana

Burkina FasoSenegalMauritania


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HIV & Income Inequality - Africa

R2 = 0.4881p=0.005%

0%

5%

10%

15%

20%

25%

30%

35%

0.25 0.35 0.45 0.55 0.65 0.75GINI Coefficient

HIV

Pre

vale

nce

Botswana

Lesotho

NamibiaZimbabwe

Zambia

Malawi

Mozambique

Tanzania


Ethiopia

Côte d'IvoireUgandaKenya

Rwanda

South Africa

Mali

NigeriaCameroon

Niger

BurundiGhana

Senegal

Swaziland


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LE a

t birt

h (h

ealth

y ye

ars)

, tot

alLo

g

25

75

GDP per capita in 1995 international dollars Log

308 53 5001 000 5 000 10 000 20 0007 0003 0002 000800600

50

70

60

40

30

Armenia

AzerbaijanBangladeshBhutan

Bolivia

Cuba

Finland

Georgia

Ghana

Haiti

Iceland

Italy

Japan

Luxembourg

Madagascar

Maldives

Mali

Mongolia

Nicaragua

Pakistan

Papua NewGuinea

Russia

Senegal

Spain

Sudan

TajikistanTurkmenistan

Uzbekistan

YemenAfrica

Americas

Arab countries

Asia

Europe

size = HIV prevalence (age 15–49)

HIV prevalence & Life expectancy

at birth 2000

Botswana

Angola

Burundi

Cameroon

CentralAfrican

Republic

Chad

Equatorial Guinea

Ethiopia

Guinea-Bissau

Kenya

Lesotho

Malawi

Mozambique

NamibiaNigeria

Sierra Leone

South Africa

Swaziland

Togo

Uganda

ZambiaZimbabwe

Burkina Faso

Côte d'Ivoire

Rwanda

Cambodia

Benin

Eritrea

Nepal

India

Honduras

Guyana

China

Ecuador

Egypt

El SalvadorIndonesia

Jordan

Morocco

Peru

Philippines

Sri Lanka

Suriname

Ukraine

Guatemala

Algeria

Argentina

Australia

Austria

Bahrain

Barbados

BelarusBelgium

Belize

Brazil

Bulgaria

Canada

Chile

Colombia

Costa Rica

Croatia

Cyprus

CzechRepublic

Denmark

DominicanRepublic

Fiji

FranceGermany

Greece

Hungary

Ireland

Israel

South Korea

Latvia

Lithuania

MalaysiaMalta

Mauritius

Mexico

Netherlands

New Zealand

Norway

Panama

Poland

Portugal

Romania

Singapore

Slovenia

Sweden

Switzerland

ThailandTrinidad and Tobago

Turkey

United Kingdom

United States of America

Uruguay

JamaicaEstonia


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•• Downstream impact: long wave impacts on Downstream impact: long wave impacts on poverty, GDP, human capital, social capitalpoverty, GDP, human capital, social capital



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Epidemic Curves, HIV, AIDS & Impact

T1 T2 Time

Numbers

A1A2

HIV prevalence

B1

A

B

AIDS - cumulative

SOCIAL AND ECONOMIC

IMPACT


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Impact of AIDS on life expectancy in five African countriesImpact of AIDS on life expectancy in five African countries19701970––20102010

Life expectancy at birth (years)

Source: United Nations Population Division (2004). World Population Prospects: The 2004 Revision, database.

Botswana

South Africa

Swaziland

Zambia

Zimbabwe

1970–1975 1975–1980

1980–19851985–1990

1990–19951995–2000

2000–20052005–2010

7065

60

55

50

45

4035

30

25

20

4.1


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Percentage of distribution of deaths by age in southern Africa, Percentage of distribution of deaths by age in southern Africa, 19851985––1990 and 20001990 and 2000––20052005

0–4 5–19 20–29 30–39 40–49 50–59 60+

40

35

30

25

20

15

10

5

0

1985-1990 2000-2005

Percentage of total deaths

Age-groups:

Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat (2005). World Population Prospects: The 2004 Revision. Highlights. New York: United Nations. 4.2

Lifetime risk of AIDS death for 15Lifetime risk of AIDS death for 15--yearyear--old boys, old boys, assuming unchanged or halved risk of becoming assuming unchanged or halved risk of becoming

infected with HIV, selected countriesinfected with HIV, selected countries

Source: Zaba B, 2000 (unpublished data)

Current adult HIV prevalence rate

Burkina Faso

CambodiaCôte d’Ivoire

Kenya

South AfricaZambia

Zimbabwe

Botswana

Burkina FasoCambodia

Côte d’IvoireKenya

South AfricaZambia

Zimbabwe

Botswana

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Ris

k of

dyi

ng o

f AID

S

current level of risk maintained

risk halved over next 15 years


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Projected reduction in African agricultural Projected reduction in African agricultural labourlabour force force due to HIV and AIDS by 2020due to HIV and AIDS by 2020

