HIV and AIDS: Accomplishments and Enduring Challenges

1. HIV and AIDS: Accomplishments and Enduring Challenges Michael J. Kelly, S.J. Maynooth 30th November 2010 mjkelly@jesuits.org.zm

2. HIV and AIDS • In June 1981, less than 30 years ago, the first report was published on what came to be known as AIDS • The condition appears to have been present in the human family for more than 100 years, since early in the 20th century, but it is only in recent years that it became a global pandemic, largely as the result of global movement and interconnectedness • Dramatic rise in the 1990s in the number of new infections, total number infected and number of AIDS-related deaths

4. The 1996 Breakthrough • Since 1987 an increasing number of drugs have been developed with potential to reduce or suppress the activity of HIV in the body • In 1996 various combinations of these drugs were found to be so effective in reducing the amount of HIV in the blood stream that they provided infected individuals with the prospect of a productive and generally healthy life • Initially a hard pill to swallow, but regimens have become more simple

5. A Tale of Two Women, before and after ART became more widely available • Before : Brigitte Syamalevwe – mother, secondary school teacher, HIV activist, tireless worker for families where there was HIV or AIDS, refused costly medication because not available for her people, allowed herself to die • After: Monique Tondoi – mother, social economist, HIV activist, passionate in championing issues of human rights especially for women and children living with HIV, her motto “you may not be able to change the whole world, but you can change your part of the world” • Both symbolise millions of others in their spirit and resilience and thereby bring hope

6. Rollout of Antiretroviral Therapy • By mid-2010 life-preserving ART had reached 5.25 million people in the non-industrialised countries • Deaths from AIDS-related illnesses have dropped substantially in the past few years and continue to decline • This must be given full credit as one of the world’s most magnificent accomplishments – scientifically, organisationally, financially • Globalisation may have helped in the spread of the epidemic, but globalisation in the best sense is helping to reverse it

7. Thank you, Ireland! • Enormous credit and thanks to the people of Ireland for the part you have played • In 2002–2010, Ireland pledged €170 million to the Global Fund for AIDS, TB and Malaria and to date has paid about 72% (€122 million) of what was pledged – considerably higher than the average of 60% for all countries combined • In addition, Ireland has made large contributions to local efforts in the Ireland Aid target countries in Africa (Ethiopia, Lesotho, Malawi, Mozambique, Tanzania, Uganda, Zambia) and regionally across Southern Africa, areas that are ravaged by the disease • Public acknowledgement of Ireland’s role a source of great and legitimate pride

8. Keep it up! • In many of our African countries, a selfless sharing strategy frequently characterises those living in poverty – the poor help the destitute by sharing what they cannot afford • In these economically difficult times, could Ireland adopt the same strategy? • Hold your head high by continuing to help the destitute, even though you can’t afford it • Continue the fight to reduce the obscene level of hunger in the world and to improve the health status of people • Continue to make funds available for HIV and AIDS, so that fewer people die, fewer children are orphaned, families stay together, the poverty of destitution is reduced

9. The Beneficial Effects of Antiretroviral Therapy (ART) • ART prevents sickness and death • ART prevents orphans • ART prevents poverty • ART prevents the break-up of households • ART reduces stigma • ART helps in reducing HIV transmission • ART restores appetites – for food, for work, for sex, for involvement

10. Challenges of ART • Treatment must last throughout life • Accessibility • Resistance • Adherence • Toxicity and side effects • Bringing down costs • Highly efficient, less costly 1st line treatment (€110 per person per year for the drugs) • More costly 2nd line treatment (€830 for the drugs), with more complex monitoring and supply problems • Complacency

11. The economic downturn and the global response to HIV and AIDS • Some health agencies have found that funding declines and uncertainties have resulted in • People who had previously been enrolled in treatment programmes no longer being able to access treatment • No new people being allowed to enroll in treatment programmes • Drug sharing and shortages • Staff layoff

12. The challenge of treating AIDS • Maintain treatment for the 5.2 million people who have already accessed it • Expand ART to the additional 9.4 million people estimated by WHO to be in need of treatment • Expand ART to the remaining 20 million persons already infected with HIV but who are not yet in need, as and when their medical condition indicates that they should move into a treatment regime • Ensure that treatment will be available in the future for the additional 2.7 million people who are becoming newly infected with HIV each year, when the time comes that their medical condition indicates that they are in need

13. Hard Choices • Despite global financial problems, maintain and increase funding for responding to the disease OR • Abandon global vision of universal access to ART and do not enrol large numbers of new patients — almost inevitably the epidemic will rage out of control and human suffering will be immense OR • Provide free ART services only to those countries or individuals who cannot pay for it — almost inevitably the poor will lose out (and the costs will still be enormous) OR • Ration access to free ART — almost inevitably corruption, cronyism, nepotism will take over OR • Reduce the non-drug-related costs of ART

