PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA

A SHARED RESPONSIBILITY

Committee on Envisioning a Strategy to Prepare for the Long-Term Burden of HIV/AIDS: African Needs and U.S. Interests

Board on Global Health

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA A SHARED RESPONSIBILITY Committee on Envisioning a Strategy to Prepare for the Long-Term Burden of HIV/AIDS: African Needs and U.S. Interests Board on Global Health

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by grants and contributions to the National Academy of Sciences from the Atlantic Philanthropies (Grant 3852); BD (Becton, Dickinson and Company) (Contribution 6387); the Bill & Melinda Gates Foundation (Grant 6445); the Carnegie Corporation of New York (Grant 6179); the Doris Duke Charitable Foundation (Grant 6143); the Ford Foundation (Grant 8407); the Institute of International Education (Grant 6456); Johnson & Johnson Services, Inc. (Grant 6346); Merck & Co., Inc. (Grant 6552); and Pfizer, Inc. (Grant 6336). The study also received in-kind support from the Rockefeller Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the orga - nizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-16018-6 International Standard Book Number-10: 0-309-16018-9 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2011. Preparing for the Future of HIV/ AIDS in Africa: A Shared Responsibility. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examina - tion of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON ENVISIONING A STRATEGY TO PREPARE FOR THE LONG-TERM BURDEN OF HIV/AIDS: AFRICAN NEEDS AND U.S. INTERESTS THOMAS C. QUINN (Co-Chair), Associate Director for International Research, National Institute of Allergies and Infectious Diseases/National Institutes of Health; Director, The Center for Global Health, Johns Hopkins University, Baltimore, MD DAVID SERWADDA (Co-Chair), Professor, School of Public Health, Makerere University, Kampala, Uganda SALIM S. ABDOOL KARIM, Pro Vice-Chancellor (Research), University of KwaZulu-Natal; Director, CAPRISA (Centre for the AIDS Programme of Research in South Africa); Professor in Clinical Epidemiology, Columbia University; Adjunct Professor in Medicine, Cornell University JENNIFER G. COOKE, Director, Africa Program, Center for Strategic and International Studies, Washington, DC AMABOO (AMES) DHAI, Director, Steve Biko Centre for Bioethics, University of the Witwatersrand, Johannesburg, South Africa GEOFFREY P. GARNETT, Professor of Microparasite Epidemiology, Imperial College London, London, England PETER NDUMBE, Dean, Faculty of Health Sciences, University of Buea, Buea, Cameroon FRANCIS OMASWA, Executive Director, African Center for Global Health & Social Transformation, Kampala, Uganda MEAD OVER, Senior Fellow, Center for Global Development, Washington, DC CARMEN PORTILLO, Professor and Chair, Department of Community Health Systems, University of California, San Francisco Schools of Nursing and Medicine, San Francisco, CA JESSICA E. PRICE, Technical Director, Africa Region, Family Health International, Nairobi, Kenya MARLA SALMON, The Robert G. and Jean A. Reid Endowed Dean in Nursing; Professor, Psychosocial and Community Health; Professor, Global Health, University of Washington School of Nursing, Seattle, WA Scholar-in-Residence ELENA O. NIGHTINGALE, Scholar-in-Residence, Institute of Medicine, National Academy of Sciences, Washington, DC v

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Consultants ROBERT BLACK, Chairman, Department of International Health; Edgar Berman Professor in International Health; Director, Institute for International Programs, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD LAWRENCE GOSTIN, Linda D. and Timothy J. O’Neill Professor of Global Health Law, Georgetown University Law Center, Washington, DC MARIA MERRITT, Assistant Professor, Department of International Health, Johns Hopkins University, Bloomberg School of Public Health and Berman Institute of Bioethics, Baltimore, MD Staff ELIZABETH HAYTMANEK, Program Officer PATRICIA CUFF, Senior Program Officer KATHLEEN OSTAPKOVICH, Research Associate (until August 2010) KENISHA PETERS, Research Assistant RACHEL PITTLUCK, Intern JULIE WILTSHIRE, Financial Associate PATRICK KELLEY, Director, Boards on Global Health and African Science Academy Development Editor RONA BRIERE vi

