HSS4331 International Health Theory

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HSS4331 International Health Theory
HIV/AIDS

• Nov 9, 2009

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Today.

• HIV/AIDS
• Africa

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Today.

• I will present to you what most researchers think
  about the HIV/AIDS pandemic
• Next week, we will have a guest lecture by
  HIV/Africa specialist Dr Ed Mills who will
  present a slightly different and maybe
  controversial-- viewpoint

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HIV/AIDS

• The basics
• Acquired Immune Deficiency Syndrome
• Caused by Human Immunodeficiency Virus
• Evidence of infection before 1970
• Current pandemic started in late 1970s, early
  1980
• AIDS defined in 1982
• First identified in gay community in USA
• Originally called GRID gay-related immune
  deficiency

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Transmitted via

• Sex
• Needle sharing
• Blood transfusions
• Mother-to-infant
• Any other activity that allows meaningful contact
  of body fluids

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Timeline

• 1983 Pasteur Institute in France discovers HIV
  Human Immunodeficiency Virus
• If not treated, those with HIV will develop AIDS
  in 8-10 years
• 1995 protease inhibitors dramatically increase
  survival of HIV patients with access

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Alternative Theory

• A minority of scientists question the link
  between HIV and AIDS
• http//www.orgonelab.org/hiv_aids.htm

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Treatment

• Cocktail
• highly active anti-retroviral therapy HAART
• ARV anti retroviral therapy
• Serious side effects
• Regimens can be complicated
• Can be very expensive

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Affordability of ARV drugs -gone down from
10,000/year to 200/year
Last year, the European Commission ruled that EU
countries are free to make available generic
versions of patented drugs for export to poor
countries which lack their own manufacturing
facilities.
Trade Related Intellectual Property Rights (TRIPS)
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Death

• People dont die from AIDS
• AIDS allows opportunistic infections
• Leading cause of death of AIDS patients is
  bacterial infection
• Tuberculosis
• Fungal infections
• Pneumonia

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Co-infection with TB

• 1/3 of the world is currently infected with TB,
  though most are not active cases
• 5-10 will develop active TB disease
• Only 25 have access to treatment
• TB accounts for 13 of all AIDS deaths
• HIV is the strongest known risk factor for a TB
  carrier to progress to full TB disease

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Co-infection with STDs

• In the presence of an STD, chance of acquiring
  HIV increases 5X
• Puts sex workers at even greater risk

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Diagnosis

• Bloodtest
• Looking for HIV antiobodies
• Cheek swab
• Not saliva, but oral mucosal transudate, a
  fluid produced by cheek cells
• Visual
• In 1985, WHO developed the Bangui Definition
  for use in countries without antibody testing
  technology
• Sometimes more informal Slim disease

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Bangui Definition

• Exclusion criteria
• Pronounced malnutrition
• Cancer
• Immunosuppressive treatment
• Inclusion criteria with the corresponding score
• Weight loss exceeding 10 of body weight 4
• Protracted asthenia 4
• Continuous or repeated attacks of fever for more
  than a month 3
• Diarrhoea lasting for more than a month 3
• Cough 2
• Pneumopathy 2
• Oropharyngeal candidiasis 4
• Chronic or relapsing cutaneous herpes 4
• Generalized pruritic dermatosis 4
• Herpes zoster (relapsing) 4
• Generalized adenopathy 2
• Neurological signs 2
• Generalized Kaposi's sarcoma 12

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CD4 Count

• A proxy measurement of the strength of a
  patients immune system
• CD4 count goes down as HIV infection progresses
• Used in coordination with

Viral Load Test

• The amount of HIV virus in the blood, lymph,
  spleen, and other body parts
• Viral load goes up as HIV infection progresses

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HIV/AIDS in the Developed World
Case study USA
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HIV/AIDS Around the World
To get current data, go to http//www.unaids.org/
en/HIV_data/2006GlobalReport/default.asp
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UNAIDS 2008
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detection bias?
New AIDS Cases Per Year Per 100,000 Population
35
Caribbean
30
25
20
North America
15
10
Latin America
5
0
2000
90
91
92
93
94
95
96
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The red bits are what we call Sub-Saharan Africa
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Percentage of the Adult (ages 15-49) population
with HIV/AIDS, 2003
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Percent of adults (15) living with HIV who are
female 19902007
2.4
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Haiti HIV Seroprevalence gender split
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Why MSM?