Sources: ILO (2004). HIV/AIDS and work: global estimates, impact and responses

Projected labor force loss (%) by year

NamibiaBotswanaZimbabwe

MozambiqueSouth Africa

KenyaMalawi

UgandaUR Tanzania

Central African RepublicCôte d’Ivoire

Cameroon

0 5 10 15 20 25 30

2020 2000

4.8


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Human capital

• Rising morbidity & mortality leading to decreased productivity in public and private sector

• investment declines at family, community, public sector and private sector levels

• Private sector: loss of skilled workforce, increased training needs, reduced management expertise

• Public sector: reduced tax revenues at a time of increased demand for health care and social support, reduced investment in child education, effects on workforce, potential for eroded governance capacity

• GDP effects: reduction of 0.5% to 1.5% in GDP growth rate over a 10 to 20 year period in high HIV prevalence countries


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Between 1990 and 2003, sub-Saharan Africa’s population of children orphaned by AIDS

increased from less than 1 million to more than 12 million

0

4

8

12

16

20

1990 1995 2000 2003 2010

Source: Children on the Brink 2004. A Joint Report of New Orphan Estimates and a Framework for Action. Fig. 6.

Number of Orphansdue to AIDS(millions)


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Intergenerational effects

• Orphans: 13% less likely to attend school than non-orphans (maternal orphans, double orphans, girls)

• Orphans overwhelming capacity of social networks and traditional patterns of intergenerational dependency, creating an uneducated, unsocialized and uncared for generation

• Lost transmission of knowledge and skills between generations (cf Bell and Deverajan): cumulative weakening from generation to generation of human and social capital


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People in subPeople in sub--Saharan Africa on antiretroviral treatment Saharan Africa on antiretroviral treatment as percentage of those in need, 2002as percentage of those in need, 2002––20052005

20022003

2004

2005

7.2Source: WHO/UNAIDS (2005). Progress on global access to HIV antiretroviral therapy: An update on “3 by 5.”


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Women as a percentage of all adults receiving antiretroviral theWomen as a percentage of all adults receiving antiretroviral therapy rapy in 30 countries: actual versus expected percentages, 2005in 30 countries: actual versus expected percentages, 2005aa

Latin America and CaribbeanLatin America and Caribbean

Guyana

ArgentinaBrazil

El Salvador

HaitiHonduras

PanamaPeru

Venezuela

0% 20% 40% 60% 80%

0% 20% 40% 60% 80%

CambodiaChinaIndia

Viet Nam

AsiaAsia

SubSub--Saharan AfricaSaharan Africa

Kenya

0% 20% 40% 60% 80%

MalawiMozambique

NamibiaNigeria

RwandaSouth AfricaUR Tanzania

UgandaZambia

Zimbabwe

Côte d'Ivoire Ethiopia

Ghana

BotswanaBurundi


Expected percentage of women receiving ARV therapy

7.4Source: WHO/UNAIDS (2006). Progress on global access to HIV antiretroviral therapy. A report on “3 by 5” and beyond.

a The expected percentage of women receiving ARV therapy is based on the percentage of people living with HIV/AIDS who are women


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Coverage of HIV-infected mothers who received antiretroviral

prophylaxis

Comparison of 2003 and 2005 data on the expansion of antiretroviComparison of 2003 and 2005 data on the expansion of antiretroviral ral therapy therapy

and coverage of HIVand coverage of HIV--infected mothers who received antiretroviral infected mothers who received antiretroviral prophylaxis in three subprophylaxis in three sub--Saharan African countriesSaharan African countries

Coverage of antiretroviral therapy

30

40

50

60

%

20

10

0Kenya UgandaNamibia

1.0

7.04.6

9.3

25.0

12.0

30

40

50

60

%

20

10

0Kenya UgandaNamibia

3.00.0

6.3

19.7

35.0

56.0

2003 2005

3.3Sources: Individual country reports (2005).


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Impact of three scenarios on HIV infection Impact of three scenarios on HIV infection in subin sub--Saharan Africa, 2003Saharan Africa, 2003––20202020

0.0

1.0

2.0

3.0

4.0

5.0

2003 2005 2010 2015 2020

Year

Treatment-centeredPrevention-centeredBaseline

Comprehensive response

Number of new HIV infections (millions)

Source: Salomon JA et al. (2005). Integrating HIV prevention and treatment: from slogans to impact6.1


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Impact of AIDSImpact of AIDS--related deaths in subrelated deaths in sub--Saharan Africa, 2003Saharan Africa, 2003––20202020

2003 2005 2010 2015 2020

Year

Treatment-centeredPrevention-centeredBaseline

Comprehensive response

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Number of AIDS-relateddeaths (millions)

Source: Salomon JA et al. (2005). Integrating HIV prevention and treatment: from slogans to impact6.2


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•• Responding to the interaction between HIV Responding to the interaction between HIV and povertyand poverty

Targets and timelines

UNGASS young people HIV-infected– 25% reduction in most affected countries 2005; 25% globally 2010

UNGASS MTCT: % HIV + infants born to HIV-infected mothers– 20% reduction by 2005; 50% reduction by 2010

3 by 5 Initiative: 3 million on ART by end 2005– Setting of next target?

