Public Health Practice I: HIV/AIDS Consequences for

Socio- Economic Development

Thomas Novotny

The World Bank

Outline of Presentation

1. The Global HIV/AIDS Pandemic

2. HIV/AIDS in Europe and Central Asia

3. Potential economic impact

4. Policy approaches

5. The Balkans, Moldova & Central Asia

6. Conclusion

+ 1 300%

+60%

+ 160% + 100%

+ 30%

+ 40%

+ 20% +20%

+ 20%

Global HIV Pandemic

UNAIDS

Adult (15-49)

HIV prevalence rate

0.6%

(range: 0.4-0.9%)

Adults (15-49)

living with HIV

1 300 000

(range: 850 000-

1 900 000)

Adults and children (0-49)

living with HIV

1 300 000

(range: 860 000-

1 900 000)

Women (15-49)

living with HIV

440 000

(range: 280 000-

650 000)AIDS deaths

(adults and children)

in 2003

49 000

(range: 32 000-

71 000)

HIV/AIDS Estimates in ECA (2003)

UNAIDS 2003

Epidemic Outlook

Eastern Europe and Central Asia confront 4 overlapping epidemics

Drug Use HIV/AIDS Sexually Transmitted Infections Tuberculosis

Epidemic drivers act regionally and can best be addressed at regional level

Trafficking in people and drugsEconomic and political migrationSex WorkPrisons

Godinho J, Renton A, Vinogradov V, Novotny T, Gotsadze G, Rivers MJ, Bravo M (2004)

Explosive Epidemics of HIV among IDU

0

20

40

60

80

198

3

198

5

198

7

198

9

199

1

199

3

199

5

HIV

pre

vale

nce

(%

)

Year

Edinburgh

Bangkok

Myanamar

Manipur

Odessa

199

7

199

9

200

1

Samara RF

Renton A 2004

STI/IDU/HIV Interactions

High STI Prevalence

Low STI Prevalence

Successful IDU harm reduction

No IDU harm

reduction

10 explosive IDU epidemic

20 larger sexually transmitted epidemic

Contained IDU epidemic

Smaller and slower 20

sexually transmitted epidemic

10 explosive IDU epidemic

Smaller and slower 20

sexually transmitted epidemic

Contained IDU epidemic

Very small and slow 20

sexually transmitted epidemic

Renton A 2004

Epidemiological Factors• Prevalence of TB in PLWH • MDR-TB Prevalence in PLWH• Duration of infectiousness in PLWH• STI and other co-morbidities

TB INFECTION ACTIVETB

CURERECURRENCE

DEATH

TBTRANSMISSION

Role of HIV/AIDS in Fueling the TB epidemic

Interventions to avert the TB epidemic fueled by HIV/AIDS

TB Preventive Treatment

Intensified case-findingDecreased delay in case detection and DOTS

BCGTB Preventive TreatmentAccess to Second-line drugs

Lack of access to• HAART• STI Treatment• Harm Reduction for IUD• Condom Use

Socio-structural Factors• Over-crowded prisons• Poverty related commercial sex• Sale and transfusion of contaminated blood

HIV/AIDS Role in Poverty

•Loss of income

•Catastrophic cost of care

•Increased dependency ratio

•Loss of productivity

(companies)

•Loss of social capital

(countries)

•Reduced national income?

Contributors to Poverty

HIV

Infection

AIDS

Epidemic DriversEconomic & Political migration

Poverty/Income

Differentials

Unemployment

DrugTrafficking

Low levels of

population awareness

and knowledge of HIV & STI

Low levels of

population awareness

and knowledge of HIV & STI

Explosion of Injecting Drug Use

Explosion of Commercial Sex Work

Epidemics of STIs

Low Level HIV Epidemic

Concentrated HIV Epidemic

Generalized HIV Epidemic

Renton 2004

Potential Economic Impact in Russia

• Economic growth rates could decline by 0.5-1.0 percent annually

• Health expenditures could increase up to 50 percent

• Costs of treatment would not be sustainable• The dependency ratio could rise• Household size & composition could change• Transfer of intellectual capital and social skills

from one generation to another could be lost

Ruhl C, Pokrovsky V, Vinogradov V 2002

Policy Approaches

• Decriminalize risk behavior

• Improve medical treatment

• Social support to PLWHA

• Legislative authority for NGOs to work with vulnerable groups

• Reproductive health & HIV/AIDS Education

IDU, CSW, MSM, Migrants

Narcology, HAART, STIs, TB Social protection, palliative

care

Harm Reduction, outreach

Schools,policymakers, general public

Information Needs

• Sentinel surveillance of high risk groups

– Behavioral

– Serologic

• Respondent-driven sampling

• Venue-based testing

• Voluntary testing and counseling

• Data used for decision making

• Harm reduction

• Education programs

• Supply chain for drugs, supplies, condoms

• Prison health system

• National AIDS Programs

Monitoring Evaluation

Non-financial Factors

Political will and perceptionSocial constraints and stigmatizationCommunity, Gender, and ValuesInstitutional capacity to implement

effective interventionsRegulatory and legal issuesDonors Coordination

Funding Needs

• Funding would have to increase from $300 million in 2001 to $1.5 billion in 200740% for prevention55% for care and treatment5% for policy, administration, research & evaluation

• For treatment of HIV/AIDS & TB, funding would have to increaseFor ARVT, from $60 million in 2002 to more than $600

million by 2007For TB control, from <1 billion in 2001 to $1.9 billion by 2007

UNAIDS and The World Bank 2003

HIV/AIDS in ECA Countries Opportunity for prevention is now Cross-border externalities important in addressing

most vulnerable groups Future burden on health systems and economic

productivity may be enormous Sentinel surveillance in high risk groups and

vulnerable populations is needed Harm reduction application and decriminalization

are needed Public information and professional education are

essential

Youth Vulnerability

• 80% of infected persons are less than 30 years of age in ECA

• Primary carriers are boys and young men• CSW and trafficking in girls and young women• IDU, heavy alcohol use, and lack of access to

reproductive health education and safe sex• Iatrogenic cases in Romania

Mobile Populations

• Sailors, truckers (37% have unsafe sex while traveling)

• Peacekeepers • Commercial Sex Workers (CSW)• Trafficked women and children• Roma and other ethnic minorities (8 million in

ECA)• Displaced people• Tourists

Harm Reduction in Prisons

Harm Reduction in Prisons

Is Harm Reduction working in Moldova?

Role of IDU in the epidemic

1992 1994 1996 1998 2000 2002 2004

0

100

200

300

400

500

Laticevschi D 2004

New Cases

HIV/AIDS in Central Asia

Why should we take HIV/AIDS seriously in ECA

Steep growth of HIV casesin the Region

Established relation betweenInjecting drug use, STI and

TB

Share of youth over 40%of the population

Low levels of knowledgeabout the epidemics

human traffickingdrug trafficking

migration zones Red: high risk oblasts, major drug routes Green: human trafficking routes

Drug and migration routes

Renton A, Gzirishvili D, Gotsadze G, Godinho J 2004

ResultsPrevention NeedsUS$208 million

Treatment CostsUS$??? million per year+

Existing Resources: 2002 to 2010US$75 million

Given needs outweigh resources what is best way to spend the money? Cercone 2004

J 2004

AIDS Challenges in ECA

Target most vulnerable groups with appropriate approaches

Improve Public Health functionsIncrease opportunities for youth to

participate in the knowledge economy