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Can the UNAIDS modes of transmission model be improved? A comparison of the original and revised model projections using data from a setting in west Africa.
AIDS. 2013 Oct 23; 27(16):2623-35.OBJECTIVE: The UNAIDS modes of transmission model (MoT) is a user-friendly model, developed to predict the distribution of new HIV infections among different subgroups. The model has been used in 29 countries to guide interventions. However, there is the risk that the simplifications inherent in the MoT produce misleading findings. Using input data from Nigeria, we compare projections from the MoT with those from a revised model that incorporates additional heterogeneity. METHODS: We revised the MoT to explicitly incorporate brothel and street-based sex-work, transactional sex, and HIV-discordant couples. Both models were parameterized using behavioural and epidemiological data from Cross River State, Nigeria. Model projections were compared, and the robustness of the revised model projections to different model assumptions, was investigated. RESULTS: The original MoT predicts 21% of new infections occur in most-at-risk-populations (MARPs), compared with 45% (40-75%, 95% Crl) once additional heterogeneity and updated parameterization is incorporated. Discordant couples, a subgroup previously not explicitly modelled, are predicted to contribute a third of new HIV infections. In addition, the new findings suggest that women engaging in transactional sex may be an important but previously less recognized risk group, with 16% of infections occurring in this subgroup. CONCLUSION: The MoT is an accessible model that can inform intervention priorities. However, the current model may be potentially misleading, with our comparisons in Nigeria suggesting that the model lacks resolution, making it challenging for the user to correctly interpret the nature of the epidemic. Our findings highlight the need for a formal review of the MoT.
Sexually Transmitted Infections. 2010 Dec; 86 Suppl 2:ii93-9.BACKGROUND: Every 2 years, the Joint United Nations Programme on HIV/AIDS (UNAIDS) produces probabilistic estimates and projections of HIV prevalence rates for countries with generalised HIV/AIDS epidemics. To do this they use a simple epidemiological model and data from antenatal clinics and household surveys. The estimates are made using the Bayesian melding method, implemented by the incremental mixture importance sampling technique. This methodology is referred to as the 'estimation and projection package (EPP) model'. This has worked well for estimating and projecting prevalence in most countries. However, there has recently been an 'uptick' in prevalence in Uganda after a long sustained decline, which the EPP model does not predict. METHODS: To address this problem, a modification of the EPP model, called the 'r stochastic model' is proposed, in which the infection rate is allowed to vary randomly in time and is applied to the entire non-infected population. RESULTS: The resulting method yielded similar estimates of past prevalence to the EPP model for four countries and also similar median ('best') projections, but produced prediction intervals whose widths increased over time and that allowed for the possibility of an uptick after a decline. This seems more realistic given the recent Ugandan experience.
Journal of the European Economic Association. 2012 Oct; 10(5):1025-1058.This paper estimates whether exports affect the incidence of HIV in Africa. This relationship has implications for HIV prevention policy as well as for the consequences of trade increases in Africa. I estimate this impact using two sources of data on HIV incidence, one generated based on UNAIDS estimates and the other based on observed HIV mortality. These data are combined with data on export value and volume. I find a fairly consistent positive relationship between exports and new HIV infections: doubling exports leads to a 10%-70% increase in new HIV infections. Consistent with theory, this relationship is larger in areas with higher baseline HIV prevalence. I interpret the result as suggesting that increased exports increase the movement of people (trucking), which increases sexual contacts. Consistent with this interpretation, the effect is larger for export growth than for income growth per se and is larger in areas with more extensive road networks.
Geneva, Switzerland, UNAIDS, 2011 Aug.  p. (UNAIDS/ JC2112E)This report shows that these global commitments will be achieved only if the unique needs of young women and men are acknowledged, and their human rights fulfilled, respected, and protected. In order to reduce new HIV infections among young people, achieve the broader equity goals set out in the MDGs, and begin to reverse the overall HIV epidemic, HIV prevention and treatment efforts must be tailored to the specific needs of young people.
