Table Of ContentDavid D. Celentano Chris Beyrer
Editors
Public Health Aspects
of HIV/AIDS
in Low and Middle
Income Countries
Epidemiology, Prevention
and Care
Public Health Aspects of HIV/AIDS
in Low and Middle Income Countries
Epidemiology, Prevention and Care
Public Health Aspects of HIV/AIDS
in Low and Middle Income Countries
Epidemiology, Prevention and Care
Edited by
David D. Celentano
JohnsHopkinsUniversity
Baltimore,MD,USA
Chris Beyrer
JohnsHopkinsUniversity
Baltimore,MD,USA
123
DavidD.Celentano ChrisBeyrer
JohnsHopkinsUniversity JohnsHopkinsUniversity
SchoolofPublicHealth SchoolofPublicHealth
DepartmentofEpidemiology DepartmentofEpidemiology
Baltimore,MD Baltimore,MD
USA USA
[email protected] [email protected]
ISBN:978-0-387-72710-3 e-ISBN:978-0-387-72711-0
DOI:10.1007/978-0-387-72711-0
LibraryofCongressControlNumber:2008929616
(cid:2)c 2008SpringerScience+BusinessMedia,LLC
Allrightsreserved.Thisworkmaynotbetranslatedorcopiedinwholeorinpartwithoutthewrittenpermissionofthe
publisher(SpringerScience+BusinessMedia,LLC,233SpringStreet,NewYork,NY10013,USA),exceptforbriefexcerpts
in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval,
electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is
forbidden.
Theuseinthispublicationoftradenames,trademarks,servicemarks,andsimilarterms,eveniftheyarenotidentifiedas
such,isnottobetakenasanexpressionofopinionastowhetherornottheyaresubjecttoproprietaryrights.
Printedonacid-freepaper
springer.com
ToLauraLynn,whohasselflesslyendurednumerousprolongedseparationsandaccom-
panyingjetlag,grantwritingandinnumerableacronymswithoutcomplaintandwitha
lotofsupport.
DavidD.Celentano
Inmemoriam,EdwardLouisLuther,1960–1991
ChrisBeyrer
Preface
Anyonewhohastheleastabilitytolookintothefuturecanalreadyseethepotential
forthisdiseasebeingmuchworsethananythingmankindhasseenbefore.
W.Cates,Newsweek,August1985
Those who know me say I’m prone to hyperbole, but I wish these words had been my typical
exaggerationratherthanwhathascometobeatragicreality.ThisquoteoccurredintheNewsweek
issue with Rock Hudson on the cover. Fewer than 12,000 AIDS cases had been reported to public
health authorities. Over the intervening two decades, the disease has become the public health is-
sueofourlifetime–affectingtensofmillionsworldwide.InAfrica,HIV/AIDShasalreadyhada
negativedemographicimpactbyerasingthemortalitygainsoftheentire20th centuryandcreating
a distorted population pyramid devoid of persons in their most productive years. On average, an
individualinSouthernAfricahasreturnedtothelifeexpectancytheywouldhavehadattheturnof
the19thcentury.Nootherhealthconditionofourtimeishaving,orhasalreadyhad,suchaprofound
publichealthimpact.
This comprehensive book addresses the interdisciplinary aspects of the global HIV/AIDS epi-
demicinitsentirety.CitingepidemiologicevidencefromthelatestUNAIDSsurveys,itsgeographic
analysisoftheglobalpatternsisbothtimelyandcomplete.Theinitialsectionofthebooksumma-
rizesthealwaysevolving,state-of-the-artoftheprevention/care/treatmentcontinuum.Thechapters
delveintotheoverlappinglayersofknowledgeaffectingHIV/AIDS,includingthebehavioralcom-
ponentsofsexualanddrugsharingpractices,theevolvingbiomedicalinterventionsbothaloneand
in combination, treatment of those infected with HIV as a means of prevention, political will as a
foundation upon which other approaches can be built, and social activism as the continued force
keepingHIV/AIDSatcenterstage.PartOne’sreviewoffersafoundationforPartTwo,whereissues
inpreventionandcarearereviewedwithintheuniquecontextsofindividualcountriesandregions.
This section provides a careful analysis of how all of the different layers of HIV/AIDS can play a
coordinatedroleinnationalprogramstoadvancethepreventionandcareagenda.
TheauthorsarealldefinitiveleadersintheHIV/AIDSfield.Theeditorshavedonearemarkable
job in pulling together pithy and synthetic contributions which are aggregated in one resource for
thefield.Mostoftheauthorshavebeeninvolvedfordecadeswiththeevolvingeffortsintheglobal
HIV/AIDSepidemic,andtheirexperiencewithprovensuccessfulprogramsonthegroundaddsto
thecredibilityoftheiranalyses.
vii
viii Preface
The well-known HIV/AIDS successes in the arena of prevention are amply documented. The
decliningHIVprevalenceinmanypartsoftheworldreflectsacombinationofbetterdata(surveil-
lance asapublichealth intervention),decreasing HIVincidence duetotargeted interventions,and
the first wave of preventable deaths before antiretrovirals were available in low-income settings.
