Transcript Document

Public Health Practice I:
HIV/AIDS Consequences for
Socio- Economic Development
Thomas Novotny
The World Bank
Outline of Presentation
1.
The Global HIV/AIDS Pandemic
2.
HIV/AIDS in Europe and Central Asia
3.
Potential economic impact
4.
Policy approaches
5.
The Balkans, Moldova & Central Asia
6.
Conclusion
Global HIV Pandemic
+ 1 300%
+20%
+ 20%
+ 100%
+ 160%
+60%
+ 40%
+ 30%
+ 20%
UNAIDS
HIV/AIDS Estimates in ECA (2003)
Adult (15-49)
HIV prevalence rate
0.6%
(range: 0.4-0.9%)
Adults (15-49)
living with HIV
1 300 000
(range: 850 0001 900 000)
Adults and children (049)
living with HIV
1 300 000
(range: 860 0001 900 000)
Women (15-49)
living with HIV
440 000
(range: 280 000650 000)
UNAIDS 2003
AIDS deaths
(adults and children)
in 2003
49 000
(range: 32 00071 000)
Epidemic Outlook
Eastern Europe and Central Asia confront 4
overlapping epidemics
 Drug Use
 HIV/AIDS
 Sexually Transmitted Infections
 Tuberculosis
Epidemic drivers act regionally and can best be
addressed at regional level
 Trafficking in people and drugs
 Economic and political migration
 Sex Work
 Prisons
Godinho J, Renton A, Vinogradov V, Novotny T, Gotsadze G, Rivers MJ, Bravo M (2004)
Explosive Epidemics of HIV
among IDU
80
Myanamar
Edinburgh
Samara
RF
Manipur
40
Bangkok
20
Odessa
Renton A 2004
Year
2001
1999
1997
1995
1993
1991
1989
1987
1985
0
1983
HIV prevalence (%)
60
STI/IDU/HIV Interactions
High STI
Prevalence
No IDU
harm
reduction
Successful
IDU harm
reduction
Renton A 2004
Low STI
Prevalence
10 explosive IDU
epidemic
10 explosive IDU
epidemic
20 larger sexually
transmitted epidemic
Smaller and slower 20
sexually transmitted
epidemic
Contained IDU epidemic
Contained IDU epidemic
Smaller and slower 20
sexually transmitted
epidemic
Very small and slow 20
sexually transmitted
epidemic
Role of HIV/AIDS in Fueling the TB epidemic
Socio-structural Factors
• Over-crowded prisons
• Poverty related commercial sex
• Sale and transfusion of
contaminated blood
TB INFECTION
BCG
TB Preventive
Treatment
Epidemiological Factors
• Prevalence of TB in PLWH
• MDR-TB Prevalence in PLWH
• Duration of infectiousness in PLWH
• STI and other co-morbidities
ACTIVE
TB
CURE
RECURRENCE
DEATH
Intensified case-finding
Decreased delay in case
detection and DOTS
Lack of access to
• HAART
• STI Treatment
• Harm Reduction for IUD
• Condom Use
TB
TRANSMISSION
TB Preventive Treatment
Access to Second-line
drugs
Interventions to avert the TB epidemic fueled by HIV/AIDS
HIV/AIDS Role in Poverty
Contributors to Poverty
•Loss of income
•Catastrophic cost of care
•Increased dependency ratio
•Loss of productivity
HIV
Infection
AIDS
(companies)
•Loss of social capital
(countries)
•Reduced national income?
