Among the study’s most interesting findings are how each
country’s HIV burden correlates with the reduction in DALYs lost to HIV since
AIDS deaths were at their peak. This peak may have happened anywhere between
1996, when antiretroviral therapy (ART) started becoming available in developed
countries, to last year.
Countries that have made large inroads into their AIDS burden
fall into two types: they are either high-income countries that controlled
their HIV burden early, or low-income countries with good ART programmes instituted more
recently. There are eight countries
where DALYs lost due to HIV have fallen by more than 80% from their peak, and they
are a mixed bag: Spain, France, Netherlands, New Zealand and Japan on the one
hand, and on the other hand Rwanda, Haiti and, top of the league with an 86.2%
reduction in DALYs lost to HIV, Cambodia.
The United Kingdom only does relatively well in this respect,
with a 63.5% fall in DALYs lost to HIV, not as large, for example, as the 75%
seen in the USA, Germany and Botswana. Other contrasting pairs include Ethiopia,
with a 68% fall in DALYs, compared with the countries on either side, Sudan and
Somalia, which have seen no fall.
The countries with the biggest number of HIV-related DALYs
lost also form a contrasting pair. In South Africa, with 11 billion DALYs lost
to HIV in 2010 (500 times as many as the UK), DALYs lost have fallen by 33%, which
is creditable given the daunting epidemic the country faces. In India they have
only fallen by 8.6%.
Next door to Cambodia is an example of a country where DALYs
lost to HIV have yet to fall – Vietnam, where HIV is the sixth most significant
cause of death and disability. Vietnam may be an example of a country where HIV
arrived quite late and is only now going through its phase of expansion: other
examples include the Philippines, Afghanistan, China and Pakistan. Most of
these countries are currently seeing rapid HIV prevalence increases in gay
men/MSM (men who have sex with men) or in people who inject drugs.
There are, however, a handful of countries where there has been
a significant HIV presence for some time but which have not succeeded in
bringing down AIDS deaths and HIV disability. As noted above, these include the
DRC, with a 2.7% fall in DALYs, Ukraine, with a 2% fall, Russia, with an 0.5%
fall and Indonesia, with no fall at all.
No doubt countries’ failure to address their HIV epidemics
have many reasons but two factors stand out: HIV treatment unsurprisingly lags
behind in countries recently torn apart by war (Sierra Leone and Liberia are
other examples), and also in countries where treatment does not get to high-prevalence
but highly stigmatised populations.
Gross economic inequality and corruption
may be a factor, too: HIV death and disability has fallen disproportionately little
in the oil-rich but extremely unequal states of Angola and Equatorial Guinea,
and the latter is the only country in the world where HIV is the number one
cause of death and disability but which has seen no fall in DALYs lost to HIV.
In Europe, economic decline may be a factor, with Portugal and Greece only
seeing relatively poor 29 and 33% declines in DALYs lost, compared to at least
twice that in their EU neighbours.
There is much good news in the report, however. One example is
Papua New Guinea, which a few years ago
was seeing such alarming rises in HIV prevalence it was being talked about as
the possible site of the first hyperepidemic of HIV outside Africa. In the last
few years, however, it has seen a 51% fall in HIV-related death and disability.
The world clearly has a long way to go before HIV is
extirpated. This report, however, offers clues, in the often unexpected contrasts
in success in fighting HIV between closely neighbouring countries, as to what
may hinder, and help, the fight against the virus.