14. On average, drugs represent only about one-third of ART costs

15. The bottom lineThe cost of universal AIDS treatment appears to be completely unaffordableWe cannot treat ourselves out of the epidemicWhat is needed is effective prevention to turn off the tap of new infections

16. Vertical Transmission Transmission of HIV from an infected parent to a child Referred to as mother-to-child transmission (MTCT), though very often the father is the original source of the infection

17. About 7 become infected during the pregnancy About 15 become infected at the time of delivery About 13 become infected through breastfeeding – most in the early weeks

18. Preventing Parent to Child Transmission • Parent to child transmission can be almost totally eliminated • Currently about 430,000 children are becoming infected in this way each year – about 1,200 each day • The number has declined, but is still unacceptably large • Excellent that PMTCT services are reaching many women, but they should reach all women in need • Considerably more than half the infected pregnant women do not have access to PMTCT services • Women blamed for refusing testing, not returning for test results, not taking drugs – but not offered ART that would protect their own lives • Need for better efforts to get men involved and for the couple to go for joint HIV testing

19. Children Living with HIV • Currently over two million worldwide • Number increasing because of more widespread availability of paediatric ARVs • The growing-up problems faced by these children: • Inflexible regimen of daily medication and regular medical examination • Need for more and better food • Avoidance of health and accident hazards • School integration • Puberty and sexual awareness

20. New HIV infections come mainly from sexual activity involving members of the general population What happens among young people is a marker for the future development of the epidemic Hence any sign that young people’s sexual behaviour is becoming more responsible or that there is less HIV among them is good news

21. There is Good News • Young people are waiting longer before becoming sexually active • Young people are having fewer sexual partners • Increasing proportions of young people report that they have never had sex • Condom use by young people during their most recent act of sex has increased • In many of the worst affected countries, HIV prevalence among young pregnant women (aged 15–24) is declining

22. More responsible sexual behaviour among young people and adults • More unmarried young people aged 15–24 are abstaining from sex • In 2009, 61% of never-married women aged 15–24 (52% in 2003) and 55% of men (42% in 2003) reported that they never had sex • The proportion of young people reporting sex before age 15 fell from 16% in 2000–2003 to 7.5% in 2009 • Fewer married men and women report having had extra-marital sex in the past year • The proportion of men reporting sex with more than one partner in the past year fell from 14.2% in 2005 to 8.7% in 2009, and for women from 2.8% in 2005 to 0.8% in 2009

23. But the HIV challenge remains • Globally, for every person who begins anti-retroviral treatment two others become newly infected • In Zambia, an estimated 41,000 adults died from AIDS conditions in 2009, more than 110 each day • In the same year, an estimated 83,000 Zambian adults became newly infected by the disease • In other words, in Zambia every adult who died of AIDS last year was replaced by at least two more who become newly infected with HIV • The real HIV and AIDS challenge is to prevent new infections • Addressing this difficult challenge needs dedication, commitment, partnerships, leadership – and resources

24. How can we prevent new infections?1. Use a combination of all available and acceptable prevention measures 2. Tackle the social, cultural and structural factors that are driving the epidemic3. Provide the necessary leadership

25. Combination Prevention Use a combination of socio-cultural, behavioural, structural and biomedical prevention approaches to achieve maximum impact in preventing HIV transmission Biomedical Approaches Behaviour Change Approaches Highly Active HIV Prevention Justice & Human Rights Interventions Socio-cultural Change Interventions

26. Socio-cultural changes • Stamp out stigma and discrimination • Change norms and values in society that • Tolerate or support sexual promiscuity, especially sexual freedom on part of men • Turn a blind eye to multiple partnerships • Tolerate or endorse sex between a young person and one who is some years older • Change practices that place people at risk of infection, such as dry sex, widow cleansing, girls having to prove their fertility, girls being married when very young • Control alcohol (“beer pressure”) and drug use

27. Justice, human rights and structural approaches • Raise the status of women • Eliminate gender-based discrimination and inequality • Eliminate gender-based violence • Reduce income inequality • Ensure food security • Increase employment opportunities • Get girls into school, keep them there for as many years as possible, and make sure they get a good education while there • Establish conditions of fair trade (so as to generate employment) • Develop the rural areas (so as, among other things, to reduce the movement of people)

28. The low status of women is at the heart of the AIDS epidemicThe central issue isn’t technological or biological: it is the inferior status or role ofwomenWhen women’s human rights and dignity are notrespected, we create and favour their vulnerability to AIDS

29. The big unanswered questionWhy is there so much HIV and AIDS in southern Africa?

30. Zikomo bwambili Twalumba kapati Thank you very much Go raibh maith agaibh