Transcript Concurrency Slides - The Bixby Center on Population and

Africa, the West, and the Fight
against AIDS
By Helen Epstein
June 6, 2007
UCLA School of Public Health
The countries in Africa
most affected by AIDS
Adult HIV Prevalence
Worldwide
Source: UNAIDS 2004: 2004 Report on the Global AIDS Epidemic
This map does not reflect a position by the UN on the legal status of
any country or territory or the delimitations of any frontiers.
Adult Prevalence
Projections, to 2030
“HIGH RISK GROUP” MODEL
• ACCORDING TO “HRG” MODEL, THE
EXTENT OF SPREAD OF HIV IN A
POPULATION WILL DEPEND ON:
• FRACTION OF PEOPLE IN “HRG”s
(CSWs, MIGRANT LABORERS, ETC)
AND
• THE DEGREE OF “MIXING” BETWEEN
HIGH AND LOWER RISK GROUPS.
Who has HIV? (Zambia)
Frequency of concurrent and suspected concurrent relationships.
Redrawn from Carael M. “Sexual Behavior” Chapter 4 in
Cleland and Ferry 1995
0.4
Rio de Janeiro
4
Rio de Janeiro
7
1
0.2
Thailand
4
Thailand
3
0.3
n/a
n/a
Sri Lanka
Singapore
n/a
n/a
Singapore
Manila
2
1
Manila
Sri Lanka
23
Lusaka
F think
4
M think
25
Tanzania
1
2
0.2
2
3
3
11
Lusaka
22
9
Tanzania
35
39
Lesotho
55
15
20
Kenya
n/a
Kenya
13
n/a
48
Cote d'Ivoire
20
10
20
36
n/a
n/a
CAR
4
0
n/a
Cote d'Ivoire
n/a
CAR
30
M do
18
4
Lesotho
F do
40
50
60
0
10
20
30
40
50
60
Concurrency Slides
By Stewart Parkinson
Effects of Concurrency
HIV Negative Male
HIV Positive Viremic Male
HIV Positive Non-Viremic Male
HIV Negative Female
HIV Positive Viremic Female
HIV Positive Non-Viremic
Female
Concurrency
December
Concurrency
January
Concurrency
February
Concurrency
March
Concurrency
April
Concurrency
May
Concurrency
June
Concurrency
July
Concurrency
August
Serial Monogamy
December
Serial Monogamy
January
Serial Monogamy
February
Serial Monogamy
March
Serial Monogamy
April
Serial Monogamy
May
Serial Monogamy
June
Serial Monogamy
July
Serial Monogamy
August
WHERE DID MARTINA MORRIS GET THE IDEA
THAT LONG TERM CONCURRENCY WAS
DRIVING THE HIV EPIDEMIC IN AFRICA?
• UGANDAN DOCTORS……
HIV Seroprevalence for Pregnant Women
Selected Urban Areas of Africa: 1985-2000
HIV Seroprevalence (%)
50
Francistown
45
40
35
Blanty re
30
25



20
15


5

1985


10 
 


1987
 

Lusaka
  




1989




Kampala
0
Kwazulu/
Natal
 

1991
Note: Includes infection from HIV-1 and/or HIV-2.
Source: U.S. Census Bureau, HIV/AIDS Surveillance Data Base, 2000.



Harare

 

  







Abidjan
Lagos


Yaounde

1993

Nairobi
 


 