US President's Emergency Plan 2008– 2 million on treatment, 7 million infections prevented, 10 million people,

including orphans, provided with care

Millennium Development Goals 2015– Halt and begin to reverse the spread of HIV/AIDS

Global Fund rolling targets over 5 years (replenishment 2006, 2007)– 1.6 million on treatment, 52 million reached by VCT; 1 million orphans


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AIDS funding requirements for lowAIDS funding requirements for low-- and middleand middle--income income countriescountries

Prevention 8.4 10.0 11.4 29.8

Care and treatment 3.0 4.0 5.3 12.3

Support for orphans and vulnerable children 1.6 2.1 2.7 6.4

Programme costs 1.5 1.4 1.8 4.6

Human resources 0.4 0.6 0.9 1.9

TOTAL 14.9 22.1 55.118.1

2006 2007 2008 2006‒2008US$ billion

Source: UNAIDS (2005). Resource needs for an expanded response to AIDS in low- and middle-income countries.10.1


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Sources of the estimated and projected funding Sources of the estimated and projected funding for the AIDS response from 2005 to 2007*for the AIDS response from 2005 to 2007*

* Assuming there are no new commitments

Source: UNAIDS (2005). Resource needs for an expanded response to AIDS in low- and middle-income countries.

Domestic

Bilateral

Multilateral

Private Sector

2005 2006 2007

US$ billion

0

2

4

6

8

10

12

10.10

Impact of external grants on the macro-economy at country level

If small share in GDP, no problemIf grants used to purchase imports (e.g. drugs), not much of a

problem— this is similar to receiving commoditiesIf grants used to purchase nontradeables (goods or services that

you can’t import) then it creates demand for local goods and services; in large amounts, it pushes up their prices which disproportionately affects poor people

It also pushes up demand for local currency, appreciating the exchange rate which can have a potentially adverse effect on exporters.

Can you use grants to improve supply-side of economy—reduce key bottlenecks?

Adverse impact on revenue mobilization? Creates dependency? Advantages of debt relief


HankinsUNAIDS


Progress towards achieving the Progress towards achieving the ““Three OnesThree Ones””: : Percentage of countries with one national coordinating body, onePercentage of countries with one national coordinating body, one national national

HIV/AIDS strategy or framework and one national monitoring and HIV/AIDS strategy or framework and one national monitoring and evaluation planevaluation plan

50

9085

0

20

40

60

80

100

National body National frameworkNational monitoringand evaluation plan

%

3.10


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Stakeholder participation in development Stakeholder participation in development of national AIDS plans in 79 countries, 2004of national AIDS plans in 79 countries, 2004

full participationinsufficient but increasing participationinsufficient participation with no signs of improvementno participation

Source: (UNAIDS 2006) From advocacy to action: A progress report on UNAIDS at country-level, UNAIDS.

UN agenciesCivil society/NGOs

People living with HIVDonors

Line ministriesMedia

District and local authoritiesFaith-based organizations

Private sectorWomen’s groups

0% 20% 40% 60% 80% 100%

11.1


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Addressing AIDS in the poorest communities and countries• AIDS money has most impact when strategies are based on the concept

of “know and act on your epidemic”.• Combine HIV programmes with poverty reduction initiatives. e.g. NGOs

integrating HIV prevention into village/community banking programmes/microfinance (Malawi) for women, and combine AIDS education with the provision of microfinance to groups of women: need to shift from smallshift from small--scale projects to largescale projects to large--scale programmesscale programmes.

• Provision of HIV treatment can help prevent poverty, delay orphaning –and indirectly contribute to HIV prevention as well.

• Development plans (whether they concern the development of productive sectors or the provision of social safety nets) must “pass the AIDS test”. e.g. World Bank-supported Chad/Cameroon Pipeline Project, supports HIV workplace interventions along the pipeline route –both for workers and for affected communities

• Poverty reduction programmes and AIDS strategies must both reduce vulnerability – particularly of women and young people: protecting human rights and tackling issues around social marginalization and stigma.

• Increased and sustained international support, driven by high-level political commitment and anchored in country ownership.


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Acknowledgements

• Peter Piot• Michel Sidibe• Robert Greener• Efren Fadriquela• Mihika Acharya• Constance Kponvi• YOU, THE AUDIENCE – THANK YOU!

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