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evi - dence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Victor De Gruttola, Harvard University, Department of Biostatistics Mark Dybul, Georgetown University, O’Neill Institute for National and Global Health Law Jason Farley, School of Nursing, Department of Community Public Health Nursing, Johns Hopkins University; Faculty of Health Sciences, Division of Nursing, Stellenbosch University Barry Kistnasamy, National Institute for Occupational Health, South Africa Jimmy Kolker, UNICEF Joseph-Matthew Mfutso-Bengo, University of Malawi, College of Medicine Marjorie Opuni-Akuamoa, Johns Hopkins University, Bloomberg School of Public Health, Department of International Health Doreen Ramogola-Masire, Botswana-UPenn Partnership, Botswana Eleanor Ross, University of Witwatersrand, Department of Social Work, School of Human and Community Development vii

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viii REVIEWERS Susan Scrimshaw, The Sage Colleges Sten Vermund, Vanderbilt University Alan Whiteside, University of KwaZulu-Natal Catherine Wilfert, Elizabeth Glaser Pediatrics AIDS Foundation Ajume Wingo, University of Colorado at Boulder, Philosophy Department Although the reviewers listed above have provided many constructive com- ments and suggestions, they were not asked to endorse the conclusions or recom- mendations nor did they see the final draft of the report before its release. The review of this report was overseen by Ronald Brookmeyer, Professor, Department of Biostatistics, School of Public Health, University of California, Los Angeles; and William Holzemer, Dean and Professor, College of Nursing-Newark & New Brunswick, Rutgers, The State University of New Jersey. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Acknowledgments This report is a product of the cooperation and contributions of many people. The committee would like to thank all the speakers and moderators who par- ticipated in committee meetings and workshops, as well as others who provided information, input, and assistance. They include Patti Abbott, Lori Bollinger, Sue K. Brown, Elizabeth Bukusi, Kathy Cahill, Robin Crewe, Rosanne Diab, Robert Einterz, Robert Garris, Jenni Gillies, Eric Goosby, Wilfred Griekspoor, James Hakim, Mark Heywood, Joan Holloway, Leigh Johnson, Michael Johnson, Quarraisha Karim, Sylvester Kimaiyo, Surabhi Lal, Umesh Lalloo, Princeton Lyman, Morakeng Malatji, Stephen Mallinga, Leslie Mancuso, Joana Mangueira, Xola Mati, Tony Mbewu, Phakamile Truth Mngadi, Steve Morrison, Mbalawa Mugabe, Neal Nathanson, Laura Podio, Takalani Rambau, Danni Ramduth, Celicia Serenata, Darrell Singer, Papa Salif Sow, Devi Sridhar, Ruth Stark, Jeff Sturchio, Nthabiseng Taole, Leana Uys, Brian Williams, and David Wilson. This report would have not been possible without the generous financial contributions of the study’s sponsors: the Atlantic Philanthropies; BD (Becton, Dickinson and Company); the Bill & Melinda Gates Foundation; the Carnegie Corporation of New York; the Doris Duke Charitable Foundation; the Ford Foun- dation; the Institute of International Education; Johnson & Johnson Services, Inc.; Merck & Co., Inc; and Pfizer, Inc. The study also received in-kind support from the Rockefeller Foundation. ix

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Contents Summary 1 1 Introduction 15 2 The Future Impact of Current Decisions 22 3 The Burden of HIV/AIDS: Implications for U.S. Interests 42 4 The Burden of HIV/AIDS: Implications for African States and Societies 70 5 Strategies to Build Capacity for Prevention, Treatment, and Care of HIV/AIDS in Africa 106 6 Strategies to Ensure Ethical Decision-Making Capacity for HIV/AIDS: Policy and Programming in Africa 148 APPENDIXES A Projecting the Burden of HIV/AIDS 171 B Demographic Variation in the Epidemic 195 C Workshop Agendas 199 D Committee Member Biographical Sketches 208 xi

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