1
Introduction

The trajectory of the HIV/AIDS pandemic1 over the next decade is expected to place demands on health care systems manyfold greater than have occurred to date. The global incidence and prevalence of HIV/AIDS and the natural progression of the disease is to the point where costly treatments are required, as well as the collateral effects on individuals, families, communities, and nations, have ominous implications for the future. The magnitude of the problem is most severe in Africa,2 which accounted for 68 percent of all HIV-infected individuals and 69 percent of all new infections in 2009 (UNAIDS, 2010). The current burden of morbidity due to the pandemic is straining resources for prevention, treatment, and care; again, this strain is felt most acutely in Africa, where the capacity of health care systems to absorb at least a tenfold increase in treatment load is especially precarious.

Antiretroviral drugs have prolonged the life of a fraction of affected individuals, yet even this accomplishment has required immense effort, supported by multibillion-dollar investments by the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and other sources of assistance. This effort is taxing human resource capacities at the risk of increasingly negative collateral effects on other health and development initiatives, especially in Africa. In fact, the impressive mobilization of donor funds to combat HIV/AIDS has created an environment in which

1

A pandemic is an epidemic occurring worldwide or over a very wide area, crossing boundaries of several countries, and usually affecting a large number of people.

2

For purposes of brevity, unless otherwise noted, the term Africa denotes sub-Saharan Africa throughout the report.



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1 Introduction The trajectory of the HIV/AIDS pandemic1 over the next decade is expected to place demands on health care systems manyfold greater than have occurred to date. The global incidence and prevalence of HIV/AIDS and the natural progres - sion of the disease is to the point where costly treatments are required, as well as the collateral effects on individuals, families, communities, and nations, have ominous implications for the future. The magnitude of the problem is most severe in Africa,2 which accounted for 68 percent of all HIV-infected individuals and 69 percent of all new infections in 2009 (UNAIDS, 2010). The current burden of morbidity due to the pandemic is straining resources for prevention, treatment, and care; again, this strain is felt most acutely in Africa, where the capacity of health care systems to absorb at least a tenfold increase in treatment load is especially precarious. Antiretroviral drugs have prolonged the life of a fraction of affected indi- viduals, yet even this accomplishment has required immense effort, supported by multibillion-dollar investments by the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and other sources of assistance. This effort is taxing human resource capacities at the risk of increasingly negative collateral effects on other health and development initiatives, especially in Africa. In fact, the impressive mobiliza- tion of donor funds to combat HIV/AIDS has created an environment in which 1 A pandemic is an epidemic occurring worldwide or over a very wide area, crossing boundaries of several countries, and usually affecting a large number of people. 2 For purposes of brevity, unless otherwise noted, the term Africa denotes sub-Saharan Africa throughout the report. 15

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16 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA the shortage of human resources has replaced funding as the major obstacle to implementing national prevention, care, and treatment programs. Furthermore, the expected growth in the burden of HIV/AIDS in the coming decade portends significant challenges for the United States and the global community in sus - taining and expanding commitments to combating HIV/AIDS in Africa. STATEMENT OF TASK AND STUDY SCOPE In this context, the task of the Institute of Medicine (IOM) Committee on Envisioning a Strategy to Prepare for the Long-Term Burden of HIV/AIDS: African Needs and U.S. Interests was to develop innovative strategies that can be used by the United States and other donor countries to respond to the challenge of HIV/AIDS in the coming decades through institutional and human resource capacity building (see Box 1-1).3 This report is the product of that effort. Although the committee’s statement of task speaks to the global nature of HIV/AIDS, it was clear from the outset of the study that the focus would be on Africa, the region most affected and most challenged by the pandemic. Accord- ingly, half of the committee members are from African states. Moreover, as the committee undertook its deliberations, it quickly became apparent that time and resource constraints would necessitate confining the scope of the study to the African context. Even within Africa, however, the epidemic is heterogeneous, as described below. Finally, with respect to its recommendations, the committee recognizes that the social determinants of health (the conditions in which people live and work, such as access to education, women’s status, and poverty) are critically impor- tant, and that improvements in these areas would help mitigate the impacts of the global HIV/AIDS pandemic. In this report, however, the committee confines its recommendations to the domain of health care systems. THE BURDEN OF HIV/AIDS In 2009, approximately 33.3 million people globally were living with HIV; an estimated 2 million people died as a result of HIV/AIDS; and 2.6 million people, including 370,000 children, were newly infected (UNAIDS, 2010). Of those global HIV infections, 22.5 million were in Africa; as noted earlier, this figure represents 68 percent of the global total, while the number of newly infected represents 69 percent of the global total (UNAIDS, 2010). Expansion of the HIV/AIDS epidemic has varied across Africa. The regional variation in prevalence of HIV among those aged 15−49 is shown in Table 1-1. The countries 3 The statement of task for this study did not call for, nor was the committee constituted to develop, a social, behavioral, or biomedical science research agenda for addressing HIV/AIDS. The committee recognizes that advances in these areas could radically change the future of the epidemic.

