hiv and development challenges for...
TRANSCRIPT
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
HIV prevalence (%) in adults in Africa, 2005HIV prevalence (%) in adults in Africa, 2005
2.5
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
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 Upstream effects: structural drivers in Africa: poverty versus income equality: Africa: poverty versus income equality: which is more powerful?which is more powerful?
• Downstream impact: long wave impacts on poverty, GDP, human capital, social capital
• Responding to the interaction between HIV and poverty
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Central African Republic
Ethiopia
Côte d'IvoireUgandaKenya
Rwanda
South Africa
Mali
NigeriaCameroon
Niger
BurundiGhana
Senegal
Swaziland
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
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 Downstream impact: long wave impacts on poverty, GDP, human capital, social capitalpoverty, GDP, human capital, social capital
• Responding to the interaction between HIV and poverty
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
Epidemic Curves, HIV, AIDS & Impact
T1 T2 Time
Numbers
A1A2
HIV prevalence
B1
A
B
AIDS - cumulative
SOCIAL AND ECONOMIC
IMPACT
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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)
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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.”
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Central African Republic
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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).
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
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 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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
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.
Warwick Univ.Sept 172007
HankinsUNAIDS
HIV and development challenges for Africa10th Anniversary, Centre for the Study of Globalisation and Regionalisation
Acknowledgements
• Peter Piot• Michel Sidibe• Robert Greener• Efren Fadriquela• Mihika Acharya• Constance Kponvi• YOU, THE AUDIENCE – THANK YOU!