The 100% condom campaign in Thailand showed that a population-level, structural intervention
involving both behavioral (decreased brothel attendance) and biologic (increased condom use in
high-risksettings)interventionscanhaveameasurableimpactonreversingescalatingHIVtrends.In
Uganda,theemphasisonthe“ABC”approachtoHIVprevention(whichmoreappropriatelyshould
be labeled “ABC...Z” to include the full alphabet of HIV prevention interventions) was successful
becauseoftheinvolvementofpoliticalleadersfromtheoutset.InSenegal,condomsocialmarketing
helped establish a behavioral norm among those most likely to transmit HIV infection. In Brazil,
universalaccesstoantiretroviralshadamultipleimpactbybothprovidingincentivesforindividuals
tolearntheirinfectionstatusandpreventionprogramsaimedatHIV-infectedindividuals.Finally,the
mostcrucialrecentscientificsuccessinthearenaofpreventionhasbeenanindicationfromresults
oftrialsthatmalecircumcisioncanmarkedlyreducetheriskofacquiringHIVinfection.
Therehavealsobeenpreventiondisappointments.Hopesfortopicalmicrobicidesandprophylac-
ticvaccineshavenotbeenrealized;infact,theHIVpreventiontrialswiththeseagentshaveshown
that – as with all science – experiments with new products must be framed for their “two-tailed”
possibilities–bothhelpfulandharmful.Butvaluablelessonshavebeenlearnedwhichhavealready
advanced our scientific approaches to future HIV prevention studies. Some scientific successes
remain unrealized due to structural and societal failures, such as access and stigma. For example,
simple regimens for the prevention of mother to child transmission are still reaching frighteningly
fewchildreninlowandmiddleincomecountries.
Wehavealsoexperiencedtremendousadvancesandchallengesincaringforthosesufferingfrom
AIDS. Scientific progress in treating AIDS has meant that AIDS need no longer be a death sen-
tence.Formanyinlowandmiddleincomecountries,however,difficultiesinfinancingandreliably
accessingcarehaveseverelyunderminedthepromiseofagenerationofprogress.
SohowshouldweproceedintothefuturetohavethegreatestpublichealthimpactonHIV/AIDS
globally? Two mutually reinforcing directions are apparent for prevention: first, HIV prevention
programsmustbeimmediatelyenhancedbyincorporatingthemosteffectiveapproachesavailable;
and second, HIV prevention research must be accelerated by focusing on new strategies that can
substantially improve the effectiveness of our current prevention efforts. In the arena of care, the
successes and failures of treatment roll out in low and middle income countries and communities
mustbecarefullymonitoredandstudied.
Our current generation of HIV/AIDS leaders must play a greater advocacy role among interna-
tional HIV/AIDS funders to coordinate prevention investments, policies and strategies. In short,
public health experts need to work along program management experts to develop a “global pre-
ventionplan.”ThiswouldbebasedonapplyingepidemiologicmethodsandemergingHIVtesting
algorithmstoidentifythehighestrisktransmissiongroups,andthendirectingpreventionresources
tothesegroups.Examplesprovidedinthisbookshowthatthistargetedpublichealthapproachisnot
onlypossible,butalsoabletobesustainedandevenscaledup.Thisfocusedstrategyisrelevantto
bothconcentratedandgeneralizedepidemicsbydirectlyaddressingthesituationsthatsustainHIV
spreadintonewgenerationsoftransmission.
HIV prevention programs must rapidly scale up proven interventions to interrupt transmission
among those most likely to transmit. The current evidence-base for HIV prevention approaches
is strongest for male circumcision services for adult men. In addition, routine infant circumcision
for requesting parents, reduction of sex/needle partners, needle exchange programs, promotion of
maleandfemalecondoms,accesstocounselingtestingforthegeneralpopulation,andantiretroviral
therapy for HIV positive pregnant women and their infants are ready for pubic health primetime.
Preface ix
ThebestkeptsecretinHIVpreventionisprovidingcontraceptivestoHIV-infectedwomenwhodo
not currently wish to become pregnant. Expanding family planning services to meet unmet need
wouldreducethenumberofunintendedHIV-infectedinfantsandorphansbydecreasingthenumber
ofunintendedpregnancies.