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17 INTRODUCTION BOX 1-1 Statement of Task The Institute of Medicine will convene an ad hoc committee to describe the long term trajectory for the global AIDS pandemic, why the problem is critically important to the U.S. and international interests and to highly affected countries, the relationship between current capacities and needed capacities, and provide consensus conclusions and recommendations for how the United States and other donor countries can innovatively respond to the challenge through institutional and human resource capacity building. Specific questions to be addressed are: 1. A decade from now (2018) what is the best projection for global inci- dence and burden of HIV/AIDS and its demographic and geographic distribution? What is the sensitivity of these projections to assumptions concerning the prevention of HIV infection? 2. What are the long term human resource and institutional implications of the projected global HIV infection prevalence on U.S. health, economic, diplomatic, industrial, scientific, academic, and other interests? 3. What are the implications of the projected HIV incidence and overall HIV/AIDS burden from the perspective of African governments and institutions including academia and the health care sector? 4. What should be the strategies for the U.S. and highly affected nations to develop now in order to ensure domestic and international capaci- ties for highly effective HIV prevention, treatment, and care efforts in the 2018–2023 timeframe? What structures, systems, and professions would be necessary to implement these strategies? a. What could be the strategic role of U.S., African, and other univer- sities in highly affected areas with respect to support for “twinning” at the level of individual faculty members, departments, schools, and entire universities? b. What could be the strategic role of other American institutions in supporting “twinning” for global capacity building relevant to HIV prevention, treatment, and care? What are the pro’s and con’s of these forms of assistance? c. How should South-South and regional considerations be incorpo- rated into national plans? d. What should be the role of African science academies in support- ing HIV/AIDS prevention, treatment, and care strategy refinements at the national level? 5. What are the implications of the projected HIV incidence and burden of HIV/AIDS for the capacity of resource-constrained countries to conduct decision making in an ethical manner?

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18 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA TABLE 1-1 Prevalence Among Those Aged 15−49 in African Countries by sub-Saharan African Region Prevalence Among Those Country Aged 15−49 (%) West Africa Ghana 1.8 Liberia 1.5 Senegal 0.9 Central Africa Chad 3.4 Congo 3.4 Central African Republic 4.7 Eastern Africa Kenya 6.3 Tanzania 5.6 Uganda 6.5 Southern Africa Botswana 24.8 South Africa 17.8 Zimbabwe 14.3 SOURCE: UNAIDS, 2010. included in the table were chosen because they are representative of the HIV prevalence in their region. In addition to the regional variation in prevalence, three main categories of countries are battling the HIV/AIDS epidemic in Africa. First are the hyperen- demic countries of southern Africa. In addition to hosting the greatest burden of disease, these countries have faced their own particular issues because some of them are middle- or lower-middle-income countries, such as South Africa and Botswana, while others are extremely poor, such as Malawi and Zambia. Additionally, while South Africa bears a great burden of disease in terms of total numbers, Botswana, Lesotho, Namibia, and Swaziland struggle with enormous proportional burdens. The second category consists of low-income countries that bear a great burden of disease, such as Uganda, Ethiopia, Kenya, and Tanzania. These countries face a different set of challenges. While their epidemics may not be on the same scale as those in the highest-prevalence countries, their resources are much more limited. For them, the challenge is how to sustain treatment when the cost of ART is many times their per capita health expenditure. The third cat - egory comprises countries with low-prevalence epidemics, such as Angola and Senegal. It is important to keep this category separate from the other two as it may not be cost-effective for them to invest in HIV/AIDS prevention, treatment, and care with the same urgency as countries in the other two categories.

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19 INTRODUCTION The committee distinguishes these three main categories of countries to make the point that HIV/AIDS is a mosaic of epidemics in Africa. As a result, the programs and policies recommended in this report will require tailoring to local circumstances; the type of epidemic and specific country context should inform the type and degree of response from African and U.S. governments and other stakeholders. Where African countries have the necessary financial resources, infrastructure, and political will, they are strongly encouraged to implement these recommendations with their own resources; financial support to these countries from the United States and other donor nations should be contingent on their using national resources to the extent possible. For the lowest-income, less- capable African countries with weak leadership around HIV/AIDS, the United States and other donors should play a larger role in the capacity-building aspects of the shared-responsibility paradigm, including leadership and infrastructure development, and should maintain strict oversight of their financial support. Given the projected burden of HIV/AIDS in the coming decades, support from international donors today can help build the infrastructure, political will, and institutional and human resource capacity that African nations will need to meet their own country-specific HIV/AIDS needs and priorities in 2020 and beyond. The committee did not deem it appropriate to prescribe certain recommenda - tions for specific African countries; rather, in keeping with the theme of shared responsibility, it is the committee’s hope that African countries will adapt the committee’s recommendations to their own needs and priorities. With respect to treatment, the percentage of those needing ART who were receiving it as of 2009 depends on which World Health Organization (WHO) guidelines are applied. According to the 2006 guidelines, treatment should be initiated at a CD4 cell count4 below 200 cells/µL. By this criterion, just 53 per- cent of those needing ART were receiving it in Africa as of December 2009. The picture becomes bleaker, however, if the 2010 guidelines are applied, under which treatment should be initiated at a CD4 cell count of below 350 cells/µL. By this criterion, the percentage needing and receiving treatment in Africa drops to just 36 percent (WHO, 2010). According to the committee’s projections (see Figure 2-5 in Chapter 2), the need for treatment will increase manyfold over the next decade. By then, approxi- mately 35 million people will be infected in Africa, and the estimated number on treatment will be 7 million, or a mere 60 percent of those needing treatment according to the 2006 WHO guidelines. 4 CD4 cell count is the number of CD4 cells (T-helper lymphocytes with CD4 cell surface marker), used to assess immune status, susceptibility to opportunistic infections, and need for ART and op - portunistic infection prophylaxis and to define AIDS (CD4 below 200).

