HIV Myths and Mysteries
USAID Mini University October 14, 2005
David Stanton
Myths?
• AIDS is a disease of the poor • Marriage is dangerous • All epidemics will “explode”
AIDS is a disease of the poor:
What Is The Relationship Between Wealth And HIV?
Hint: AIDS is caused by a virus transmitted by human behavior
GNI per Capita and HIV Prevalence Global
60, 000. 00
50, 000. 00
40, 000. 00
30, 000. 00
20, 000. 00
10, 000. 00
0. 00 0. 00 -10, 000. 00 5. 00 10. 00 15. 00 20. 00 25. 00 30. 00 35. 00 40. 00 45. 00
R 2 = 0.041 5
H I V pr eval ence
p=0.01 4
-20, 000. 00
GNI per Capita and HIV Prevalence Sub Saharan Africa
5, 000. 00 4, 500. 00 4, 000. 00 3, 500. 00 3, 000. 00 2, 500. 00 2, 000. 00 1, 500. 00 1, 000. 00 500. 00 0. 00 0. 00 5. 00 10. 00 15. 00 20. 00 25. 00 30. 00 35. 00 40. 00 45. 00
P = 0.000532 R 2 = 0.2878
H I V pr eval ence
Economic Status and HIV prevalence in Kenya
12 10 8 6 4 2 0 lowest second middle fourth highest women men
2003 DHS
Economic Status and HIV prevalence in Tanzania
12 10 8 6 4 2 0 lowest second middle fourth highest women men
2003-2004 AIS
The Role of Poverty and Other Social Factors in the AIDS Pandemic
Secretary-General Kofi Annan in late 2002:
" [HIV/AIDS] has exacerbated the problems of poverty, discrimination, malnutrition and sexual exploitation of girls and women…”
Is poverty or wealth at the root of HIV? Shelton, Cassell, Adentuji, Lancet 2005
• Concurrent sexual networks contribute greatly to epidemic sexual spread of HIV • The average number of partners need not be high • Wealth is associated with time, mobility, and resources to maintain concurrent partnerships
Is poverty or wealth at the root of HIV? A word of warning about associating HIV infection with other variables • Current HIV tests used for surveillance cannot determine the timing of infection. • Therefore HIV status reflects something that could have happened over an 8 to 10 year period • Whether this can correlate with data regarding a certain point in time needs to be considered.
Secondary School Enrollment % and HIV Prevalence Global
100 90 80 70 60 50 40 30 20 10 0 0. 00 5. 00 10. 00 15. 00 20. 00 25. 00 30. 00 35. 00 40. 00 45. 00
P = 0.000024 R = 0.149
2
H I V P r eval ence
Secondary School Enrollment % and HIV Prevalence Sub Saharan Africa
100 90 80 70 60 50 40 30 20 10 0 0. 00 5. 00 10. 00 15. 00 20. 00 25. 00 30. 00 35. 00 40. 00 45. 00
R 2 = 0.31 6 P = 0.004
H I V P r eval ence
Education Status and HIV prevalence in Kenya
12 10 8 6 4 2 0 no primary education incomplete primary secondary+ complete women men
2003 DHS
Education Status and HIV prevalence in Tanzania
10 9 8 7 6 5 4 3 2 1 0 no primary education incomplete primary secondary+ complete
women men
2003-2004 AISS
Percent of Urban Population with Access to Improved Sanitation Facilities Global
100. 00 90. 00 80. 00 70. 00 60. 00 50. 00 40. 00 30. 00 20. 00 10. 00 0. 00 0. 00 5. 00 10. 00 15. 00 20. 00 25. 00 30. 00 35. 00 40. 00 45. 00
R 2 = 0.1 031 P = 0.0003
H I V P r eval ence
Percent of Urban Population with Access to Improved Sanitation Facilities Sub Saharan Africa
100. 00 90. 00 80. 00 70. 00 60. 00 50. 00 40. 00 30. 00 20. 00 10. 00 0. 00 0. 00 5. 00 10. 00 15. 00 20. 00 25. 00 30. 00 35. 00 40. 00 45. 00
R 2 = 0.1 258 P = 0.03
H I V P r eval ence
Fertility and HIV Prevalence Global
8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00
R 2 = 0.1 4 31 P = 0.000006
H I V P r e v a l e nc e
Fertility and HIV Prevalence Sub Saharan Africa
8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00
R 2 = 0.255 P = 0.001
H I V P r e v a l e nc e
Is Marriage Dangerous?
