1. Is HIV/AIDS still exceptional? Alan Whiteside Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal Durban Presentation to Daniel J. Evans School of Public Affairs University of Washington Monday 9 th February 2009 www.heard.org.za

3. Lancet editorial 18/10/08 It is time to unwind the rhetoric, and reposition the responses to HIV/AIDS as one of several important health challenges. …. UNAIDS needs to abandon AIDS exceptionalism. Actually no. AIDS is exceptional, but not everywhere!

4. Key Points The State of the Epidemic Why AIDS is exceptional –Three waves and long periods –AIDS and the global disease burden –The hyper epidemic countries –The demographic impacts in Africa and Eastern Europe –The cost of care Big issues

5. 2007 Global HIV Infection 33 million people [30–36 million] living with HIV, 2.2

6. Global numbers living with HIV and adult HIV prevalence Source: UNAIDS 2008

7. Epidemic Curve: HIV, AIDS and Impact 27Aug01 -Report I:Epidem’gy & Lit. p.27 T 1 T 2 Time Numbers A 1 A 2 HIV prevalence B 1 A B AIDS - cumulative Impact

8. Global Baseline Death Projections (Non-Communicable Diseases) Source: Mathers and Loncar 2002, Projections of Global Mortality and Burden of Disease from 2002 to 2030, World Health Organization, Geneva, Switzerland

9. Global Baseline Deaths Projections Communicable Diseases Source: Mathers and Loncar 2002, Projections of Global Mortality and Burden of Disease from 2002 to 2030, World Health Organization, Geneva, Switzerland

10. RankingLow incomeMiddle incomeHigh incomeWorld 1Ischaemic heart disease 13.2 Cerebrovascular disease 14.4 Ischaemic heart disease 15.2 Ischaemic heart disease 13.4 2 HIV/AIDS 13.2 Ischaemic heart disease 12.7 Cerebrovascular disease 9.0 Cerebrovascular disease 10.6 3Cerebrovascular disease 8.2 COPD 12.0Trachea, bronchus lung cancers 5.1 HIV/AIDS 8.9 4COPD 5.5 HIV/AIDS 6.2 Diabetes mellitus 4.8 COPD 7.8 5Lower respiratory tract infections 5.1 Trachea, bronchus lung cancers 4.3 COPD 4.1Lower respiratory tract infections 3.5 Cause of Death by Income and Percentage in 2030

11. 2007 Global HIV Infection 33 million people [30–36 million] living with HIV, 2.2

12. 2007 HIV Prevalence, African Adults (15–49) 2.8

13. HIV Prevalence in Antenatal Clinic Surveys: Southern Africa Source: UNAIDS Global AIDS report 2008

14. Demographic and Health Survey HIV Prevalence

15. HIV and AIDS CountryPopulationNumber living with HIV/AIDS 18.8% prevalence rate Swaziland 1,200,000225,600 USA 301,140,00056,614,320 UK 60,776,00011,425,888 EU 492,964,00092,677,000

16. Republican Voters in 2008 56 000 000 Number of American’s who would be infected if the USA had Swaziland's prevalence 56 614 320

17. The Demographic Impacts Young people die Children are not born Population decline Falling life expectancy Orphaning

18. Population Decline: Russia & Ukraine Source: World bank HNP Statistics

19. Ukraine

20. Demographics: Population Growth

21. Swaziland 2007 Preliminary Census Results Population Data (de facto) 1997 929 718 2007 912 229 There were 17 499 fewer people over 10 years Estimated for 2006 1 200 000

22. Demographics: Population Growth

23. Demographics: Life Expectancy

24. AIDS can not be cured People will need treatment For life And it is expensive

25. Per capita health expenditure Country Health Expenditure Per capita (USD) Cost of ARV treatment per person/year (USD) Botswana1711500* Swaziland66168 Mozambique11960** Rwanda11400 Source: Summary country profiles for HIV/AIDS treatment scale up, WHO 2005. *ARV treatment publicly funded. Source: Introducing ARV Therapy in the Public sector in Botswana Case study, 2004. ** Mozambique offers subsidized ARV therapy at approx. 80 USD/month. Source: Provision of Antiretroviral Therapy in resource limited settings: a review of experience. WHO/DFID 2003

26. Mopping the Floor while the tap is running

27. Long term impacts The impact of the epidemic is still unfolding and will do so for at least a generation Lessons from climate change??

28. Agriculture

29. Big Issues AIDS interest (& funding) may have peaked –Financial melt-down and recession –Global environmental change –Food availability and prices –Peak oil Treatment challenges –Cost and Coverage –Sustainable financing Prevention (can we and how) Leadership and ownership (who and how)

30. What needs to be done differently Honest discussion about costs, choices, sustainability and prospects Prevention –A reassessment of existing programmes –Ownership (leadership in Africa does not own the epidemic) –Male female dynamics –Sexual networks Impact –Save the human capital Leadership