Here is a brilliant talk by the World Bank's David Wilson delivered in Africa. Myanmar Burma is not included because the quality of the data is not as high as in other Southeast Asian countries.
It is a transcript so there are typos.
[him] moderator
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Plenary: Knowing Your Epidemic and Response
4 June 2008
DAVID WILSON, PH.D: Good morning. I have chosen to speak without slides today because I think our core challenge today is not to revisit the many of data in a context where there has been so little progress and prevention science in the last two years. But, rather to try to integrate our data into a coherent argument.
And our quest to know our epidemics must begin with the simple accretion that there is no such thing as the global AIDS epidemic, but rather a multitude of diverse epidemics. No single set of prescriptions can be valid in, for example, Uganda, the Ukraine, Papua New Guinea or elsewhere.
The error of global guidance is truly over, but the most central and enduring distinction in HIV remains the difference between concentrated and generalized epidemics. Which are fundamentally different and not because of prevalence, but rather because of who gets infected and how. For two long globally, we have pursued concentrated approaches in generalized epidemics, generalized solutions and concentrated ones. Or simply hedged our bets and done a bit of everything, everywhere.
If only we had heeded the core distinction between concentrated and generalized epidemics from the outset, we would have avoided numerous futile arguments about the A,B and C's and we would have averted a lot of wasted programming. At the global extremes, the distinctions between concentrated and generalized epidemics are starkly clear.
South and North America, Europe and the Middle East and Asia are and always will be concentrated epidemics. In contrast, much of Eastern and Southern Africa face highly generalized epidemics. Yet, large swages in between these two extremes are unresolved. Are for example, the Caribbean, West
Africa and parts of the Pacific, concentrated, low grade generalized or mixed epidemic. This really matters and unless we resolve it, we cannot program optimally.
The global move to know our epidemics which Mark introduced is extremely welcome. After all, it has enabled us to debate HIV prevention with greater vigor and boldness than ever before. But there are pitfalls that we can and must avoid. First and above all, we need to understand, but not over complicate, we could spend years painstakingly analyzing our epidemics and micro epidemics, but broad, bold, brush strokes are sufficient for effective, intelligent action.
And galvanized into intelligent actions, we can build and bolster our ships as we sail, without being deflected by endless analysis. So then instead, seeking to answer an overarching question, are our epidemics concentrated, generalized or mixed, and where in broad categories are our new infections, our emblematic last 1,000 infections occurring.
In sex work, among men having sex with men, and injecting drug use, or among adults with multiple partners. More specific answers can be distilled from and alongside well evaluated, large scale programs.
Second and related, modeling incident infections to better know our epidemics has an important role that must be used cautiously and must be carefully triangulated. After all the seductive graphs and spurious precision that they have produced are alluring, but potentially misleading, and simply reflect on how much of the edifus of our understanding of East Asian epidemics relies on models, not actual evidence.
Third, in many countries we have seen inclusive participatory consensual approaches to better know our epidemics and these are laudable, but they may compromise rigor if they inadvertently reintroduce this credited orthodoxies. After all, simple reflect how many decades it took us to learn that there is no simple direct association between education, income, gender and HIV.
Numerous DHS classes and other studies have shown us that better educated upper income adults in richer countries with greater gender equality have more, not less HIV. What we know for certain is that we can prevent HIV if we tackle its direct immediate causes, multiple, unprotected sexual partnerships. And nothing should deflect us from that call focus.
Fourth, in the crucible of Southern Africa's raging epidemics, epitomized by Swazi Land, Botswana, Lasutu in South Africa, with uniformly high HIV prevalence. Our central challenge is not to know our epidemics better, we understand them. They are fueled by multiple sexual partnerships in the
general population, but rather to ask ourselves how can we effect the fundamental changes in community norms and values required for behavior change?
Once we know our epidemics, in broad brush strokes, we can move to knowing our responses, but can we respond with proven approaches? The evidence to date as I suggest dispiriting. Simple consider concentrated epidemics driven familiar resources, sex work, men having sex with men and injecting drug use.
If we face concentrated epidemics driven by sex work, we know what to do in the real world end of scale. We know that programs promoting education, condoms, sexual health, solidarity, empowerment and rights can and have curved HIV in Asia's three sexually initiated epidemics. Thailand, Cambodia, and South and West India.
But, turning to men having sex with men, the picture in the developing world is much less encouraging. While we know that programs focusing on education, condoms, sexual health and rights can work, particularly in context sex conducive to programs for men having sex with men, such as India where the National Aids Authority has recently petition the Supreme Court to legalize homosexuality or in Napaul where the third gender is in a official legal category. Or, in much of Southeast Asia where attitudes towards transgender communities are tolerant.