Epidemic Drivers
Poverty/
Income
Differential
s
Unemploym
ent
Drug
Traffickin
g
Renton 2004
Economic
& Political
migration
Low Level HIV
Epidemic
Explosion of
Injecting
Drug Use
Explosion of
Commercial
Sex Work
Low levels
of
population
awareness
and
knowledge
of HIV &
STI
Concentrated HIV
Epidemic
Epidemics
of STIs
Low levels
of
population
awareness
and
knowledge
of HIV &
STI
Generalized HIV
Epidemic
Potential Economic Impact in
Russia
• Economic growth rates could decline by 0.5-1.0
percent annually
• Health expenditures could increase up to 50
percent
• Costs of treatment would not be sustainable
• The dependency ratio could rise
• Household size & composition could change
• Transfer of intellectual capital and social skills
from one generation to another could be lost
Ruhl C, Pokrovsky V, Vinogradov V 2002
Policy Approaches
• Decriminalize risk
behavior
• Improve medical
treatment
• Social support to
PLWHA
• Legislative authority for
NGOs to work with
vulnerable groups
• Reproductive health &
HIV/AIDS Education
 IDU, CSW, MSM, Migrants
 Narcology, HAART, STIs, TB
 Social protection, palliative
care
 Harm Reduction, outreach
 Schools,policymakers, general
public
Information Needs
Monitoring
• Sentinel surveillance of high
risk groups
– Behavioral
– Serologic
• Respondent-driven sampling
• Venue-based testing
• Voluntary testing and
counseling
• Data used for decision
making
Evaluation
• Harm reduction
• Education programs
• Supply chain for drugs,
supplies, condoms
• Prison health system
• National AIDS Programs
Non-financial Factors
Political will and perception
Social constraints and stigmatization
Community, Gender, and Values
Institutional capacity to implement
effective interventions
Regulatory and legal issues
Donors Coordination
Funding Needs
• Funding would have to increase from $300 million
in 2001 to $1.5 billion in 2007
 40% for prevention
 55% for care and treatment
 5% for policy, administration, research & evaluation
• For treatment of HIV/AIDS & TB, funding would
have to increase
 For ARVT, from $60 million in 2002 to more than $600
million by 2007
 For TB control, from <1 billion in 2001 to $1.9 billion
by 2007
UNAIDS and The World Bank 2003
HIV/AIDS in ECA Countries
 Opportunity for prevention is now
 Cross-border externalities important in addressing
most vulnerable groups
 Future burden on health systems and economic
productivity may be enormous
 Sentinel surveillance in high risk groups and
vulnerable populations is needed
 Harm reduction application and decriminalization
are needed
 Public information and professional education are
essential
Youth Vulnerability
• 80% of infected persons are less than 30 years
of age in ECA
• Primary carriers are boys and young men
• CSW and trafficking in girls and young women
• IDU, heavy alcohol use, and lack of access to
reproductive health education and safe sex
• Iatrogenic cases in Romania
Mobile Populations
• Sailors, truckers (37% have unsafe sex while
traveling)
• Peacekeepers
• Commercial Sex Workers (CSW)
• Trafficked women and children
• Roma and other ethnic minorities (8 million in
ECA)
• Displaced people
• Tourists
Harm Reduction in Prisons
Harm Reduction in Prisons
Is Harm Reduction working in
Moldova?
Role of IDU in the epidemic
New Cases
500
400
300
200
100
0
1992
Laticevschi D 2004
1994
1996
1998
2000
2002
2004
HIV/AIDS in Central Asia
Why should we take HIV/AIDS
seriously in ECA
Steep growth of HIV cases
in the Region
Low levels of knowledge
about the epidemics
Established relation between
Injecting drug use, STI and
TB
Share of youth over 40%
of the population
Drug and migration routes
human trafficking
drug trafficking
migration
zones
Red: high risk oblasts, major drug routes
Renton A, Gzirishvili D, Gotsadze G, Godinho J 2004
Green: human trafficking routes
Results
Prevention Needs
US$208 million
+
Treatment Costs
US$??? million per year
Existing Resources: 2002 to 2010
US$75 million
Given needs outweigh resources what is
best way to spend the money?
Cercone 2004
J 2004
AIDS Challenges in ECA
Target most vulnerable groups with
appropriate approaches
Improve Public Health functions
Increase opportunities for youth to
participate in the knowledge
economy