HIV Analysis

Comparative Background Analysis of HIV/AIDS in the United States, Turkey, and Malawi Katharine Yang [26 April 2013]

Haseki Research and Training Hospital in Istanbul, Turkey, which cares for over 350 HIV patients Photo by Katharine Yang

President Barack Obama, World AIDS Day. 1 Dec 2011. http://www.whitehouse.gov/administration/eop/onap

HIV Orphans in Lilongwe, Malawi. 4 May 2006. http://www.flickr.com/photos/khym54/145558686/

Created for Global Urban Lab Rice University: School of Social Sciences & Kinder Institute for Urban Research

Table of Contents

Table of Contents.......................................................................................................................................... 1 Executive Summary....................................................................................................................................... 2 Report ...........................................................................................................................................................3 The Issue ...................................................................................................................................................3 The Research............................................................................................................................................. 3 The Findings .............................................................................................................................................. 4 Prevalence............................................................................................................................................. 4 Incidence ...............................................................................................................................................6 Modes of Transmission .........................................................................................................................7 Regions of HIV Concentration...............................................................................................................8 Cost of Care........................................................................................................................................... 9 Conclusions and Implications....................................................................................................................9 Malawi...................................................................................................................................................9 Turkey .................................................................................................................................................10 United States.......................................................................................................................................11 Concluding Thoughts ..........................................................................................................................12 Acknowledgements.....................................................................................................................................13 Bibliography ................................................................................................................................................14

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Executive Summary HIV/AIDS is a worldwide pandemic that, as of 2009, has caused almost 30 million deaths. It continues to spread internationally at a rapid rate. In this study, I focus on HIV/AIDS in three countries—the United States, Turkey and Malawi and find significant differences in the prevalence rates, incidence, and modes of transmission in these countries. Adult prevalence rates are up to 11% in Malawi, compared to 0.6% and 0.1% in the U.S. and Turkey, respectively. In the US, the predominant mode of transmission is homosexual relationships, whereas in Turkey and Malawi, heterosexual relationships account for the majority of new cases per year. In light of these results, I discuss verified and speculative reasons behind the differences and conclude that the overall most effective method to mitigate the spread of HIV/AIDS is further awareness through education. Further research is necessary to devise specific plans for addressing HIV/AIDS in each country.

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Report I.

The Issue

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a worldwide pandemic that, as of 2009, has caused almost 30 million deaths, and continues to spread internationally at a rapid rate. Aside from just affecting the health of its victims, HIV/AIDS impacts the quality of life, the ability to find employment, as well as the economic factors of a country—such as its GDP, employment rate, and poverty level. Evaluating trends in prevalence (number of existing cases per population per year) and incidence (number of new cases per population per year) over time in countries with HIV/AIDS is important in understanding the reasons behind the spread and to address needs for elimination of the disease.

However, the method of addressing HIV/AIDS is different for every country based on its specific economic circumstances, culture, and government policy. According to the World Systems Theory, there are 3 categories of countries—core countries, which are industrialized capitalist countries that control the global market, periphery countries, which are receive a small share of global health and depend on core and semiperiphery countries, and semiperiphery countries which are countries that fall between core and periphery and are becoming more industrialized. For this study, I am interested in comparing HIV presence, mode of transmission, and vulnerable populations for one country of each category, and for this reason, I have selected the United States, Turkey, and Malawi. Doing so can provide clues as to how HIV prevention efforts should be tailored to countries of these different categories.

II.

The Research

Adult HIV Prevalence rates from the US, Turkey, and Malawi were collected from the CIA World Factbooks 1999, 2001, 2003, 2007, and 2009. The data of estimated number of adults and children living with HIV was collected from the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2011 Global HIV/AIDS Report. Statistics on the number of new cases of HIV in each country were collected from the UNAIDS, the Centralized Information System for Infectious Diseases (CISID), a part of the World Health Organization (WHO) that is responsible for collecting statistics for European countries, and the Center of Disease Control (CDC), a part of the Department of Health and Human Services in the United States.

Research conducted on the common modes of transmission in the three countries were collected from the CDC for the United States, and from public health literature for Malawi, and from literature research and in-person interviews conducted with Dr. Pınar Ay, MD, a public health physician at the Marmara University of Medicine, and Dr. Hayat Kumbasar Karaosmanoğlu, MD, an infectious diseases physician at the Haseki Training and Research Hospital in Istanbul, for Turkey.

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III.

The Findings

Population HIV/AIDS is a problem in the United States, Turkey, and Malawi. But in order to understand the scope of the problem in each country, it is important to consider their respective populations. As depicted by Figure 1, the United States has a population of 313,232,044, Turkey, a population of 78,785,548, and Malawi, a population of 15,879,252, as of July 2011 (National Foreign Assessment Center (U.S.) and United States. Central Intelligence Agency.)