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20 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA ADDRESSING THE LONG-TERM BURDEN OF HIV/AIDS: GUIDING PRINCIPLES In deliberating about how best to address the long-term burden of HIV/AIDS in Africa, the committee was particularly mindful of several factors: (1) the pro - jected trajectory of the epidemic (see Appendix A), (2) the resource and funding constraints facing the United States and other donor nations, (3) the limited resources and capacity of African states, (4) the need for sustainable approaches, and (5) the overarching imperative to lessen the suffering of those affected by HIV/AIDS. Two guiding principles emerged from consideration of these factors: • The burden of morbidity and mortality in Africa cannot be alleviated through treatment interventions alone. Treatment can reach only a fraction of those who need it, and its costs are not sustainable for the foreseeable future. Therefore, greater emphasis must be placed on reducing incidence by preventing new infections. • African states and societies must become full partners in the fight against HIV/AIDS. If this shared-responsibility model is to be feasible, how - ever, they must have greater resources (particularly human resources) and capacity at all levels, from national governments to local communities. STUDY APPROACH In conducting this study, the 12-member committee drew on the extensive and varied experience of its members; testimony from subject matter experts in the field; input from numerous organizations; and the published literature on HIV/ AIDS epidemiology and issues of financing, foreign policy, the global health workforce, and ethics related to the pandemic. Over the course of the study, the committee held four meetings and two public workshops. The first committee meeting, held in Washington, DC, in February 2010, featured the project sponsors and a discussion of the committee’s charge; a portion of this meeting was open to the public and included testimony from U.S.-based experts in HIV/AIDS epi - demiology, foreign policy, and programming. At the second committee meeting, held in Pretoria, South Africa, in April 2010, the committee heard from a range of African government officials, program managers, academics, and activists during a 2-day public workshop held in collaboration with the Academy of Science of South Africa. Through the generous sponsorship of the Rockefeller Foundation, the committee held its third meeting in June 2010 in Bellagio, Italy, to formulate its recommendations and draft this report. In September 2010, the committee held its fourth and final meeting in Washington, DC, to review a draft of the report and reach consensus on its recommendations. The information gathered from these many sources informed the committee’s deliberations, the content of this report, and the committee’s recommendations for how the U.S. and African governments

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21 INTRODUCTION and nongovernmental institutions should prepare for the future impacts of HIV/ AIDS in Africa. ORGANIZATION OF THE REPORT Chapter 2 sets the stage for the remainder of the report by examining the future impact of current decisions with respect to the potential for reducing HIV/ AIDS incidence and treatment needs, as well as the policy choices and associated trade-offs that must be considered in designing optimum strategies to combat the epidemic in Africa. Chapters 3 and 4, respectively, elaborate on the foundation for these decisions by detailing the implications of the burden of HIV/AIDS for the United States and African states and societies. Chapter 5 builds on Chapters 2 through 4 to present strategies identified by the committee as both effective and feasible for responding to the long-term burden of HIV/AIDS in Africa. The emphasis of these strategies is on sustain - ability and shared responsibility between the United States and other donor nations and African states. Finally, Chapter 6 addresses the crucial issue of building the capacity of African leadership for ethical decision making in dealing with the very difficult and inevitable choices that must be made in the face of the gap between treatment needs and available resources. Chapters 2 through 6 end with recommendations formulated by the committee as a result of its delibera - tions on the respective topics. In addition, four appendixes are provided. Appendix A addresses the issue of projecting the future burden of HIV/AIDS, examining both epidemiological and economic projections. Appendix B briefly reviews the demographic variation of the epidemic in Africa. Appendix C presents the agendas for the two public workshops held in conjunction with the committee’s February and April 2010 meetings, while Appendix D contains biographical sketches of the committee members. REFERENCES UNAIDS (The Joint United Nations Programme on HIV/AIDS). 2010. Global report: UNAIDS report on the global AIDS epidemic 2010. Geneva: UNAIDS. WHO. 2010. Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010. Geneva: WHO.