It Depends
Is Marriage Dangerous?
It Depends
20 18 16 14 12 10 8 6 4 2 0 never in union currently married or in union formerly married
women men total
Tanzania 03-04 AIDS indicator survey
Is Marriage Dangerous?
It Depends
• The risk of marriage appears to be driven by a number of factors including • Young age of the woman • Age difference of between partners • Patterns of sexual behavior
HIV Discordancy in Couples in High HIV Prevalence African Settings
10% 15% 10%
65%
• 65% couples both negative • 15% couples both positive • 20% discordant (approximately equal M:F) • 40% infected persons in discordant relationship • Many HIV infections occur in stable couples
Mother+ FatherBoth HIV+ Mother- Father+ Both HIVK. Decock et al.
Is Marriage Dangerous?
It Depends
• Studies of HIV status of HIV discordant couples in many countries in Sub Saharan Africa paint puzzling picture: • Almost every study finds a nearly 50/50 split between men and women being the infected partner • The pathway to discordance is not fully known and probably is very different for men and women
Is Marriage Dangerous?
It Depends
• In communities and cultures where female sexual behavior is highly restricted while male sexual behavior is highly unrestricted, marriage as an HIV risk factor for women is highly likely. • But this is not the pattern in most high prevalence countries. • AND this does not preclude the social vulnerability of women and girls.
Do epidemics explode?
Hint: NO
50 45
HIV Seroprevalence (%)
Francistown 40 HIV-Seroprevalence for Pregnant Women in Selected Urban 35 Areas of Africa: 1985-2000 Blantyre Kwazulu/
30
Kampala Harare Nairobi
Natal
25 20
Lusaka
15
Abidjan
10
Lagos
5 0 1985
Dakar
Yaounde
1987
1989
1991
1993
1995
1997
1999
2001
Source: US Census Bureau
HIV-Seroprevalence for Pregnant Women in Selected Urban Areas of Africa: 1985-2000
50 45 40 35 30
Kampala Kwazulu/ Natal
HIV Seroprevalence (%)
25 20 15 10 5 0 1985
Dakar
1987
1989
1991
1993
1995
1997
1999
2001
Source: US Census Bureau
The HIV/AIDS Pandemic
• The HIV/AIDS pandemic is composed of three separate and relatively independent epidemics, involving MSM, IDU, and heterosexuals with multiple and concurrent sex partners.
Median HIV prevalence in pregnant women attending antenatal clinics in sub-Saharan Africa, 1997/98-2003
Southern Africa
40
Eastern Africa
40
Botswana
% HIV prevalence
% HIV prevalence
30 20
South Africa
30 20 10 0
Mozambique
10 0 1997-1998 1999-2000 2001 2002 2003
Ethiopia Uganda
1997-1998 1999-2000 2001 2002
Kenya
2003
West Africa
40
% HIV prevalence
30 20 10
Ghana
0 1997-1998 1999-2000
Nigeria
2001
Cote d'Ivoire
Senegal
2002 2003
Source: Adapted from Asamoah-Odei, et al., (2004). Data from consistently reporting antenatal clinics. AIDS epidemic update, December 2004. Fig. 6.
Do Epidemics Explode?
• Experience from the last 20+ years tells us that HIV epidemics need not reach the high prevalence levels of sub Saharan Africa • Heterosexual epidemics are driven by sexual networks, HSV2, and lack of male circumcision (see you at 1PM) • The African epidemics may be the “perfect storm” which we don’t see playing out in other parts of the world.
Conclusion
• There are paradoxical associations with a variety of development indicators and HIV infection in Sub Saharan Africa. • These associations are associated with risk behaviors although the association is not fully understood
Conclusion
• Marriage can be a risk factor for women but not always • This does not preclude the sexual vulnerability of women and girls • The inevitable explosion of heterosexual epidemics in non-African countries is not a foregone conclusion and will probably be very exceptional and localized
Conclusion
AIDS is caused by a virus spread by human behavior
Thank You