Transcript A public health response to HIV/AIDS in South Africa The role of

What specific actions can be
identified for their effectiveness in
addressing the prevention or
treatment of HIV and AIDS
What works?
What can we learn from the papers
Among the most
challenging contexts and
target groups on the planet
Despite seeing many important advances in our understanding of the basic
science, the epidemiology of infection, and novel approaches for the care
and treatment of people living with AIDS, there has been a relentless
progression of disease in country after country (Mann and Tarantola 1996)
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33 million people living with HIV (UNAIDS 2007)
Prevailing strategies for HIV prevention (UNAIDS 2005)
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change sexual and drug-using behaviours;
Promote consistent condom use
Partner reduction
improve STI management
VCT
PMTCT (Pre- exposure Prophylaxis)
Harm reduction for IVDU
promote medical male circumcision
infection control in health care settings
Insufficient implementation and uptake
Failure to translate into population-level gains
4 papers: Common themes
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Challenge prevailing approaches
Contain some element of social capital
strengthening, multiple-types
Most address immediate needs as an entry point
Locally-generated, bottom-up
Peer-led
Intervene at multiple levels simultaneously
“combined interventions”
 Peer groups + Social spaces + economic support
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Common elements
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Kibera, Kenya: addressing economic and social
opportunities (BONDING, BRIDGING to MF
instittion)
S. Africa: ‘Bridging/linking social capital’ to generate
improvements in care, peer support, access to grants.
Community AIDS Competence. (BONDING,
BRIDGING to clinics, government, traditional leaders)
Western Kenya: cash transfers to mobilize collective
responses (BONDING, BRIDGING to adult
community members)
India: creating ‘safe spaces’/drop-in centres; outreach by
vulnerable group members (BONDING, BRIDGING to
providers)
All are structural interventions (Sumartojo AIDS 2000)
Groups and
populations
rather than
individuals
Legal and Policy
Sexual Behaviour
HIV infection
Working
“Upstream”
Physical environment
Socio economic conditions
Cultural context
Diverse, progressive, novel
assessment methodologies
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Kibera: pre-post study with historical controls
S. Africa: detailed process evaluation
Western Kenya: photonovella
India: in-depth qualitative work
What have we learned:
Encouraging results
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Kibera: significant proportions of women exited sex
work, lower numbers of regular partners after 2 yrs
S. Africa: enhance the skills and capacity of
volunteers, meet needs of AIDS-affected HH,
increase social spaces to talk openly about AIDS
W Kenya: gains in social capital, collective
mobilization, children constructed positive identity
India: reduction in stigma, increased awareness,
skills, behaviour change (condom use, STIs), lower
STI prevalence in AP
Challenges
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Kibera: methodological older women,
historical controls, no biological markers, hard
to assess attribution/causality
S. Africa: major challenges to building bridges
W Kenya: “that 10 year old is a grown up”
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what does the future hold?
India: how safe are safe spaces? Stigma. Causal
pathways between intervention and outcomes
difficult to elucidate
General challenges to structural
interventions
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Causal links may be unclear/indirect
Don’t easily conform to experimental design and evaluation
frameworks
Difficult to standardize; contextual
Diffuse benefits; take time to accrue
Require expertise outside health sector
Hard to change structural conditions!
How do we take the handle off
the pump?
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John Snow, Cholera
Outbreak, London 1854
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HIV isn’t the first time
we’ve been here…..
How might social capital help us?
Infectious Agent
Host / reservoir
Environment
Infectious Agent
Fall of the Roman Empire
instability
Host / reservoir
Environment
Rapid shifts in networks, norms, resource flows
Infectious Agent
Fall of the Roman Empire
instability
Host / reservoir
Environment
Environmental changes:
• Population expansion
• Movement into cities
• Poverty
• Inadequate sanitation
• Poor quality wood housing
Yersenia Pestis
Infectious Agent
Fall of the Roman Empire
instability
Host / reservoir
Humans
Fleas
Rats
Environment
Environmental changes:
• Population expansion
• Movement into cities
• Poverty
• Inadequate sanitation
• Poor quality wood housing
The historical decline of TB deaths in
England and Wales 1848-1961
Death
Rate
per
Million
McKeown T, Record RG, Turner RD Population Studies 1975
3000
2500
2000
1500
Introduction of
Chemotherapy
1000
500
1848-53
1901 1921 1931 1941 1951 1961 1971
Introduction of new infectious agent: HIV
Infectious Agent
instability
Host/reservoir
Environment
Shifts in the social and economic environment:
• poverty, under-development, social inequality
• Mobility and migration
• Gender-based inequalities and gender-violence
• Social change/conflict & civil disorder
•Shifting norms (media), networks (travel)
HIV and Social transition
For 80 per cent of humanity the Middle Ages ended
suddenly in the 1950's
(Eric Hobsbawm, Age of Extremes, 1994)
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Fall of the Roman Empire: Black death
Industrial revolution: TB, cholera
Globalization : free flow of people, goods,
capital, ideas
Rapidly shifting networks and norms
 Tension between tradition and modernity
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If not HIV, something else?
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for the past two decades, average of one
outbreak with a previously unidentified
infectious pathogen each year (McMichael
2001)
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Bird flu, SARS, BSE/Mad Cow Disease,
hantavirus, Marburg-like hemorrhagic fever
Social capital and HIV control
HIV Infections, San Francisco, USA
(Wolfheiler, STI 2002)
Declining HIV prevalence in Uganda’s
generalized epidemic
Stoneburner and Low-beer, Science, 2004
Can social capital be intentionally generated?
Effects on HIV Risk
SSM 2008, 67 : 1559-1570
AIDS, 2008, 22: 1659-1665
Social Capital
0.1
Risk ratio
1
10
Participation in social groups
1.85 (0.95-3.61)
Perceptions of solidarity
1.65 (0.81-3.37)
Take part in collective action
2.06 (0.92-4.49)
HIV risk behaviour
HIV-related communication
1.46 (1.01-2.12)
Went for HIV testing in HH
1.64 (1.06-2.56)
Unprotected sex
0.76 (0.6-0.86)
HIV/AIDS Competent World
North America
1.2 million
Caribbean
590 000
Latin America
1.9
million
99000-E-1 – 1 December 1999
Eastern Europe
Western Europe & Central Asia
680 000 1.8 million
East Asia & Pacific
North Africa
1.3 million
& Middle East South
Asia
730 000 & South-East
8.2 million
Sub-Saharan
Africa
28.2
million
Australia
& New
Zealand
18 000