HIV/AIDS, AIDS exceptionalism, data,

1. Is HIV/AIDS still exceptional?
Alan Whiteside
Health Economics and HIV/AIDS Research Division,
University of KwaZulu-Natal
Durban
Presentation to
Daniel J. Evans School of Public Affairs
University of Washington
Monday 9th February 2009
www.heard.org.za

3. 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!

4. 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

5. 2007 Global HIV Infection
33 million people [30–36 million] living with HIV,
2.2

6. Global numbers living with HIV and
adult HIV prevalence
Source: UNAIDS 2008

7. Epidemic Curve: HIV, AIDS and
Impact
Numbers
HIV prevalence
Impact
A2
A1
A
AIDS - cumulative
B B1
T1 T2 Time
27Aug01 -Report I: Epidem’gy & Lit. p. 27

8. 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

9. 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

10. Cause of Death by Income and
Percentage in 2030
Ranking Low income Middle income High income World
1 Ischaemic heart Cerebrovascular Ischaemic heart Ischaemic heart
disease 13.2 disease 14.4 disease 15.2 disease 13.4
2 HIV/AIDS 13.2 Ischaemic heart Cerebrovascular Cerebrovascular
disease 12.7 disease 9.0 disease 10.6
3 Cerebrovascular COPD 12.0 Trachea, bronchus HIV/AIDS 8.9
disease 8.2 lung cancers 5.1
4 COPD 5.5 HIV/AIDS 6.2 Diabetes mellitus COPD 7.8
4.8
5 Lower respiratory Trachea, bronchus COPD 4.1 Lower respiratory
tract infections 5.1 lung cancers 4.3 tract infections 3.5

11. 2007 Global HIV Infection
33 million people [30–36 million] living with HIV,
2.2

12. 2007 HIV Prevalence, African Adults (15–49)
2.8

13. HIV Prevalence in Antenatal Clinic
Surveys: Southern Africa
Source: UNAIDS Global AIDS report 2008

14. Demographic and Health Survey
HIV Prevalence

15. 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

16. 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

17. The Demographic Impacts
• Young people die
• Children are not born
• Population decline
• Falling life expectancy
• Orphaning

18. Population Decline: Russia & Ukraine
Ukraine
5.4
population (millions)
5.2
5
Ukraine
4.8
4.6
4.4
1990 1995 2000 2002 2004 2006
year
Russia
14.9
14.8
population (millions)
14.7
14.6
14.5
14.4 Russia
14.3
14.2
14.1
14
13.9
1990 1995 2000 2002 2004 2006
year
Source: World bank HNP Statistics

19. Ukraine

20. Demographics:
Population Growth

21. 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

22. Demographics:
Population Growth

23. Demographics:
Life Expectancy

24. AIDS can not be cured
• People will need treatment
• For life
• And it is expensive

25. Per capita health expenditure
Country Health Expenditure Cost of ARV
Per capita (USD) 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

26. Mopping the Floor while the tap is
running

27. Long term impacts
The impact of the epidemic is still
unfolding and will do so for at least a
generation
Lessons from climate change??

28. Agriculture

29. 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)

30. 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