Sexually Transmitted Infections. 2008; 84(Suppl 1):i1-i4.This introductory article refers to the journal supplement that assembles important new data relating to several assumptions used for the new HIV and AIDS estimates. The collection of methodological papers in the supplement, aim to provide easy access to the scientific basis underlying the latest HIV and AIDS estimates for 2007.
Geneva, Switzerland, UNAIDS, . 13 p.For over 25 years, our world has been living with HIV. And in just this short time, AIDS has become one of the make-or-break global crises of our age, undermining not just the health prospects of entire societies but also their ability to reduce poverty, promote development, and maintain national security. And in too many regions AIDS continues to expand - every single day 11 000 people are newly infected with HIV, and nearly 8 000 people die from AIDS-related illnesses. Yet, despite the magnitude of the AIDS crisis, today we are at a time of great hope and great opportunity to get ahead of the epidemic. Our crisis-response tactics have led to real progress against AIDS. Funding for efforts against AIDS has risen from 'millions' to 'billions' in just a decade. Political commitment and leadership on AIDS is higher than ever before. In more and more countries - including some of the world's poorest - we are seeing real results in terms of lives saved because effective HIV prevention and treatment programmes are being made widely available. Leaders of both developing and rich countries have now committed themselves to working together so as to get close to universal access to HIV prevention, treatment, care and support by 2010 - a critical stepping stone to halting the epidemic by 2015, as set out in the Millennium Development Goals. (excerpt)
Geneva, Switzerland, UNAIDS, 2007 Dec. 50 p. (UNAIDS/07.27E; JC1322E)Every day, over 6800 persons become infected with HIV and over 5700 persons die from AIDS, mostly because of inadequate access to HIV prevention and treatment services. The HIV pandemic remains the most serious of infectious disease challenges to public health. Nonetheless, the current epidemiologic assessment has encouraging elements since it suggests: the global prevalence of HIV infection (percentage of persons infected with HIV) is remaining at the same level, although the global number of persons living with HIV is increasing because of ongoing accumulation of new infections with longer survival times, measured over a continuously growing general population; there are localized reductions in prevalence in specific countries; a reduction in HIV-associated deaths, partly attributable to the recent scaling up of treatment access; and a reduction in the number of annual new HIV infections globally. Examination of global and regional trends suggests the pandemic has formed two broad patterns: generalized epidemics sustained in the general populations of many sub-Saharan African countries, especially in the southern part of the continent; and epidemics in the rest of the world that are primarily concentrated among populations most at risk, such as men who have sex with men, injecting drug users, sex workers and their sexual partners. (excerpt)
Geneva, Switzerland, UNAIDS, 2007.  p. (UNAIDS/07.07E; JC1274E)These Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access are designed to provide policy makers and planners with practical guidance to tailor their national HIV prevention response so that they respond to the epidemic dynamics and social context of the country and populations who remain most vulnerable to and at risk of HIV infection. They have been developed in consultation with the UNAIDS cosponsors, international collaborating partners, government, civil society leaders and other experts. They build on Intensifying HIV Prevention: UNAIDS Policy Position Paper and the UNAIDS Action Plan on Intensifying HIV Prevention. In 2006, governments committed themselves to scaling up HIV prevention and treatment responses to ensure universal access by 2010. While in the past five years treatment access has expanded rapidly, the number of new HIV infections has not decreased - estimated at 4.3 (3.6-6.6) million in 2006 - with many people unable to access prevention services to prevent HIV infection. These Guidelines recognize that to sustain the advances in antiretroviral treatment and to ensure true universal access requires that prevention services be scaled up simultaneously with treatment. (excerpt)
Journal of Infectious Diseases. 2007 Aug 15; 196 Suppl 1:S5-S14.Tuberculosis (TB) and human immunodeficiency virus (HIV) infection make each other's control significantly more difficult. Coordination in addressing this "cursed duet" is insufficient at both global and national levels. However, global policy for TB/HIV coordination has been set, and there is consensus around this policy from both the TB and HIV control communities. The policy aims to provide all necessary care for the prevention and management of HIV-associated TB, but its implementation is hindered by real technical difficulties and shortages of resources. All major global-level institutions involved in HIV care and prevention must include TB control as part of their corporate policy. Country-level decision makers need to work together to expand both TB and HIV services, and civil society and community representatives need to hold those responsible accountable for their delivery. The TB and HIV communities should join forces to address the health-sector weaknesses that confront them both. (author's)