• Sexuality is culturally defined
• Men having sex with men do not necessarily
  self-identify as homosexual
• Sociologically
• MSM refers to the sexual relationship between two
  men
• Homosexuality refers to broader relationships
  between men, beyond the sexual

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Truck Drivers

• Yes, truck drivers
• The spread of HIV in Africa is linked to the
  movement of labour between rural and urban
  centres
• Geographical link between HIV clusters and road
  networks
• Truck drivers have high-risk behaviour of
  sleeping with prostitutes and a tendency to
  spread the infection along trade routes

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Impact of AIDS on Sub-Saharan Africa

• 2/3 of all people with HIV live in this region
• 75 of all AIDS deaths occur here
• (region comprises only 10 of world population)
• Each year, gt2 million people died of AIDS in this
  region
• In this region, direct medical treatment related
  to AIDS (not including ARV) US30 per person
  per year
• Overall public health spending is ltUS10 per
  person per year

UNAIDS 2002 Report on the Global AIDS Epidemic
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Impact

• Hospitals
• People with HIV occupy half of all hospital beds
• Shortage means only people in later stages are
  admitted, resulting in lessened treatment success
  
• Health Care Workers
• Large numbers are HIV or AIDS positive
• Dwindling numbers
• Providing ARVs requires more training

UNAIDS, 2006 Report on the Global AIDS Epidemic,
chapter 4 The impact of AIDS on people and
societies
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Household Impact

• Wage earners killed off -gt impoverished families
• Young forced into prostitution -gt increased
  disease transmission
• AIDS has erased much of the anti-poverty progress
  made over the past 6 decades
• Basic necessities not being provided
• There are entire communities with no adults left
  -gt households led by small childen
• No transfer of knowledge from adults to children

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Food Production

• Not enough labour to work fields
• In Malawi, Botswana, Zimbabe, agricultural output
  will drop 14-20 by 2020 due to AIDS
• The use of ARV requires proper nutrition
• Vicious cycle
• AIDS -gt poor food production -gt poor nutrition -gt
  more AIDS

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Anti Retrovirals
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Gender Disparity

• The impact of AIDS in Africa is felt
  disproportionately by women
• In many circles, AIDS is no longer a gay
  disease, but a womans disease, since gt50 of
  all cases are borne by heterosexual women
• Women function as family care givers, and are now
  the sole providers
• Leading to neglect in care-giving

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AIDS Virgin Myth

• It is believed that an HIV-infected man will be
  cured if he has unprotected sex with a virginal
  female
• -gt epidemic of child rape
• -gt emerging epidemic of rape of the disabled
• Global movement to re-educate those at risk
• South African group Love Life
• www.lovelife.org.za

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Circumcision

• Some studies suggest that male circumcision can
  reduce HIV transmission (via sex) by gt50
• Presently, there are vocal advocates to make
  circumcision mandatory in high risk communities
• Global teams offering free, safe circumcisions in
  Swaziland, Botswana and elsewhere

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Nice Summary

• Of some of the AIDS impacts is found here
• http//www.avert.org/aidsimpact.htm

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Orphans A Lost Generation

• Numbers are large and growing
• Social support systems are overwhelmed
• Risk of a lost generation
• little or no education
• poor socialization
• social upheaval
• economic underclass

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Debt
-Kenya pays 17X more on debt repayment than on
HIV control
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Economic Growth Impact of HIV (1990-97)
(Data from 80 developing countries)
0
-0.2
-0.4
-0.6
-0.8
Reduction in growth rate GDP per capita (, per
year)
-1
-1.2
-1.4
-1.6
0
5
10
15
20
25
30
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HIV Prevalence Rate ()
Source R. Bonnel (2000) Economic Analysis
ofHIV/AIDS, ADF2000 Background paper, World Bank
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There are two refrains which Ive regularly (and
painfully) heard over the last three years
traveling in Africa, always coming from young
African women with their children in tow What
will happen to my children when I die? and You
have drugs to treat people in your country why
cant I have drugs to stay alive in my country?
-Stephen Lewis
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Even if we made ARVs dirt cheap, would this solve
the problem?

• Bill Clinton "90 of HIV positive people in the
  developing world are unaware of their disease
  status.
• Bill Gates "The capacity to treat AIDS is not
  so much gated by access to drugs as it is by the
  availability of trained personnel."