Transcript Title of Presentation

Scaling Up Prevention Is Imperative for
Global Health Progress
Deborah L. Birx
Director, Global AIDS Program
Centers for Disease Control and Prevention
Healthier, safer, longer,
and more productive lives
worldwide
Factors that affect health
Examples
from global
health
Smallest
Impact
Counseling
& Education
Education on infant care;
instruction on water
sanitization, condom use
Clinical
Interventions
Treatment for infectious
disease (HIV, TB, etc.);
Rx for htn, diabetes, etc.
Long-lasting
Protective Interventions
Vaccines; mass drug Rx
for tropical diseases; IRS;
bed nets; circumcision
Changing the Context
Individuals making healthy choices
Largest
Impact
Socioeconomic Factors
Clean air & water; control
of toxic substances; food
& drug safety; safe roads
Poverty; education;
housing; inequality
Prevention is a best buy
• Healthier
communities are
more productive
• Prevention
increases health
value from health
dollars
• Prevention can
reduce per capita
annual health care
costs
Saving Lives:
Changing the Course of the HIV/AIDS Epidemic
There is a link between services and
prevention and HIV can be a model
Decreasing Prevalence of HIV/AIDS
2001, 2009
Prevalence in Sub-Saharan Africa
6
HIV Prevalence (%)
5.8
5.6
5.4
5.2
5
4.8
4.6
4.4
2001
Data source : UNAIDS Global Report 2010
Year
2009
Decreasing Mortality in Sub-Saharan Africa
Deaths/year in Sub-Saharan Africa
1,700,000
1,600,000
1,500,000
1,400,000
1,300,000
1,200,000
1,100,000
2004
2005
2006
2007
Deaths/year in Sub-Saharan Africa
Data source : UNAIDS Global Report 2010
2008
2009
2010
% Change in Incidence
-20
-40
-60
-80
-100
Data source : UNAIDS Global Report 2010
Uganda
Nigeria
Kenya
Angola
Cameroon
Lesotho
Tanzania
Malawi
Zambia
Mozambique
Swaziland
South Africa
Rwanda
Botswana
Zimbabwe
CAR
Cote D'Ivoire
Namibia
Decreasing HIV Incidence in Sub-Saharan Africa
Percent Change in HIV Incidence
0
Embracing scientific breakthroughs
and using evidence to guide programs
• We have the tools in our hands today to end
the epidemic as we know it
– Transmission impact from ARVs as treatment,
ARVs in microbicides, ARVs as pre-exposure
prophylaxis
– Male Circumcision, PMTCT
– Promising new data for HIV vaccines
Efficacy of biomedical interventions for
sexual transmission of HIV
Effect size (CI)
ARV for partner
96% (43; 100)
Oral TDF PrEP
62% (34; 78)
Oral FTC/TDF PrEP
73% (49; 85)
iPrEx PrEP
44% (15; 63)
CDC PrEP
63% (22; 83)
Circumcision
57% (42; 68)
((Orange Farm, Rakai, Kisumu)
HIV Vaccine
31% (1; 51)
(Thai RV144)
Microbicide
39% (6; 60)
(CAPRISA 004 tenofovir gel)
0% 10
20
30
40
50
Efficacy
Adapted from Padian et al, 2010; Abdool Karim, 2010
60
70
80
90 100%
Need for More Coverage with
Efficacious Interventions
Intervention
Efficacy
Coverage
Improved interventions With effective PMTCT programs, HIV
for PMTCT
transmission can be reduced to 2-4%
57%
Observational data of sero-discordant
Antiretroviral treatment
couples suggest up to 92% reduction in HIV
as prevention
transmission
36%
Male circumcision
50-60% efficacy
3.4%
HIV vaccine
31% efficacy
Vaginal microbicide
39% efficacy; 54% among high adherers
Pre-exposure
prophylaxis
Trial #1: MSM (44% efficacy; 74% among high adherers)
Trial #2: High-risk women (no evidence of efficacy)
Trial #3 Partner PrEP – (62-73% efficacy)
For the first time in global history…
• More people live in
urban than rural areas
• There are more people
who are overweight than
underweight
• There are more deaths
among adults than
children
• Higher rates of NCDs in
developing than
developed countries
Slum dwellings in Singapore
Non-communicable diseases
in the developing world
• NCDs now kill more people globally than
infectious disease
• NCD burden has risen rapidly and is a
major threat to economic and social
development
• By 2020, NCDs will kill almost 4x as many
people globally as infectious disease
• Will affect the poor most heavily, who die
at earlier ages
40 years ago, there were a similar number of deaths among
children and young/middle-aged adults. Today there are more
than 3 times as many deaths among young/middle-aged adults
as among children
Number of deaths
(millions)
25
20
15
10
5
0
1970
1980
Under Age 5 (Deaths)
1990
2000
Adults Age 15-60 (Deaths)
2010
Non-communicable disease kills far more
people than infectious disease – even in
low-income countries
1600
Injuries
NonCommunicable
Infectious/Nutrition
Age Adjusted Deaths
(per 100,000 Population)
1200
800
400
0
Low
Data: WHO, 2004.