PLoS Medicine. 2007 Jan; 4(1):e44.The HIV/AIDS area has always been highly politically and emotionally charged, and we wrote a controversial and provocative piece. Most of the responses to it were unreasoned. The most cogent response came from UNAIDS (the Joint United Nations Programme on HIV/AIDS), and it generally restated an already well articulated position. We disagree with a number of the points for the reasons discussed in our original essay, and applaud one point. First, a brief restatement of our argument is warranted. There is good evidence that HIV-related stigma adversely affects the lives of people living with HIV/AIDS. There is little or no evidence, however, to support the notion that HIV-related stigma is one of the determinants of the global HIV epidemic. Furthermore, an argument could be made for why stigma might slow or contain the spread of infection in the general population. Given the very different effect the two positions would have on policy and the significance of the HIV epidemic, they deserve investigation. Among epidemiologists, two competing hypotheses, for which there is no strong evidence either way, would constitute a position of equipoise. (excerpt)
PLoS Medicine. 2007 Jan; 4(1):e51.In their essay "HIV, Stigma, and Rates of Infection: A Rumour without Evidence", Daniel Reidpath and Kit Yee Chan rightly underscore the insufficient body of research on the relationship between stigma and discrimination and HIV transmission . Increased scientific attention and effective programming against stigma and discrimination are both sorely needed. But the Joint United Nations Programme on HIV/AIDS (UNAIDS) does not accept a number of points made in the essay. Discrimination based on health status, including HIV, is a human rights violation, and stigma is the social form of this violation. HIV stigma and discrimination are wrong in and of themselves, and should be stopped for that reason alone. Reidpath and Chan suggest, as "an alternative hypothesis to the UNAIDS position", that stigma against certain groups, including people living with HIV, may have a public health value because it "could reduce opportunities for contact between high- and low-risk groups". UNAIDS cannot endorse a hypothesis that bases a public health goal on a human rights violation; nor do we believe it is either right, or necessary, to pit the public health against human rights. (excerpt)
Reaching regional consensus on improved behavioural and serosurveillance for HIV: report from a regional conference in East Africa.
Geneva, Switzerland, Joint United Nations Programme on HIV / AIDS [UNAIDS], 1998. 12 p. (UNAIDS Best Practice Collection. Key Material; UNAIDS/98.9)This report documents a regional workshop on surveillance systems for HIV held in Nairobi, Kenya, on 10.13 February 1997. The UNAIDS-funded workshop gathered government epidemiologists, AIDS programme managers, and social scientists from Kenya, Malawi, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe as well as specialists from UNAIDS and other partner institutions. The group aimed to present current data and to work together to suggest practical guidelines for improving HIV surveillance systems in a maturing epidemic. (excerpt)
Geneva, Switzerland, UNAIDS, 1997 Oct. 7 p. (UNAIDS Best Practice Collection; UNAIDS Point of View)The TB germ, a bacterium called Mycobacterium tuberculosis, is highly prevalent in much of the developing world and in poor urban "pockets" of industrialized countries. In these communities, people typically become infected in childhood. But a healthy immune system usually keeps the infection in check. People can remain infected for life with dormant, uninfectious TB. Such people are called TB carriers. In the past, most TB- infected people remained healthy carriers. Only 5-10% ever developed active tuberculosis. Those few kept the TB epidemic alive by transmitting the TB germ to their close contacts. TB germs can be spread through the air from patients with active pulmonary (lung) tuberculosis. Today, as TB carriers increasingly become infected with HIV, many more are developing active tuberculosis because the virus is destroying their immune system. For these dually infected people, the risk of developing active tuberculosis is 30-50-fold higher than for people infected with TB alone. (excerpt)
Geneva, Switzerland, UNAIDS, 2000 Jul. 47 p. (UNAIDS Best Practice Collection. Key Material; UNAIDS/00.28E)Surveillance is the radar of public health. Nevertheless, its precise contours and justifications remain a matter of contention. Although the World Health Organization (WHO) Epidemiological Surveillance Unit in the Division of Communicable Diseases has defined disease surveillance quite broadly, most public health authorities, such as the United States Centers for Disease Prevention and Control (CDC) and the World Health Assembly, typically identify three key elements of surveillance. Surveillance involves the ongoing, systematic collection of health data, the evaluation and interpretation of these data for the purpose of shaping public health practice and outcomes, and the prompt dissemination of the results to those responsible for disease prevention and control. Surveillance, then, encompasses more than just disease reporting. "The critical challenge in public health surveillance today," conclude two prominent figures who have helped to define surveillance in the United States, "remains the ensurance of its usefulness." Two issues emerge from this understanding of surveillance. The first entails a question of efficacy. The second involves matters of privacy. Although conceptually distinct, the two are nevertheless intimately related. While the necessities of surveillance may justifiably limit some elements of privacy, such limitations are only justifiable to the extent that they in fact benefit the public's health. (excerpt)
