1. 00001-E-1– 27 June 2000 Why does AIDS persist at such a high rate in Sub-Saharan Africa? infidelity l Helen Epstein, in NY Times Magazine, June 13, 2004, suggests that the reason is infidelity. –In South Africa, Kenya and other countries, men have several on-going commitments. This contrasts to the US pattern of either “one night stands” or serial monogamy. l This argument is highly charged emotionally. l Can we evaluate it biologically?

2. 00001-E-2– 27 June 2000 A global view of HIV infection 33 million adults living with HIV/AIDS as of end 1999 Adult prevalence rate 15.0% – 36.0% 5.0% – 15.0% 1.0% – 5.0% 0.5% – 1.0% 0.1% – 0.5% 0.0% – 0.1% not available

3. 00001-E-3– 27 June 2000 Leading causes of disease burden globally, 1999 l 1 Acute lower respiratory infections l 2 HIV/AIDS l 3 Perinatal conditions l 4 Diarrhoeal diseases l 5 Ischaemic heart disease l 6 Unipolar major depression l 7 Cerebrovascular disease l 8 Malaria l 12 Tuberculosis 6.7 6.2 5.0 4.1 3.5 3.1 2.3 Source: The World Health Report 2000, WHO Rank % of total

4. 00001-E-4– 27 June 2000 Leading causes of death globally, 1999 l 1 Ischaemic heart disease l 2 Cerebrovascular disease l 3 Acute lower respiratory infections l 4 HIV/AIDS l 5 Chronic obstructive pulmonary disease l 6 Perinatal conditions l 7 Diarrhoeal diseases l 8 Tuberculosis l 11 Malaria 12.7 9.9 7.1 4.8 4.2 4.0 3.0 1.9 Source: The World Health Report 2000, WHO Rank % of total

5. 00001-E-5– 27 June 2000 Leading causes of disease burden in Africa, 1999 l 1HIV/AIDS l 2 Malaria l 3 Acute lower respiratory infections l 4 Diarrhoeal diseases l 5 Perinatal conditions l 6 Measles l 7 Maternal conditions l 8 Tuberculosis l 9 Congenital abnormalities l 10 Road traffic accidents 19.9 9.9 8.5 6.5 4.7 3.4 2.3 1.7 Source: The World Health Report 2000, WHO Rank % of total

6. 00001-E-6– 27 June 2000 Leading causes of death in Africa, 1999 l 1 HIV/AIDS l 2 Acute lower respiratory infections l 3 Malaria l 4 Diarrhoeal diseases l 5 Perinatal conditions l 6 Measles l 7 Tuberculosis l 8 Cerebrovascular disease l 9 Ischaemic heart disease l 10 Maternal conditions 20.6 10.3 9.1 7.3 5.9 4.9 3.4 3.2 3.0 2.4 Source: The World Health Report 2000, WHO Rank % of total

7. 00001-E-7– 27 June 2000 Changes in life expectancy in selected African countries with high HIV prevalence, 1950 to 2000 South-Africa 35 40 45 50 55 60 65 1950-551955-601960-651965-701970-751975-801980-851985-901990-951995-00 Life expectancy at birth, in years Botswana Uganda Zambia Zimbabwe Source: United Nations Population Division, 1998

8. 00001-E-8– 27 June 2000 Estimated adult HIV prevalence in Kenya, 1990-1999 Source: National AIDS and STD Control Programme, 1999 and UNAIDS 0 2 4 6 8 10 12 14 16 90919293949596979899 HIV prevalence (%)

9. 00001-E-9– 27 June 2000 HIV prevalence among pregnant women in South Africa, 1990 to 1999 Source: Department of Health, South Africa 0.7 1.7 2.1 4 7.6 10.4 14.2 17 22.8 22.4 0 5 10 15 20 25 90919293949596979899 HIV prevalence (%)

10. 00001-E-10– 27 June 2000 HIV prevalence (%) Median HIV prevalence among pregnant women in urban areas in Uganda, 1985 to 1998 Source: STD/AIDS Control Programme, Uganda 0 5 10 15 20 25 30 35 85 86 87 88 89 90 91 92 93 94 95 96 97 98

11. 00001-E-11– 27 June 2000 HIV prevalence in military personnel in Africa l Nigeria: 11% among peacekeepers returning from Sierra Leone and Liberia vs 5% in adult population l South Africa: 60-70% in military vs 20% in adult population Source: Nigeria AIDS bulletin No 15, May 20, 2000; The Mail & Guardian, Pretoria, March 31, 2000; UNAIDS/WHO 1999 estimate

12. 00001-E-12– 27 June 2000 HIV prevalence rate and frequency of sexually transmitted infection (STI) episodes, Carletonville miners, South Africa, 1991-1998 0 10 20 30 40 50 60 70 80 90 12-45-910+ Number of STI episodes HIV prevalence (%) Source: Ballard R, 2000 (unpublished data).

