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					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
                            4                                                                    Rio de Janeiro                  7
Rio de Janeiro        1                                                                                                0.2
                            4                                                                         Thailand               3
     Thailand         0.3
                                                                                                                        1
                      n/a                                                                            Sri Lanka              2
    Sri Lanka         n/a
                                                                                                                       0.2
                      n/a                                                                            Singapore           2
    Singapore         n/a
                                                                                                                             3
                        2                                                                               Manila               3
       Manila          1
                                                                                                                                          11
                                                    23                                 F think          Lusaka                                           22
       Lusaka                                                                                                                                                                                F do
                            4
                                                                                       M think                                        9                                                      M do
                                                         25                                           Tanzania                                      18
     Tanzania               4
                                                                                                                                                                         39
                                                                   35                                  Lesotho                                                                     55
      Lesotho                        15
                                                                                                                       n/a
                                               20                                                        Kenya                                 13
        Kenya         n/a
                                                                                                                       n/a
                                                                             48                    Cote d'Ivoire                                                   36
  Cote d'Ivoire       n/a
                                                                                                                       n/a
                                               20                                                         CAR          n/a
         CAR                4

                  0             10        20                  30        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
45                                                                                                     Francistown

40
                                                                                                                 Kwazulu/
35                                                                                            Blantyre
                                                                                                                 Natal    
                                                                                            Harare                 
30                                                                             
                                     Kampala                                                             
                                                                                            
25
                                                                   
                                                                                       
                                                                                   Nairobi
                                                                               
20
                                                                                              
                                                                                       
                                                                                        
                    Lusaka                                         
15                                                                                           
                                                                                        Abidjan
                                                                                                             
                                                                                                             
10                                                                  
                                                                       
                                                                      
                                                                                             Lagos
                                                                                                                     
 5                                  
                                                                                                                 Yaounde
                                                           
                                                           
                                                                                                         Dakar
 0                              
 1985         1987           1989              1991            1993            1995              1997         1999         2001
Note: Includes infection from HIV-1 and/or HIV-2.
Source: U.S. Census Bureau, HIV/AIDS Surveillance Data Base, 2000.
     Premarital sex: % of never married women 15-
       24 years old who had sex in the past year
      early-1990s
        Early 90s/late 80s
        Mid 90s
      mid-1990s
70      Late 90s/early 2000s
      late 1990s
60                              48   52
                                     52
                                48
50                                           33 35 32
       35 22 27   39
                  39 34 26                       35
40    35             34
                                              33     32
             27            26                             18 13 15
30      22
                                                          18
20                                                             13 15
10

 0
      Uganda          Zambia      Cameroon    Kenya         Zimbabwe
      Uganda        Zambia      Cameroon      Kenya       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
    40
                                                                                 Female
    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%                                                                                         5,000,000


             45.00%      HIV                                                                                4,500,000


             40.00%      Prevalence                                                                         4,000,000


             35.00%                                                                                         3,500,000


             30.00%                                                                                         3,000,000




                                                                                                                        Condom Sales
Prevalence




             25.00%                                                                                         2,500,000


             20.00%                                                                                         2,000,000


             15.00%                                                                                         1,500,000


             10.00%                                                      Condom sales                       1,000,000


             5.00%                                                                                          500,000


             0.00%                                                                                          0
                      1990   1991    1992   1993   1994   1995    1996   1997   1998   1999   2000   2001
                                                             Year

                                                          Urban     Rural       PSI
                  C is for condomize
Uganda:                                             Botswana:
  100                                                 100

  80                                                  80

  60                                        Women     60                                                   Women
  40                                        Men       40                                                   Men

  20                                                  20

      0                                                   0
          Condom Use Last Higher-Risk Sex                     Condom Use Last Higher-Risk Sex (BAIS
             (UNAIDS 2000, ages 15-24)                                 2001, ages 15-24)
Women                  37.8                         Women                     75.3
Men                    58.9                         Men                       88.3




 “Ever” use of condoms                              Botswana may have the
 among adults increased                                highest levels of
 from 15 to 30 percent in
 men, and from 7 to 20                              reported condom use in
 percent for women, from                              Sub-Saharan Africa
 1989 to 19951
                                                                                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                                 Truck drivers
30                                 Uniformed Personnel
20                                 Minibus Drivers
10
 0
     With Sex    With With wives
     Workers    Regular
                Partner
                                     B is for be faithful                                     Uganda:
                                                                                                   Reported higher risk sex in the past 12-months2
                                                                                                          100




  Uganda1:                                                                                                90


                                                                                                          80


                                                                                                          70


40                                                                                                        60


                                                                                                          50                                     15-49 year olds


                                                                                                          40

30                                                                                                        30


                                                                                                          20

                                                                                       1989               10
20
                                                                                       1995                   0
                                                                                                                      Men            Women
                                                                                              15-49 year olds         28.4            14.1

10
                                                                                              Botswana:
                                                                                                    Reported higher risk sex in the past 12-months3
 0       Men with one or more Women with one of more Men with three or more                                100
       "casual" partners in past "casual" partners in past "non-regular" partners in
                                                                                                              90
                 year                      year                  the past year
                                                                                                              80
1989              35                        16                        15
                                                                                                              70
1995              15                         6                         3
                                                                                                              60


                                                                                                              50                                 15-49 year olds


                                                                                                              40


                                                                                                              30


      Uganda coined (from                                                                                     20


                                                                                                              10


 agricultural tradition) the “zero-                                                                               0
                                                                                                                       Men           Women


      grazing” approach to                                                                     15-49 year olds        64.5            53.6


                                                                                                          1Shelton,     et al (in press)     3BAIS

            prevention                                                                                    (2001)
                                                                                                          2
Types of Reported Behavior Change in
         Uganda: DHS 1995
Never-Married People’s Behavior Change to Avoid AIDS
               Delayed First Restricted                 Did Not
                                          Began Using
                  Sex or     Sex to One                 Change
                                           Condoms
               Stopped Sex    Partner                   Behavior
  Percent of
                   29           27            17          15
    Men:
  Percent of
                   38           29            3           27
   Women:
Types of Reported Behavior Change in
         Uganda: DHS 1995
   Married People’s Behavior Change to Avoid AIDS
                  Restricted Sex to   Began Using   Did Not Change
                    One Partner        Condoms         Behavior
Percent of Men:          66               5              11
  Percent of
                         58               1              38
   Women:
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?
The importance of evidence-based practice
How does what is being done…




                               •Mass-mediated
                               advertising targeting
                               young men
                               •“Miss Lovers Plus”
                               beauty pageant
                               •Youth-oriented jam
                               sessions
                               •Etc…
      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.

				
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