Geneva, Switzerland, UNAIDS, 2005 Dec.  p. (UNAIDS/05.19E)Acquired Immunodeficiency Syndrome (AIDS) has killed more than 25 million people since it was first recognized in 1981, making it one of the most destructive epidemics in recorded history. Despite recent, improved access to antiretroviral treatment and care in many regions of the world, the AIDS epidemic claimed 3.1 million [2.8--3.6 million] lives in 2005; more than half a million (570 000) were children. The total number of people living with the human immunodeficiency virus (HIV) reached its highest level: an estimated 40.3 million [36.7--45.3 million] people are now living with HIV. Close to 5 million people were newly infected with the virus in 2005. There is ample evidence that HIV does yield to determined and concerted interventions. Sustained efforts in diverse settings have helped bring about decreases in HIV incidence among men who have sex with men in many Western countries, among young people in Uganda, among sex workers and their clients in Thailand and Cambodia, and among injecting drug users in Spain and Brazil. Now there is new evidence that prevention programmes initiated some time ago are finally helping to bring down HIV prevalence in Kenya and Zimbabwe, as well as in urban Haiti. The number of people living with HIV has increased in all but one region in the past two years. In the Caribbean, the second-most affected region in the world, HIV prevalence overall showed no change in 2005, compared with 2003. (excerpt)
AIDS Bulletin. 2005 Jun; 14(2):3-4.What we do now and how we choose to do it will affect Africa’s future and future generations. It seems a clear and obvious truism – yet not always one easy to live by in a world of instant need and gratification. UNAIDS has recently released a new report entitled AIDS in Africa: Three scenarios to 2025 which sketches three very different scenarios for AIDS in Africa and points out that our actions today determine our future tomorrow in terms of this epidemic and our continent. UNAIDS is quick to point out that the scenarios are not predictions rather they are stories about our possible futures and how the epidemic may develop. The aim is to highlight the various choices that will face African governments and societies in the coming decades, and to unpack the many broader factors that fuel the epidemic and examine how these interact. What is very stark is that depending on our actions today up to 43 million infections could be averted over the next 20 years – roughly equal to the population of South Africa. The report faces up the reality that the death toll will rise no matter what, but it is still possible to influence how much it rises. The scenarios, presented as stories, were developed by a team of people over a two-year period and involved collaboration with the African Union, the African Development Bank, the UN Economic Commission for Africa, the United Nations Development Programme, the World Bank and Royal Dutch Shell. They look at the possible course of the epidemic by 2025 when “no one under the age of 50 will remember a time without AIDS”. The stories are intended to be provocative and to stimulate debate and thus more informed decision making. (excerpt)
Bangkok, Thailand, UNAIDS, Asia Pacific Intercountry Team, 2000 Oct. 236 p.Drug use in Asian countries continues to increase and new and ever more hazardous and harmful drug use patterns are continuing to emerge. Many use multiple substances, inject in preference to smoking, ‘chasing’ or snorting, share needles, syringes, drug paraphernalia and drug solutions and preparations indiscriminately, and use alcohol and other psychoactive drugs excessively. These drug use behaviours occur in the context of countries in Asia, which are highly affected by HIV/AIDS. The present study was commissioned by the UNAIDS Asia Pacific Inter-country Team, Bangkok, to follow upon the report ‘Situation Assessment of Injecting Drug use in South East and East Asia in the context of HIV’ which was conducted by the Asian Harm Reduction Network (AHRN) in 1997. The situation assessment indicated that urgent action is needed to reduce the transmission of HIV/AIDS among drug users and their sexual partners. (excerpt)
VIDAS. 1999 Jan; 2(12):5-8.According to the most recent estimates of the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO), at the end of 1998 the number of people living with HIV (the virus that causes AIDS) will have grown to 33.4 million, 10% more than just a year earlier. The epidemic has not been controlled anywhere. In practically all countries of the world, new infections occurred in 1998. (excerpt)
[90 percent cases of HIV transmission are due to perinatal contagion or breastfeeding. One million children were HIV positive in 1977] El 90 por ciento de casos por contagio perinatal o lactancia. Un millon de niños/as portan VIH en 1977.
