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HIV Epidemiology : Progress, challenges and Human Rights implications

HIV Epidemiology : Progress, challenges and Human Rights implications. Yves SOUTEYRAND Rodney KORT Ani SHAKARISHVILI Thomas REHLE Txema GARCIA-CALLEJA.

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HIV Epidemiology : Progress, challenges and Human Rights implications

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  1. HIV Epidemiology:Progress, challenges and Human Rights implications Yves SOUTEYRAND Rodney KORT Ani SHAKARISHVILI Thomas REHLE Txema GARCIA-CALLEJA

  2. "To understand a problem with clarity is already half way towards solving it. …Ignorance of the effectiveness of societal intervention contributes greatly to resignation, fatalism and, ultimately, callousness. This is true of the global epidemic of AIDS today as it has been of other major human disasters, in the past" Amartya Sen, Nobel Prize in Economics AIDS Sutra, 2008

  3. Outline Is the epidemic contained? Trends in global epidemic Dynamics of the epidemic Epidemiology, response and Human Rights Health information and Human Rights Vulnerable and most-at-risk populations: Human Rights implications of HIV epidemiology

  4. Thirty years into the epidemic UNAIDS/WHO Epi update, 2009

  5. Over 7 400 HIV infections/day in 2008 • About 1 200 children under 15 years of age • Each day 5 000 people die of AIDS • Each day 3 000 more people on Antiretroviral Therapy • 97% in low- and middle-income countries, 70% in Sub Saharan Africa • Down from 8 800 daily infectionsin 2001

  6. Dynamics of the epidemic: Prevention works • Declines in prevalence and risky sexual behaviors • Young people in 21 generalized epidemic countries: Prevalence declining in most countries (more than 25% reduction in 10 of them) along with risky sexual behaviors (Gouws et al, AIDS Conference 2010 – TUAC0204) • General population modelling in Zimbabwe: Between 460 000 and 860 000 infections averted due to reduction of high risk behaviours between 1999 and 2004 (Hallett et al, Epidemics, 2009)

  7. PMTCT impact: infections averted among infants 70 000 60 000 50 000 40 000 Infant infections averted 30 000 20 000 10 000 0 1997 1999 2001 2003 2005 2007 1996 1998 2000 2002 2004 2006 2008 Estimate of the annual number of infant infections averted through the provision of antiretroviral prophylaxis to HIV-positive pregnant women, globally, 1996–2008, UNAIDS 2009

  8. ART impact on the epidemic: South Africa Rehle et al. PLoS ONE, 2010

  9. Impact of ART on HIV incidence Growing evidence on impact of ART on decreasing transmission Discordant couples in Africa (Donnell, 2010) Decreasing HIV incidence at community level Taiwan, China (Fang, 2004) San Francisco (Das Douglass, 2010) Vancouver (Wood/Montaner , 2010) Models suggest large potential epidemic effect with Universal ART (Granich, 2008)

  10. Outline Is the epidemic contained? Trends in global epidemic Dynamics of the epidemic Epidemiology, response and Human Rights Health information and Human Rights Vulnerable and most-at-risk populations: Human Rights implications of HIV epidemiology

  11. Social determinants of health and health inequities Socioeconomic & political context Governance Policy (Macroeconomic, Social, Health) Cultural and societal norms and values Social position Material circumstances Social cohesion Psychological factors Behaviours Biological factors Distribution of health and well-being EducationOccupationIncome Gender Ethnicity / Race Health Care System Source: Commission on Social Determinants of Health conceptual framework Amended from Solar & Irwin, 2007

  12. How are Epidemiology and Human Rights linked? Human rights violations are a barrier to knowing your epidemic Unethical HIV surveillance violates human rights Human rights violations contribute to HIV transmission Failure to act on epidemiological evidence worsen human rights challenges

  13. Surveillance: progress and gaps Quality of HIV surveillance systems, 2009, WHO/UNAIDS • Weak surveillance systems in most countries with concentrated and low epidemics • Surveillance among MARPs insufficient in most countries with generalized epidemics • Stigma and discrimination challenge epidemiology

  14. Ethics of HIV surveillance: Human Rights considerations Appropriate framework Informed and voluntary consent Confidentiality protection Community involvement Responsiveness "Without a commitment to using surveillance findings to benefit the vulnerable, the moral foundations of the activity vanish" 2010 WHO/UNAIDS guidelines on ethical issues on HIV surveillance, in press

