Is HIV/AIDS still exceptional?

Alan WhitesideHealth Economics and HIV/AIDS Research Division,

University of KwaZulu-NatalDurban

Presentation to Daniel J. Evans School of Public Affairs

University of WashingtonMonday 9th February 2009

www.heard.org.za

Lancet editorial 18/10/08

It is time to unwind the rhetoric, and

reposition the responses to HIV/AIDS as

one of several important health

challenges. …. UNAIDS needs to

abandon AIDS exceptionalism.

Actually no. AIDS is exceptional, but not

everywhere!

Key Points

• The State of the Epidemic

• Why AIDS is exceptional

– Three waves and long periods

– AIDS and the global disease burden

– The hyper epidemic countries

– The demographic impacts in Africa and Eastern Europe

– The cost of care

• Big issues

2007 Global HIV Infection33 million people [30–36 million] living with HIV,

2.2

Global numbers living with HIV and

adult HIV prevalence

Source: UNAIDS 2008

Epidemic Curve: HIV, AIDS and

Impact

27Aug01 -Report I: Epidem’gy & Lit. p. 27

T1 T2 Time

Numbers

A1

A2

HIV prevalence

B1

A

B

AIDS - cumulative

Impact

Global Baseline Death Projections

(Non-Communicable Diseases)

Source: Mathers and Loncar 2002, Projections of Global Mortality and Burden of Disease from 2002 to 2030, World Health

Organization, Geneva, Switzerland

Global Baseline Deaths Projections

Communicable Diseases

Source: Mathers and Loncar 2002, Projections of Global Mortality and Burden of Disease from 2002 to 2030, World Health

Organization, Geneva, Switzerland

Ranking Low income Middle income High income World

1 Ischaemic heart

disease 13.2

Cerebrovascular

disease 14.4

Ischaemic heart

disease 15.2

Ischaemic heart

disease 13.4

2 HIV/AIDS 13.2 Ischaemic heart

disease 12.7

Cerebrovascular

disease 9.0

Cerebrovascular

disease 10.6

3 Cerebrovascular

disease 8.2

COPD 12.0 Trachea, bronchus

lung cancers 5.1HIV/AIDS 8.9

4 COPD 5.5 HIV/AIDS 6.2 Diabetes mellitus

4.8

COPD 7.8

5 Lower respiratory

tract infections 5.1

Trachea, bronchus

lung cancers 4.3

COPD 4.1 Lower respiratory

tract infections 3.5

Cause of Death by Income and

Percentage in 2030

2007 Global HIV Infection33 million people [30–36 million] living with HIV,

2.2

2007 HIV Prevalence, African Adults (15–49)

2.8

HIV Prevalence in Antenatal Clinic

Surveys: Southern Africa

Source: UNAIDS Global AIDS report 2008

Demographic and Health Survey

HIV Prevalence

HIV and AIDS

Country Population Number living with

HIV/AIDS 18.8%

prevalence rate

Swaziland 1,200,000 225,600

USA 301,140,000 56,614,320

UK 60,776,000 11,425,888

EU 492,964,000 92,677,000

Republican Voters in 2008

56 000 000

Number of American’s who

would be infected if the USA

had Swaziland's prevalence

56 614 320

The Demographic Impacts

• Young people die

• Children are not born

• Population decline

• Falling life expectancy

• Orphaning

Population Decline: Russia & Ukraine

Ukraine

4.4

4.6

4.8

5

5.2

5.4

1990 1995 2000 2002 2004 2006

year

popula

tion (

millio

ns)

Ukraine

Russia

13.914

14.114.214.314.414.514.614.714.814.9

1990 1995 2000 2002 2004 2006

year

popula

tion (

mill

ions)

Russia

Source: World bank HNP Statistics

Ukraine

Demographics:

Population Growth

Swaziland 2007 Preliminary

Census Results

Population Data (de facto)

1997 929 718

2007 912 229

There were 17 499 fewer people over 10 years

Estimated for 2006 1 200 000

Demographics:

Population Growth

Demographics:

Life Expectancy

AIDS can not be cured

• People will need treatment

• For life

• And it is expensive

Per capita health expenditure

Country Health Expenditure

Per capita (USD)

Cost of ARV

treatment per

person/year (USD)

Botswana 171 1500*

Swaziland 66 168

Mozambique 11 960**

Rwanda 11 400

Source: Summary country profiles for HIV/AIDS treatment scale up, WHO 2005.

*ARV treatment publicly funded. Source: Introducing ARV Therapy in the Public sector in Botswana Case study, 2004.

** Mozambique offers subsidized ARV therapy at approx. 80 USD/month. Source: Provision of Antiretroviral Therapy in resource limited

settings: a review of experience. WHO/DFID 2003

Mopping the Floor while the tap is

running

Long term impacts

The impact of the epidemic is still

unfolding and will do so for at least a

generation

Lessons from climate change??

Agriculture

Big Issues

• AIDS interest (& funding) may have peaked– Financial melt-down and recession

– Global environmental change

– Food availability and prices

– Peak oil

• Treatment challenges – Cost and Coverage

– Sustainable financing

• Prevention (can we and how)

• Leadership and ownership (who and how)

What needs to be done differently

• Honest discussion about costs, choices, sustainability and prospects

• Prevention – A reassessment of existing programmes

– Ownership (leadership in Africa does not own the epidemic)

– Male female dynamics

– Sexual networks

• Impact – Save the human capital

• Leadership