RedAda. 1997 Dec; (26):22-24.A million children under 15 years of age will have contracted HIV worldwide by 1997, while in 1996, of the one and a half million people who died of this disease, 350,000 were under 15, according to UNAID numbers released on the occasion of the world AIDS campaign (December 1), whose theme this year is "Children in a World with AIDS." Approximately 90 percent of children with HIV were infected by their mothers, during pregnancy or childbirth or through mother's milk, according to the UN organization. (excerpt)
Emerging Infectious Diseases. 2004 Nov; 10(11):1979-1983.The mechanisms, techniques, and data sources used to monitor and evaluate global AIDS prevention and treatment services may vary according to gender. The Joint United Nations Programme on HIV/AIDS has been charged with tracking the response to the pandemic by using a set of indicators developed as part of the Declaration of Commitment endorsed at the U.N. General Assembly Special Session on AIDS in 2001. Statistics on prevalence and incidence indicate that the pandemic has increasingly affected women during the past decade. Women’s biologic, cultural, economic, and social status can increase their likelihood of becoming infected with HIV. Since 2000, global financial resources have increased to allow expansion of both prevention and treatment services through a number of new initiatives, such as the Global Fund to Fight AIDS, TB and Malaria; the U.S. President’s Emergency Plan for AIDS Relief; and the World Bank MAP program. Programs should be monitored and evaluated to ensure these investments are used to maximum effect. Different types of data should be included when assessing the status of the HIV/AIDS epidemic and effectiveness of the response. Each of these “data streams” provides information to enhance program planning and implementation. (excerpt)
Trends in antenatal human immunodeficiency virus prevalence in western Kenya and eastern Uganda: evidence of differences in health policies?
International Journal of Epidemiology. 2004 Jun; 33(3):542-548.The objective was to observe recent trends in human immunodeficiency virus (HIV) prevalence in antenatal clinic attendees to determine if previously noted falls in HIV prevalence are occurring on both sides of the Kenyan-Ugandan border. An ecologic study was conducted at the district level comparing HIV prevalence rates over time using data available through reports published by the Kenyan and Ugandan Ministries of Health and UNAIDS. Sentinel sites were compared with respect to population, ethnicity, language group, and the prevalence of circumcision practice. The prevalence of HIV found at each sentinel site was recorded for the years 1990–2000 and analysed visually and by conducting bivariate correlations. Ethnographic analysis revealed a wide mix of ethnic and language groups and circumcision rates on both sides of the border. All sentinel surveillance sites in Uganda showed trends towards decreasing HIV prevalence, with three of five sites showing statistically significant declines (r = -0.87, -0.85, -0.86, P <0.05). In contrast, all of the surveillance sites in Kenya showed trends toward increasing HIV prevalence, with two of the five sites showing statistically significant increases (r = 0.62, 0.84, P <0.05). The declines in HIV prevalence occurring in Uganda are not being seen in geographically proximal districts of Kenya. No obvious differences in ethnic groupings or their associated prevalence of circumcision appeared to explain these differences. This suggests that decreasing HIV prevalence in Uganda is not due to the natural course of the epidemic but reflects real success in terms of HIV control policies. (author's)
Geneva, Switzerland, WHO, 2004. 60 p.By tracking the past course of the HIV/AIDS epidemic, warning of possible future spread and measuring changes in infection and behaviour over time, second- generation surveillance is designed to produce information that is useful in planning and evaluating HIV/AIDS prevention and care activities over time. This objective has been met in many countries, where useful, high-quality data are now available. Nevertheless, a gap remains between the collection of useful data and the actual use of these data to reduce people's exposure to HIV infection and to improve the lives of those infected. More effort has been put into improving the quality of data collection than into ensuring the appropriate use of data. Collecting high-quality data is an important prerequisite