The “demand side” of prevention efforts also needs to be examined through greater investment
in community mobilization for uptake of HIV/AIDS prevention and care services. Investments in
HIVpreventionandcarecreateopportunitiesforstrengtheninghealthcaresystemswithinresource-
poorsettings.Inthefaceofseverelylimitedhumanresourcesinhealthcare,evidenceisemerging
fromRwandaandothercountriesshowingthatHIV/AIDSinvestmentshavehadapositivespin-off
impact on the broader community, specifically through improvements in other preventive health
servicesincludingimmunizations,familyplanningandpre-andpost-natalcare.Developing better
systems to measure the impact of HIV/AIDS investments not only on the overall health system,
but also on broader economic development within countries, will be essential. For example, the
building of long-term, sustainable capacities in the most heavily HIV-affected countries will allow
services to be more broadly available, even as those infected with HIV live longer and have other
healthneeds.Integratingspecificprogramservices(familyplanning/HIV,TB/HIV,malaria/HIV)is
an important step both to provide comprehensive care as well as to address non-HIV/AIDS needs
withincommunities.
In conclusion, this book is a wonderful resource for those wishing to understand the multiple
aspectsoftheglobalHIV/AIDSepidemic.Westillhavealongwaytogoinaddressingthispublic
healthpriority.Despitethesuccesses,morepersonsbecomeinfectedwithHIVeverydaythanweare
able access with HIV/AIDS care and treatment programs. No scientific “magic bullet” is around
the corner to provide a panacea for eliminating global HIV spread. The successes and failures
documented in this book show we have evolved in positive directions, that we can learn from our
disappointments,andthatpreventionandcaretogetherwillbenecessarytomoveahead.
WillardCatesJr.,MD,MPH
FamilyHealthInternational
Acknowledgments
Manyindividualsgraciouslydevotedsubstantialtimeandexpertisetothiseffort.TeeradaSripaipan,
AdrienneShapiro,CatherineSutcliffe,AmandaLatimore,BeckyGenberg,AbbyRudolph,andCarla
Zelayahelpedtremendouslywiththefinalcopy-editingandproof-reading-anyremainingerrorsare
thesoleresponsibilityoftheeditors.JoeSchool,DirectorofCartographicServicesattheUniversity
of Maryland, Baltimore County’s Department of Geography and Environmental Systems demon-
stratedendlessgoodhumorandpatienceasheandhisstaffworkedtoproducethecountryandre-
gionalmapsfoundthroughoutthebook.Wethinkthathisteam’sworkreallyaddstremendousadded
valuetothisendeavor.TheKaiserFamilyFoundationwasalsotremendouslyhelpful;painstakingly
adapting a series of web based global HIV/AIDS maps for our use. Evonne Carroll Young, Web
Development Manager kindly helped us with our initial request, while Shobana Ramachandran, a
KFFRosenfieldFellow,andAliciaCarbaugh,aSeniorPolicyAnalystforHIVPolicy,spentconsid-
erabletimeandcarereviewingthemapsandsuggestingrevisionstoimprovetheirusefulnessforour
readers.TeresaBailey,aSeniorInteractiveDesignerwithVelirStudiosexpertlytranslatedcolorful
interactive maps toversions suitableforblackand whitetext.Teresaworked painstakingly onthis
for us for months, pausing ever so briefly to deliver her beautiful baby girl. We are indebted to all
fortheirpersistentgoodcheerandfortheirinsistenceondeliveringtheverybestproductpossible.
WendyDaviswasthetruelifelineofthisproject.Fromtheinitialproposaltothefinalcopyediting
of these many chapters, Wendy was on the job. It is always a challenging job keeping on top of
all of these authors with deadlines, time zones and competing interests. It is clear to us that the
book would not exist without Wendy’s dedicated and devoted efforts. We are deeply in her debt!
Thankyouall.
xi
Contents
Preface........................................................................ vii
Part I: Introduction
1. EpidemiologyofHIV/AIDSinLowandMiddleIncomeCountries:WhereGlobal
AIDSisandWhereitisGoing................................................. 3
DavidD.Celentano,WendyW.Davis,andChrisBeyrer
2. HIVPreventionNeeds:PrimaryPreventionandPreventionforPeopleLivingwith
HIV/AIDS................................................................. 19
Nalini Tarakeshwar, Seth C.Kalichman, Leickness C.Simbayi, and Kathleen J.
Sikkema
3. FutureofHIV/AIDSCareinLow-andMiddle-IncomeCountries .................. 41
ChristopherJ.Hoffmann, LisaA.Mills,andJoelE.Gallant
4. HIV/AIDSCare:TheMinimumPackageandScalingUp ......................... 71
JoiaMukherjee
5. HIV/AIDSVaccineResearch ................................................. 85
RuanneV.Barnabas,AnnC.Duerr,andJudithN.Wasserheit
6. MicrobicideDevelopment................................................... 115
IanMcGowan
7. HowthePandemicShapesthePublicHealthResponse–theCaseofHIV/AIDSin
Brazil.................................................................... 135
JaneGalva˜o,PauloRobertoTeixeira,MarcoVito´ria,andMauroSchechter
8. Advocacy,Activism,CommunityandtheAIDSResponseinAfrica ................ 151
EmilyBass,GreggGonsalves,andMillyKatana
xiii
