HIV Epidemiology Epidemiology Progress challenges and Human Rights

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

"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

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

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

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 3 000 more people on Antiretroviral Therapy • 97% in low- and middle-income countries, in Sub Saharan Africa • Down from 8 800 daily infections in 2001 70%

Dynamics of the epidemic: Prevention works v 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 – TUAC 0204) • 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)

PMTCT impact: infections averted among infants 70 000 Infant infections averted 60 000 50 000 40 000 30 000 20 000 10 000 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 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

ART impact on the epidemic: South Africa Observed HIV prevalence in 2008 (15– 49) Excess HIV prevalence thanks to ART in 2008 Adjusted HIV Prevalence without ART in 2008 16. 9% 1. 7% (440 000) 15. 2% Rehle et al. PLo. S ONE, 2010

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)

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

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 Education Psychological factors Occupation Behaviours Income Biological factors Gender Ethnicity / Race Health Care System Source: Commission on Social Determinants of Health conceptual framework Amended from Solar & Irwin, 2007 Distribution of health and well-being

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

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

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

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

Epidemic among migrants in Western Europe France 2008 Other 11% Africa 37% Spain 2008 (10 regions) (modelled; sexual transmission only) Caribbean 26% France 52% In. VS, 2009 The Netherlands 2010 Netherlands 21% Africa 53% Xiridou, RIVM, 2010 Other 9% Latin America 16% Africa 12% Spain 63% SPNS, 2010 Distribution of new HIV cases by country/region of origin

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)

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

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, PLo. S 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, PLo. S ONE, 2007)

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, PLo. S 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

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)

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 662 infections averted 2– 5% decrease in incidence 343 infections 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)

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)

Conclusion 1. Strong health information and vital registration systems are essential for informing the nature and scope of the epidemic 2. Human Rights abuses continue to blind our knowledge of the epidemic and to challenge our ability to respond 3. Concerted efforts have decreased new infections and deaths – challenge is to expand the response to reach populations facing human rights abuses 4. Universal access to prevention and treatment cannot be achieved without universal access to Human Rights

"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

Acknowledgements Rodney Kort, Ani Shakarishvili, Thomas Rehle, Txema Garcia-Calleja And 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 Isabelle de Vincenzi Helena Nygren Krug Florence Rusciano UNAIDS Peter Ghys Eleanor Gouws Mary Mahy Jason Sirgudson Robert Greener And Jhoney Barcarolo Kevin De. Cock Michel Carael Maria Xiridou Chris Beyrer Steffanie Strathdee Robert Booth Timothy Hallett Alain Volny-Anne Véronique Collard Parijat Baijal Jean Paul Moatti Bruno Spire But not least Ludovic Coutière