Dakar
1995
1997
1999
2001
Premarital sex: % of never married women 1524 years old who had sex in the past year
70
early-1990s
Early 90s/late 80s
Mid 90s
mid-1990s
Late
90s/early 2000s
late
1990s
48
60
48
50
40
30
35 22 27
35
22
27
52
52
39 34 26
39
34
33 35 32
35
33
32
26
18 13 15
18
20
13 15
10
0
Uganda
Uganda
Zambia
Zambia
Cameroon
Cameroon
Kenya
Kenya
Zimbabwe
Zimbabwe
ORC Macro
Teenage pregnancy in Uganda
Percentage who have had children or who are currently pregnant
From USAID funded Demographic and Health Surveys
15 year olds
16 year olds
17year olds
18 year olds
19 year olds
1988
8.7
20.8
44.1
58.3
59.4
1995
7.7
22.1
43.3
64.7
70.8
2000/1
3.3
12.9
23.2
54.0
61.2
Condoms?
Since the beginning of the HIV/AIDS epidemic, a considerable amount of
programmatic effort has focused on condom promotion…
Reported condom use last higher-risk sex for ages 15-24 (UNAIDS, 2001 & BAIS 2001)
90
80
70
60
50
Male
Female
40
30
20
10
0
Botswana
Uganda Zimbabwe Rwanda
Senegal
Kenya
Malawi
Given that Botswana has for some time featured some of the highest
rates of (self-reported) condom use in the world, why isn’t Botswana
hailed alongside of Uganda as a major success story?
The condom quandary
HIV Prevalence in Pregnant Women VS PSI Condom Sales
50.00%
Prevalence
40.00%
HIV
Prevalence
4,500,000
4,000,000
35.00%
3,500,000
30.00%
3,000,000
25.00%
2,500,000
20.00%
2,000,000
15.00%
1,500,000
Condom sales
10.00%
1,000,000
5.00%
500,000
0.00%
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
Year
Urban
Rural
PSI
1999
2000
2001
Condom Sales
45.00%
5,000,000
C is for condomize
Uganda:
Botswana:
100
100
80
80
60
Women
Men
40
20
0
60
Women
Men
40
20
0
Condom Use Last Higher-Risk Sex
(UNAIDS 2000, ages 15-24)
Condom Use Last Higher-Risk Sex (BAIS
2001, ages 15-24)
Women
37.8
Women
75.3
Men
58.9
Men
88.3
“Ever” use of condoms
among adults increased
from 15 to 30 percent in
men, and from 7 to 20
percent for women, from
1989 to 19951
Botswana may have the
highest levels of
reported condom use in
Sub-Saharan Africa
1Shelton,
et al (2004)
“CONSISTENT” CONDOM USE PROTECTS, BUT NOT
TOTALLY….(PROBABLY BECAUSE THE USE IS NOT AS CONSISTENT AS
IT SHOULD BE.)
Consistent condom use by type
of partner, Zambia 2003
90
80
70
60
50
40
30
20
10
0
Truck drivers
Uniformed Personnel
Minibus Drivers
With Sex
Workers
With With wives
Regular
Partner
B is for be faithful
Uganda:
2
Reported higher risk sex in the past 12-months
100
Uganda1:
90
80
70
40
60
50
15-49 year olds
40
30
30
20
1989
1995
20
10
0
15-49 year olds
10
0
Men
Women
28.4
14.1
Botswana:
3
Reported higher risk sex in the past 12-months
Men with one or more Women with one of more Men with three or more
"casual" partners in past "casual" partners in past "non-regular" partners in
year
year
the past year
1989
35
16
15
1995
15
6
3
100
90
80
70
60
50
15-49 year olds
40
30
Uganda coined (from
agricultural tradition) the “zerograzing” approach to
prevention
20
10
0
15-49 year olds
Men
Women
64.5
53.6
1Shelton,
(2001)
2
et al (in press)
3BAIS
T yp e s o f R e p o rte d B e h a vio r C h a n g e in
U ganda: D H S 1995
N e v e r-M a rrie d P e o p le ’s B e h a vio r C h a n g e to A v o id A ID S
P e rce n t o f
M en:
P e rce n t o f
W om e n :
D e la ye d F irst
Sex or
S to p p e d S e x
R e stricte d
S e x to O n e
P a rtn e r
B e g a n U sin g
C ondom s
D id N o t
C hange
B e h a vio r
29
27
17
15
38
29
3
27
Types of Reported Behavior Change in
Uganda: DHS 1995
Married People’s Behavior Change to Avoid AIDS
Restricted Sex to
One Partner
Began Using
Condoms
Did Not Change
Behavior
Percent of Men:
66
5
11
Percent of
Women:
58
1
38
Early successes: Uganda and
“zero grazing”
From Warren Winkelstein Jr et al, “The San Francisco Men’s Health Study: Continued Decline in HIV
Seroconversion Rates among Homosexual/Bisexual Men.” AJPH November 1988 vol 78, pp. 1472-4
Early successes: Thailand
and “100% condoms”
The HIV rate is beginning to
decline in several African
countries, including Kenya,
Zimbabwe and I think maybe
Malawi and Zambia.
But—why did it take so long?
And why is the HIV rate still so
high in southern Africa?
T h e im p o rta n c e o f e v id e n c e -b a s e d p ra c tic e
H o w d o e s w h a t is b e in g d o n e …
•M a ss-m e d ia te d
a d ve rtis in g ta rg e tin g
young m en
•“M iss L o v e rs P lu s ”
b e a u ty p a g e a n t
•Y o u th -o rie n te d ja m
s e s s io n s
•E tc …
IMPLICATIONS FOR PREVENTION?
•
•
•
•
AFRICAN PEOPLE NEED TO KNOW WHERE THEIR RISKS ARE COMING
FROM—IE NOT JUST FROM “PROMISCUOUS PEOPLE.”
MY HYPOTHESIS IN INVISIBLE CURE IS THAT AN UNDERSTANDING OF
CONCURRENCY NETWORKS COULD HELP REDUCE THE STIGMA AND DENIAL
SURROUNDING THE EPIDEMIC IN MUCH OF SOUTHERN AFRICA, AS IT DID IN
UGANDA, AND THIS COULD FOSTER A MORE PRAGMATIC RESPONSE TO THE
EPIDEMIC..
UGANDANS DID KNOW EARLY ON THAT HIV WAS SPREADING THROUGH
CONCURRENT LONG TERM RELATIONSHIPS ALTHOUGH THEY DIDN’T USE
THE WORLD “CONCURRENCY.” UGANDAN GOVERNMENT CAMPAIGNS MADE
IT CLEAR THAT EVERYONE WAS AT RISK, NOT JUST SEX WORKERS AND
PROMISCUOUS, ‘IMMORAL’ PEOPLE. THIS HELPED ROUSE A MORE
COMPASSIONATE, OPEN REPONSE TO THE AFFLICTED, AND A GENERAL
RECOGNITION THAT AIDS WAS NEITHER AN ACT OF GOD OR A PUNISHMENT
FOR SIN, BUT A TERRIBLE DISEASE THAT NO ONE DESERVES.
TOO MANY HIV PREVENTION PROGRAMS HAVE DIVIDED PEOPLE: HIV POS
FROM HIV NEG, MORAL FROM IMMORAL, YOUNGER PEOPLE FROM ELDERS,
MEN FROM WOMEN. WHAT WE NEED ARE MORE PROGRAMS THAT BRING
PEOPLE TOGETHER: WOMEN’S RIGHTS PROGRAMS, MICROFINANCE
PROGRAMS, ORPHAN CARE PROGRAMS, HOME BASED CARE PROGRAMS,
ETC.