13. 00001-E-13– 27 June 2000 Individuals are more infectious to others when they have been newly infected l Epstein argues that the concurrent partners strategy favors widespread transmission because a newly infected individual is likely to visit several partners during the highly infectious period. l An individual with “one night stands” or serial monogamy may put fewer people at risk during this period even if the total partners per 6 months is similar.

14. 00001-E-14– 27 June 2000

15. 00001-E-15– 27 June 2000 Condom use l Numerous studies have found that people in many locales have increased use of condoms with “casual” partners or prostitutes. l Use of condoms with regular partners has increased less dramatically. l What if there are several “regular partners?”

16. 00001-E-16– 27 June 2000 Why does this behavior persist? l Women without access to funds (especially younger women) rely on male partners for financial contributions l In Kenya and South Africa, “sugar daddies” commonly help girls with school fees as well as luxuries.

17. 00001-E-17– 27 June 2000 Uganda’s success l Early devastating epidemic created public awareness l Cultural openness about sexual matters l Visible campaign- –ABC: Abstain, Be Faithful, Use Condoms –Zero Grazing l Participation of women’s activist groups

18. 00001-E-18– 27 June 2000 The AIDS story as it is told in Uganda

19. 00001-E-19– 27 June 2000 What do we know? What do we need to know? l How can we shape this into a workable case study? l Is there adequate room for complexity, for multiple approaches, for scientific investigation? l Can we tie in questions that lead students to explore the mechanisms of drug action, vaccines or the immune response?

20. 00001-E-20– 27 June 2000 Impact of HIV/AIDS on urban households, Côte d’Ivoire General population Families living with AIDS Source: Simulation-based on data from Bechu, Delcroix and Guillaume, 1997 Monthly income per capita Monthly income per capita Monthly consumption per capita Monthly consumption per capita 0 0 5 000 10 000 15 000 20 000 25 000 – 5 000 30 000 Francs CFA Savings/Disavings

21. 00001-E-21– 27 June 2000 Reduction in production in a household with an AIDS death, Zimbabwe Crops l Maize l Cotton l Vegetables l Groundnuts l Cattle owned Reduction in output 61% 47% 49% 37% 29% Source: Stover & Bollinger, 1999

22. 00001-E-22– 27 June 2000 HIV prevalence rate among teenagers in Kisumu, Kenya, by age 00 3.6 2.2 8.6 8.3 17.9 29.4 22 33.3 0 5 10 15 20 25 30 35 1516171819 Age in years HIV prevalence (%) boys girls Source: National AIDS Programme, Kenya, and Population Council, 1999

23. 00001-E-23– 27 June 2000 Projected population structure with and without the AIDS epidemic, Botswana, 2020 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 020406080100120140020406080100120140 Males Females Deficits due to AIDS Projected population structure in 2020 Population (thousands) Age in years Source: US Census Bureau, World Population Profile 2000

24. 00001-E-24– 27 June 2000 HIV prevalence rate among 13 to 19-year-olds, Masaka, Uganda, 1989 to 1997 0 1 2 3 4 5 1989/901990/911991/921992/931993/941994/951995/961996/97 girls boys Source: Kamali et al. AIDS 2000, 14: 427-434 HIV prevalence (%)

25. 00001-E-25– 27 June 2000 HIV prevalence rate among pregnant 15-24 year-olds by educational status, Uganda 0 5 10 15 20 25 30 1991-19941995-1997 HIV prevalence (%) illiterate primary education secondary education Source: Kilian A et al. AIDS 1999, 13: 391-398.

26. 00001-E-26– 27 June 2000 Estimated impact of AIDS on under-5 child mortality rates, selected African countries, 2010 Botswana Kenya Malawi Tanzania Zambia Zimbabwe 0 50 100 150 200 250 Deaths per 1000 live births Without AIDS With AIDS Source: US Census Bureau

27. 00001-E-27– 27 June 2000 Source: National STD/AIDS Control Programmes, Senegal and Uganda Armed Forces Research Institute of Medical Sciences, Thailand 0 5 10 15 20 25 30 89909192939495969798 99 HIV prevalence (%) Kampala, <20 year old ANC Thailand, 21 year old military conscripts Dakar, all ages ANC Trends in HIV prevalence in selected populations in Kampala, Uganda; Dakar, Senegal; and Thailand; 1989 to 1999