Is AIDS still an emergency?

The rate of new HIV infections, which has fuelled the global HIV/AIDS epidemic since the 1980s, has peaked throughout the world and is now declining.

But population growth and the life-prolonging effects of antiretroviral (ARV) treatment mean that the total global number of HIV-infected people is likely to remain about the same for another two decades and will continue to increase in sub-Saharan Africa.

Based on these findings from the study, Has the HIV epidemic peaked?, published in the June issue of Population and Development Review, its lead author, John Bongaarts, believes it is time for the international community and governments to rethink their prioritisation of AIDS over other infectious diseases.

"AIDS has gotten special treatment because of its emergency status; that view is no longer valid because the epidemic has peaked," he told IRIN/PlusNews on the phone from the New York headquarters of the Population Council, an international non-governmental research organisation of which he is vice-president.

The study, which Bongaarts carried out with three demographers from the United Nations Population Division, examined the course HIV epidemics have taken in different regions and used mathematical models that combined population projections with data collected by UNAIDS to project the future demographic impact of HIV/AIDS.

The authors explain that peaks in HIV prevalence, which reflect the total number of people living with the virus, lag about a decade behind peaks in HIV incidence - the rate of new infections. This is because someone infected with HIV can live with the virus for about a decade after infection, and for much longer if they start ARV treatment.

Research showed that the global peak in HIV incidence occurred as long ago as 1995, with the first peak occurring in North America in the early 1980s, and the last in Eastern Europe in 2001. According to Bongaarts, this finding is not new, but it has been against the interests of agencies like UNAIDS to highlight it.

"I think UNAIDS was afraid that donors would decide not to spend so much money on AIDS and, secondly, that governments would say, 'this is no longer something to worry about'," he said. "My own feeling is that the amount that's devoted to AIDS treatment is out of proportion to other health problems."

His comments come on the heels of recent admissions by former senior UNAIDS and World Health Organisation officials that they exaggerated the size of the HIV epidemic and its potential for further growth to create public alarm and maintain the flow of donor money to the global industry that AIDS had spawned.

The backlash against global HIV expenditure started in February with an article in the British Medical Journal by Roger England of Health Systems Workshop, a health-policy charity, who pointed out that AIDS receives about a quarter of global health aid but constitutes only five percent of the disease burden in low- and middle-income countries.

Speaking to IRIN/PlusNews, Bongaarts agreed with England's argument that more lives could be saved by investing in strengthening health systems and combating other diseases with inexpensive interventions like immunisations, mosquito nets and family planning.

"AIDS should now be treated like any other disease, and the world community should look at its investments in health and prepare the most cost-effective interventions," he said. "I'm not advocating less money for AIDS treatment, but I want more spent on AIDS prevention and other diseases. We can save lives for a few dollars."

What is new about the Population Council study are the predictions it makes about the future demographic implications of the HIV epidemic. According to the authors, the presence of AIDS will not prevent populations from increasing. Even in sub-Saharan Africa, where the death toll from AIDS will continue to be high, the population is expected to grow by one billion between 2005 and 2050.

However, AIDS will slow population growth in the worst-hit countries: in South Africa, for example, the population size by 2050 is projected to be 29 percent lower than it would have been without the presence of AIDS. - PLUSNEWS

ifp

Estimating incidence from prevalence in generalised HIV epidemics:
Methods and validation
PLoS Medicine. 2008 Apr;5(4):e80.
Hallett TB | Zaba B | Todd J | Lopman B | Mwita W
HIV surveillance of generalised epidemics in Africa primarily relies on prevalence at antenatal clinics, but estimates of incidence in the general population would be more useful. Repeated cross-sectional measures of HIV prevalence are now becoming available for general populations in many countries, and we aim to develop and validate methods that use these data to estimate HIV incidence. Two methods were developed that decompose observed changes in prevalence between two serosurveys into the contributions of new infections and mortality. Method 1 uses cohort mortality rates, and method 2 uses information on survival after infection. The performance of these two methods was assessed using simulated data from a mathematical model and actual data from three community-based cohort studies in Africa. Comparison with simulated data indicated that these methods can accurately estimates incidence rates and changes in incidence in a variety of epidemic conditions. Method 1 is simple to implement but relies on locally appropriate mortality data, whilst method 2 can make use of the same survival distribution in a wide range of scenarios. The estimates from both methods are within the 95% confidence intervals of almost all actual measurements of HIV incidence in adults and young people, and the patterns of incidence over age are correctly captured. It is possible to estimate incidence from cross-sectional prevalence data with sufficient accuracy to monitor the HIV epidemic. Although these methods will theoretically work in any context, we have able to test them only in southern and eastern Africa, where HIV epidemics are mature and generalised. The choice of method will depend on the local availability of HIV mortality data.

compatibility

Comparability of contraceptive prevalence estimates for women from the 2002 Behavioral Risk Factor Surveillance System
http://www.publichealthreports.org/archives/issuecontents.cfm?Volume=123&Issue=2
Public Health Reports. 2008 Mar-Apr;123(2):147-154.
Santelli J | Lindberg LD | Finer LB | Rickert VI | Bensyl D | Posner S | Makleff S | Kost K | Singh S

This article assesses the comparability of contraceptive use estimates for adult women obtained from the 2002 Behavioral Risk Factor Surveillance System (BRFSS), using the 2002 National Survey of Family Growth (NSFG) as a benchmark. The 2002 BRFSS uses data collection methods that are considerably different from the NSFG. We compared demographic differences and national estimates of current contraceptive methods being used and reasons for nonuse. Variables were recoded in the BRFSS and NSFG systems to make the two samples comparable. Women in the NSFG and BRFSS were similar in age and race/ethnicity. Compared with the NSFG, the BRFSS sample was more educated and of higher income, less likely to be cohabiting, and more likely to be married. After adjusting for differences in the coding of hysterectomy, many BRFSS estimates for current contraceptive use were statistically similar to those
from the NSFG. Small but statistically significant differences were found for vasectomy (7.7% and 6.3%), the pill (21.9% and 19.6%), rhythm (1.5% and 1.0%), the diaphragm (0.5% and 0.2%), and withdrawal (0.3% and 2.7%) for the BRFSS and NSFG, respectively. Major reasons for nonuse were similar: seeking pregnancy and currently pregnant. The percentage of women who were not currently sexually active was higher in the BRFSS (16.0%) compared with the NSFG (12.5%). The BRFSS is a useful source of population-based data on contraceptive use for reproductive health program planning; however, planners should be cognizant that lower-income women are not fully represented in telephone surveys.