  15. Outline Is the epidemic contained? Trends in global epidemic Dynamics of the epidemic Epidemiology, response and Human Rights Health information and Human Rights Vulnerable and most-at-risk populations: Human Rights implications of HIV epidemiology

  16. Epidemic among migrants in Western Europe Spain2008(10 regions) The Netherlands 2010 (modelled; sexual transmission only) France 2008 Other9% Other11% LatinAmerica16% Caribbean26% Netherlands21% Spain63% Africa12% Africa37% France52% Africa53% InVS, 2009 Xiridou, RIVM, 2010 SPNS, 2010 Distribution of new HIV cases by country/region of origin

  17. Epidemic among migrants in Western Europe: Human Rights challenges • Gaps in information prevent adequate response • Tensions between immigration, interior and health policies are counterproductive to effective service provision • Economic crisis exacerbate negative attitudes towards migrants (ECDC report on Migrant Health: access to HIV prevention, treatment and care, 2009)

  18. Modes of transmission in sub-Saharan African countries Distribution of new infections by sources of riskModes of transmission in South, East and West Africa, 2008–2009

  19. Men who have sex with men (MSM) epidemics and response Recent steady increases in rate of HIV infections among MSM in North America, Western Europe and Australia (2009 UNAIDS/WHO Epi Update) MSM have 19.3 times greater risk of being infected with HIV than the general population (Baral et al, PLoS Medicine, 2007) High HIV prevalence among MSM in African countries: 19.7% in Botswana, 21.4% in Malawi, 12.4% in Namibia (Baral et al, PLoS ONE, 2007)

  20. MSM epidemics: law and the response • Homosexuality criminalized in 80 countries (Global Forum on MSM and HIV) • High prevalence of homophobic attitudes (Baral et al, PLoS ONE, 2007) • For most countries prevention for MSM has not started or is underfunded (Beyrer, Clin Infect Dis 2010) HIV Prevalence and Criminalization of Homosexuality in the Caribbean Global Forum on MSM and HIV, May 2010

  21. Injecting Drug Users (IDUs) epidemics and response In Eastern Europe and Central Asia, among 100 IDUs living with HIV, one is receiving ART In 40% of countries, laws reduce accessibility of HIV services for people who inject drugs Extrajudicial systems of closed detention of IDUs in 11 Asian countries (Mathers et al, Lancet 2010; Cohen et al, Plos Medicine, 2008)

  22. Modeled impact of structural changes on epidemic HIV infections among IDUs averted by structural changes 4–19% decrease in incidence 3–9% decrease in incidence 2–5% decrease in incidence 662 infections averted 343infections averted 209 Elimination of police beatings (Ukraine) Strathdee et al., HIV Risks Among Injection Drug Using Populations: Past, Present, and Projections for the Future (Lancet 2010)

  23. IDUs epidemic and response in Ukraine: a success story? Decrease in HIV prevalence among recent Injecting Drug Users (median sentinel surveillance in 8 cities, Ukraine - International HIV/AIDS Alliance, 2009)

  24. Conclusion Strong health information and vital registration systems are essential for informing the nature and scope of the epidemic Human Rights abuses continue to blind our knowledge of the epidemic and to challenge our ability to respond Concerted efforts have decreased new infections and deaths – challenge is to expand the response to reach populations facing human rights abuses Universal access to prevention and treatment cannot be achieved without universal access to Human Rights

  25. "We, Head of States, … reaffirm that the full realization of all human rights and fundamental freedoms for all is an essential element in the global response to the HIV/AIDS pandemic" United Nations High-Level Meeting on AIDS, New York, June 2006

  26. Acknowledgements WHO Gottfried Hirnschall Andrew Ball Michel Beusenberg Keith Sabin Jean Michel Tassie Cyril Pervilhac Chika Hayashi Carla Obermeyer Theresa Babovic Vincent Habiyambere Francoise Renaud-Théry Boni Dongmo Nguimfack Gundo Weiler Reuben Granich Kim Dickson Jos Perriens Ying Lo-Ru Tunga Namjilsuren Rodney Kort, Ani Shakarishvili, Thomas Rehle, Txema Garcia-Calleja And Alain Volny-Anne Véronique Collard Parijat Baijal Jean Paul Moatti Bruno Spire But not least Ludovic Coutière Isabelle de Vincenzi Helena Nygren Krug Florence Rusciano UNAIDS Peter Ghys Eleanor Gouws Mary Mahy Jason Sirgudson Robert Greener And Jhoney Barcarolo Kevin DeCock Michel Carael Maria Xiridou Chris Beyrer Steffanie Strathdee Robert Booth Timothy Hallett

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