to using them well, but why are available data not used better? One reason is that surveillance systems are often fragmented. This means that many departments or groups are responsible for various aspects of data collection. Each considers its job done after it has held its own "dissemination workshop". No single entity is responsible for compiling all the data, analysing them and presenting them as a cohesive whole. Further, very few countries budget adequately for analysing, presenting and using data, either the financial or human resources. When financial resources are allocated, people often underestimate the skills and time required to use data well. Many surveillance officials responding to an informal WHO/UNAIDS survey gave one final reason: they simply do not know how to use the data. This is hardly surprising: most people responsible for surveillance systems are physicians and public health professionals who are good at interpreting trends in disease but who have limited training in the different ways HIV surveillance data can be used to improve programming, measure the success of prevention, lobby for policy change and engage affected communities in the response. This publication aims to provide guidance in these areas. It discusses the three major areas of data use: programme planning, programme monitoring and evaluation and advocacy, giving examples of how data can be used effectively in these contexts. The publication concentrates on the mechanics of using data: not just what can be done with data but how it can be done. How can data be packaged for different audiences? Who should be involved in dissemination? What makes a good press release? What steps are required to produce a national report? Practical guidance is given on how to develop interesting and persuasive presentations and how to present data effectively. Suggestions are made for bringing together programme planning and advocacy. Different countries have different epidemics, different surveillance systems and different data use needs. It is hoped, however, that all countries can find some general principles that will provide pointers on how to improve performance in areas of data use relevant to them. (excerpt)
Progress towards implementation of the Declaration of Commitment on HIV/AIDS. Report of the Secretary-General.
New York, New York, United Nations, General Assembly, 2003 Jul 25. 21 p. (A/58/184)The present report is submitted pursuant to paragraph 100 of the Declaration of Commitment on HIV/AIDS (General Assembly resolution S-26/2, annex), adopted by the Assembly at its special session on the human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) on 27 June 2001. The year 2003 is especially significant since it is the year in which the first of the time-bound targets set out in the Declaration of Commitment fall due. The majority targets in 2003 pertain to the establishment of an enabling policy environment, which set the stage for the programme and impact targets of 2005 and 2010. The report is based primarily on responses provided by 100 Member States on 18 global and national indicators developed by the Joint United Nations Programme on AIDS to measure progress towards implementation of the Declaration. The regional breakdown of States that responded is as follows: sub-Saharan Africa — 29; Asia and the Pacific — 15; Latin America and the Caribbean — 21; Eastern Europe and Central Asia — 13; North Africa and the Middle East — 8; high-income countries — 14. Virtually all heavily affected countries provided information relating to policy issues addressed by the indicators. The activities cited in the report are intended to be illustrative and not a comprehensive listing of all activities that have been undertaken in order to implement the Declaration. (excerpt)
Lancet. 2003 Sep 13; 362(9387):879.In a damning indictment of China’s efforts to control the spread of HIV/AIDS, an international human rights organisation has accused the country’s central and local authorities of a cover-up that fosters discrimination, prevents adequate treatment, and threatens to worsen what is already one of the world’s largest outbreaks of the disease. (excerpt)
AIDS Alert. 2003 Feb; 18(2):22.HIV prevention continues to offer the world's best hope in stopping the AIDS epidemic, and recent success stories in South Africa and Uganda prove that these work, according to the recent AIDS Epidemic Update report by UNAIDS and the World Health Organization (WHO) in Geneva, Switzerland. (excerpt)