Lower Middle
Upper Middle
High
People in poorer countries are more likely
to die prematurely from NCDs
than people in wealthier countries
Percent of NCD Deaths
Under Age 60
40%
30%
20%
10%
0%
Low
Lower Middle
Upper Middle
High
Tobacco is now the world’s leading
single agent of death
6
5.4
Global Deaths per Year
(millions)
5
3.9
4
3
2.2
2.1
2
1.7
1.3
1.1
0.8
1
0
Tobacco
Acute Resp
Infect
World Health Organization
AIDS
Diarrheal
Disease
TB
Traffic Injuries
Malaria
Measles
MPOWER interventions reduced smoking
prevalence in Uruguay
– Only 2 data points
• Coordinated package of
interventions
– Smoking ban (first country in
Americas to go 100% smokefree)
– Comprehensive ad ban
– Large pictorial warning labels
– Cessation services
– High taxes
35%
Adult smoking prevalence
• One of the sharpest
declines ever reported
1 in 4
smokers
quit
30%
25%
20%
2006
Data: Global
Adult Tobacco
Survey
2008
Community prevention saves
many more lives, at much lower cost,
than clinical prevention
Reason for quitting
Intervention
Cost per
smoker who
quits
Clinical care
~$4000
Quit lines
~$400
Anti-tobacco ads
~$100
Smoke-free laws
~$0
Increased taxes
Revenue
of $250 or
more
Taxes
Other/ Synergies
43%
28%
Free NRT
8%
SF
Law
9%
Taxes +
SF Law
12%
Road Traffic Safety
• Large and growing burden
• Road traffic accidents kill
>1.2 million, injure up to 50
million annually worldwide
– Epidemic is still increasing in
most parts of the world
– Legal interventions are
proven effective
• Relatively inexpensive and
highly cost-effective
Road traffic injuries to be 5th leading
cause of death globally by 2030
2004
2030
(actual)
(projected)
Road traffic crashes currently cause more than 1.2 million deaths a
year – but by 2030 will kill an estimated 2.4 million people per year
Road traffic fatalities disproportionally
affect younger people
Top 3 leading causes of death globally, people age 5-44
Rank among other age groups
0-4 yrs: #14
45-69 yrs: #8
70+ yrs: #20
Road traffic death rates twice as high
in low-income countries
Per 100,000 population
25
21.5
19.5
20
15
10.3
10
5
0
Low-Income
Medium-Income
>90% of world’s traffic deaths occur in low/middleincome countries – despite these countries having
less than half of the world’s registered vehicles
High-Income
Evidence-based interventions
Only 15% of countries have sufficiently comprehensive
road safety laws covering all five main safety risk factors
• Drunk driving – 0.05% BAC limit
• Seatbelts – drivers and passengers
• Child restraints – age/weight
limits; safety standards
• Helmets – riders and passengers
(also bicycles); safety standards
• Speed limits – under 50 km/h in
urban areas
Cardiovascular disease is the leading
cause of death globally
• Worldwide in 2003, CVD
caused 17 million deaths
(~30% of total)
• Leading cause of death among
people aged 60+, second among
those aged 15-59
• Leading cause of death in the developing world
(with exception of sub-Saharan Africa)
• Half or more of all strokes and heart attacks
globally attributable to high blood pressure
• Disproportionately affects working-age
adults of lower socioeconomic status
Heart disease and stroke will continue
to kill the most people worldwide
2004
2030
(actual)
(projected)
Proportion of people worldwide who die
from heart disease and stroke is unlikely
to change over the next two decades
Global deaths attributable to
leading risk factors (2000)
Major
cardiovascular
disease risks
High mortality, developing region
Lower mortality, developing region
Developed region
0
1
2
3
4
5
6
Attributable Mortality
(In millions; total 55,861,000)
Ezzati et al. WHO 2000 Report. Lancet 2002;360:1347-1360.
7
8
Lower blood pressure = Lower risk
Risk of Coronary Heart Disease Death
Many people with “normal” blood pressure
have strokes and heart attacks
30
Higher BP,
Higher Risk
25
20
15
10
Lower BP,
Lower Risk
5
0
110-119
120-129
130-139
140-149
150-159
Systolic Blood Pressure
Data Source: Lewington S, et al., Lancet 2002;360:1903-13,
Using population risk estimates for ages 50-59 years old.
160-169
170-179
Sodium is a leading contributor to
high blood pressure
• Reducing salt
content of processed
food could prevent
~14 million deaths
globally over 10
years
High salt intake increases
risk of death
1.75
Hazard Ratio
• After tobacco control,
most cost-effective
intervention may be
reduction of sodium
intake
CHD
Death
CVD
Death
All
Death
1.50
High salt
intake
1.25
1.00
0.75
0.50
He FJ, MacGregor GA. J Hum Hypertens.
2002;16:761-70.
Lower
salt
intake
Medical complications of obesity
(In addition to medical and societal costs)
Source: Rudd Center for Food Policy and Obesity
Global cancer prevention
• ~8 million global cancer deaths each year
– 10 million/yr by 2020 if no action is taken
– Nearly half of cancer is preventable (tobacco, healthy
diet, physical activity)
• Strengthen tobacco control
• 1.5 million tobacco-caused
cancer deaths per year
• Improve vaccine coverage
• 650,000 deaths/yr from
liver cancer
• Expand colorectal and
cervical cancer screening
• 650,000 colon cancer
deaths and 225,000
cervical cancer deaths/yr
• Address availability and
price of alcohol
• 300,000 alcohol-related
cancer deaths/yr
• Increase fruit/vegetable
consumption
• Could prevent up to 1
million cancer deaths/yr
Prevention
• Break the cycle of transmission of HIV and
other communicable diseases
• Prevent NCDs
– Tobacco control, sodium reduction, healthy oils
• Changes to food and physical environments
• Regulatory and policy interventions and
enforcement to improve road traffic safety
– Improved clinical care for NCDs
– Community interventions more cost-effective than
clinical care
Thank you!