But we also know that in un-conducive environments we have made little progress to protect men having sex with men. Simply consider the example of Egypt, where a recent ground breaking Sierra Survey of HIV prevalence in Alexandria simply led to the accelerated arrests and imprisonment of men having sex with men. Or consider Iran, when an estimated 4,000 men having sex with men have been executed since 1979.
And when we turn to injecting drug users, the picture is perhaps even starker. We can no longer keep saying that needless syringe programs and s substitution therapy work in the form of Soviet Union or Asia when we are no closer to implementing these programs at the population level required.
As Veteran Harm Reduction Specialist, Nick Kraft concluded in his recent Go a Harm Reduction Plenary, he no longer knows what to do to convince Asian Governments to promote harm reduction. Or as the Deputy Director of Indonesian's Bureau of Narcotics said to us, with exquisite job in these in these subtleties he was certain Indonesia would heed harm reduction advice if only it emanated from the United States Drug Enforcement Agency.
We are not the right voices and we do not have the ears of he right people if we are to reverse epidemics among injecting drug users.
Turning to generalized epidemics, we face three major challenges. First, many of our most trusted interventions, mass media, school and youth programs, condom social marketing, SCI care and BCT are at best and proven at worse disproven at the population level.
Second, the most effective HIV prevention intervention in the history of this epidemic, male circumcision, has scarcely advanced since the three trials ended with an erringly, identical results two years ago. Ask ourselves how many extra men in Eastern and Southern Africa have received this remarkable partial vaccine since the studies ended, limitably few and yet, the scope for action is enormous.
In seven of the eight highest prevalence countries globally, all in Southern Africa, less than 20-percent of all men are currently circumcised. And where we have seen HIV fall in generalized epidemics, it has been because of partner reduction in the general population and at population level.
We have seen this in country after country and yet, accept in early Uganda, these changes occurred largely in spite of, and not because of, formal programs. And so we know limitedly little about how to effect partner reduction that this should not weaken our resolve to invest in programs to promote partner reduction. Alongside studies to better understand how to achieve population level, partner reduction.
Turning briefly to the undetermined character of HIV transmission in the in determined epidemics of the Caribbean, West Africa, and the Pacific. If these epidemics are concentrated and due to sex work, we face the achievable objective of making sex work safe, which we know how to do. But if these are mixed, or low grade generalized epidemics we face a far, far harder challenge. How do we encourage countries such as the Taconga with an approximately 1-percent prevalence and numerous competing health and social challenges to invest in the fundamental, social and cultural change required for large scale population based change.
And this question poses a related challenge that I believe we can defer no longer. What is the proportionate AIDS response? HIV funding is vast, but largely concentrated in 15 to 20 countries in Eastern and Southern Africa. And in the crucible of Southern Africa's epidemics epitomized by Swazi
Land, Botswana, Lasuta, South Africa. The question is not whether we are distorting too much in favor of HIV programs, but whether we are actually distorting enough.
Simply consider Francistown, Botswana, where fully 70-percent of a household population survey of women age 30 to 34, were HIV positive. In that context how can we possibly distort too much? And yet, there are also in large bounds of countries in Eastern and West Africa with a much lower prevalence than in previously believed and numerous competing health challenges.
Where HIV receives a far greater share of the funding than, other major causes of disease burden. In these context, we have to reposition, and integrate
HIV in effective, well evaluated support of other health challenges. And paradoxically counter intuitively even, there are large number of lower and middle prevalence countries outside Eastern and Southern Africa where HIV maybe under funded. Consider the much stated example of Thailand, where HIV still contributes 14-percent of disease burden, and yet receives only 2-percent of recurrent health spending.
Or consider Indonesia, which has Asia's fastest growing HIV epidemic and in West Papua which it share with the Island of Papua New Guinea, the world's highest HIV epidemic outside Africa. And yet, HIV prevention funding maybe falling in Indonesia compromising vital programs.
In conclusion, let me reemphasize three key points. First, the move to know our epidemics is welcomed, but must not be overcomplicated. Broad, sturdy brush strokes are sufficient for decisive, intelligent action. Second, concentrated epidemics driven by sex work are imminently preventable, but protecting men who have sex with men and injecting drug users will require novel evidence, arguments, advocacy and allies. Our existing approaches simply are not working at the scale required.
And third, in generalized epidemics our core challenge is to reallocate priorities and resources away from the unproven or disproven approaches which currently predominate to the two proven that admittedly sensitive interventions that we do have, male circumcision and partner reduction.
So will we, in conclusion connectively have the courage not simply to abandon orthodoxies and entrenched interest, and accept the evidence that also the remorseless, unrelenting focus required to apply proven solutions at scale because that ultimately is what knowing our epidemics and knowing our responses must entail. Thank you.
