Scaling Up Prevention Is Imperative for Global Health Progress

1. Scaling Up Prevention Is Imperative for Global Health Progress Deborah L. Birx Director, Global AIDS Program Centers for Disease Control and Prevention

2. Healthier, safer, longer, and more productive lives worldwide

3. Smallest Impact Largest Impact Factors that affect health Examples from global health Education on infant care; instruction on water sanitization, condom use Counseling & Education Treatment for infectious disease (HIV, TB, etc.); Rx for htn, diabetes, etc. Clinical Interventions Vaccines; mass drug Rx for tropical diseases; IRS; bed nets; circumcision Long-lasting Protective Interventions Clean air & water; control of toxic substances; food & drug safety; safe roads Changing the Context Individuals making healthy choices Poverty; education; housing; inequality Socioeconomic Factors

4. 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

5. Saving Lives: Changing the Course of the HIV/AIDS Epidemic There is a link between services and prevention and HIV can be a model

6. Decreasing Prevalence of HIV/AIDS2001, 2009 HIV Prevalence (%) Year Data source : UNAIDS Global Report 2010

7. Decreasing Mortality in Sub-Saharan Africa Data source : UNAIDS Global Report 2010

8. Decreasing HIV Incidence in Sub-Saharan Africa Percent Change in HIV Incidence % Change in Incidence Data source : UNAIDS Global Report 2010

9. 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

10. Efficacy of biomedical interventions for sexual transmission of HIV Effect size (CI) ARV for partner 96% (43; 100) Oral TDF PrEP 62% (34; 78) HIV Vaccine (Thai RV144) 31% (1; 51) Oral FTC/TDF PrEP 73% (49; 85) iPrExPrEP 44% (15; 63) CDC PrEP Microbicide (CAPRISA 004 tenofovir gel) 63% (22; 83) 39% (6; 60) Circumcision ((Orange Farm, Rakai, Kisumu) 57% (42; 68) 0% 10 20 30 40 50 60 70 80 90 100% Efficacy Adapted from Padian et al, 2010; Abdool Karim, 2010

11. Need for More Coverage with EfficaciousInterventions

12. 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

13. 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

14. 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

15. Non-communicable disease kills far more people than infectious disease – even in low-income countries Data: WHO, 2004.

16. People in poorer countries are more likely to die prematurely from NCDsthan people in wealthier countries

17. Tobacco is now the world’s leading single agent of death Tobacco kills more people worldwide each year than HIV, TB and malaria combined World Health Organization

18. MPOWER interventions reduced smoking prevalence in Uruguay 1 in 4 smokers quit Data: Global Adult Tobacco Survey • One of the sharpest declines ever reported • Only 2 data points • Coordinated package of interventions • Smoking ban (first country in Americas to go 100% smoke-free) • Comprehensive ad ban • Large pictorial warning labels • Cessation services • High taxes

19. Community prevention savesmany more lives, at much lower cost, than clinical prevention Reason for quitting

20. 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

21. Road traffic injuries to be 5th leading cause of death globally by 2030 2004 (actual) 2030 (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

22. Road traffic fatalities disproportionally affect younger peopleTop 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

23. Road traffic death rates twice as highin low-income countries Per 100,000 population • >90% of world’s traffic deaths occur in low/middle-income countries –despite these countries having less than half of the world’s registered vehicles

24. Evidence-based interventionsOnly 15% of countries have sufficiently comprehensiveroad 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

25. Cardiovascular disease is the leading cause of death globally • 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 oflower socioeconomic status • 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

26. Heart disease and stroke will continueto kill the most people worldwide 2004 (actual) 2030 (projected) Proportion of people worldwide who die from heart disease and stroke is unlikely to change over the next two decades

27. Global deaths attributable toleading risk factors (2000) High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity High mortality, developing region Lower mortality, developing region Developed region Alcohol Indoor smoke from solid fuels Iron deficiency 0 1 2 3 4 5 6 7 8 Attributable Mortality (In millions; total 55,861,000) Major cardiovascular disease risks Ezzati et al. WHO 2000 Report. Lancet 2002;360:1347-1360.

28. Lower blood pressure = Lower riskMany people with “normal” blood pressure have strokes and heart attacks 30 Higher BP, Higher Risk 25 20 15 Risk of Coronary Heart Disease Death Lower BP, Lower Risk 10 5 0 110-119 120-129 130-139 140-149 150-159 160-169 170-179 Systolic Blood Pressure Data Source: Lewington S, et al., Lancet 2002;360:1903-13, Using population risk estimates for ages 50-59 years old.

29. CHD Death CVD Death All Death 1.75 1.50 1.25 Hazard Ratio 1.00 0.75 0.50 Sodium is a leading contributor tohigh blood pressure • After tobacco control, most cost-effective intervention may be reduction of sodium intake • Reducing salt content of processed food could prevent ~14 million deaths globally over 10 years High salt intake increases risk of death High salt intake Lower salt intake He FJ, MacGregor GA. J Hum Hypertens. 2002;16:761-70.

30. Medical complications of obesity (In addition to medical and societal costs) Source: Rudd Center for Food Policy and Obesity

31. 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

32. 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 toimprove road traffic safety Improved clinical care for NCDs Community interventions more cost-effective than clinical care Prevention

33. Thank you!