Population in the US, Turkey, and Malawi 350

Population (millions)

300 250 200 150 100 50 0 US

Turkey

M alawi

Country

Figure 1. Populations of US, Turkey, and Malawi

Prevalence The prevalence rates of adult HIV/AIDS in the United States, Turkey, and Malawi are displayed in Figure 2. Though Malawi has the smallest population of the three countries, its prevalence has consistently been higher than those of the United States and Turkey, with a rate of 16% in 1999, which has steadily decreased to 11% in 2009, due to large efforts internally and from international humanitarian aid ("Global Report: Unaids Report on the Global Aids Epidemic 2012"). The United States and Turkey, on the other hand, have remained relatively steady at a prevalence rate of 0.6% and 0.1%, respectively, from 1999 to 2009 (National Foreign Assessment Center (U.S.) and United States. Central Intelligence Agency.).

From Figure 2, it can be seen that Malawi’s prevalence is more than ten fold greater than the US’s prevalence, and more than 100 fold greater than Turkey’s prevalence. As a result, HIV/AIDS is a much more urgent problem in Malawi than in the United States or Turkey.

With a HIV prevalence of about 0.6%, the United States still stands with 6 fold greater HIV prevalence than Turkey, which has a prevalence of less than 0.1%. Most Turkish people do not think HIV is of much concern and do not think it needs to be addressed.

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HIV/AIDS Adult Prevalence Rate 18 16 14 Malawi

Percentage

12

Turkey 10

US Linear (Malawi)

8

Linear (US ) 6

Linear (Turkey)

4 2 0 1998

2000

2002

2004

2006

2008

2010

Year

Figure 2. HIV/AIDS Adult Prevalence rate in the U.S., Turkey, and Malawi from 1999-2009 (National Foreign Assessment Center (U.S.) and United States. Central Intelligence Agency.)

Estimated Adults and Children Living with HIV

Number of people living with HIV

1,400,000 1,200,000 1,000,000 800,000

Malawi Turkey US

600,000 400,000 200,000 0 1985

1990

1995

2000

2005

2010

2015

Year

Figure 3. Estimated Number of Adults and Children living with HIV in U.S., Turkey, and Malawi ("Global Report: Unaids Report on the Global Aids Epidemic 2012") The total estimated number of adults and children living with HIV in the US, Turkey, and Malawi are displayed in Figure 3. The estimated number of adults and children with HIV in the United States and Malawi were increasing significantly between 1990 and 2009. In the United States, the number of people living with HIV was 810,000 in 1900 and 1,300,000 in 2011, a 61% increase, while in Malawi, the statistics were 360,000 and 910,000 in 1900 and 2011, respectively, a 152% increase.

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In Turkey, the estimated number of HIV-infected people was dramatically lower and relatively constant, indicating that its individual spread is not nearly as rapid as the spread in the other two countries. Despite the fact that Turkey’s numbers are not considered serious, its estimated number of HIV-infected people was 200 in 1990 and increased to 5500 in 2011.

Incidence In the United States, the number of new HIV cases each year has been relatively constant, staying around 50,000 since the 1990s (Hall et al.), while the number of new HIV cases in Turkey and Malawi have fluctuated more. Figure 4 shows how Malawi had an estimated 79,000 new cases in 1990, which rapidly increased to 100,000 new cases by 1997. This number began to drop in 2004, and by 2011, the number of new cases in 2011 had dropped to 46,000 ("Global Report: UNAIDS Report on the Global Aids Epidemic 2012"). The number of new cases in Turkey, on the other hand, was 2 to 3 magnitudes below that of Malawi, beginning with 4 reported cases in 1985 to 653 cases in 2011 (CISID). Though small in number, the exponential growth of HIV in Turkey is concerning, as displayed in Figure 5. Dr. Pınar Ay from the Marmara University School of Medicine in Istanbul says that the “situation is not urgent, but deserves attention and awareness” (Ay).

Incidence of HIV in Malawi

Number of Adults and Children newly infected with HIV

120000

100000

80000

60000

40000

20000

0 1985

1990

1995

2000

2005

2010

2015

Year

Figure 4. Number of HIV cases in Malawi from 1990-2011 ("Global Report: UNAIDS Report on the Global Aids Epidemic 2012")

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Number of HIV cases in Turkey 700 600

Number of cases

500 400 300 200 100 0 1980

1985

1990

1995

2000

2005

2010

2015

Year

Figure 5. Number of new HIV cases in Turkey from 1985-2011

Modes of Transmission The predominant modes of transmission in each of the three countries are also notably different. As displayed in Figure 6, in the United States, men having sex with men (MSM) accounted for 63% of new HIV reported cases in 2010, heterosexual intercourse accounted for 25% of cases, Intravenous Drug Use (IDU) accounted 8% of causes, and joint MSM-IDU accounted for 3% of cases ("New Infections in the United States").

Modes of Transmission in Turkey (2010)

Modes of New HIV Infections in the United States (2010) 1%

Heterosexual sex

3%

Heterosexual

30%

8% Men having sex with men (MSM)

Men having sex with men (MSM)

Intravenous Drug Usage (IDU)

25% 63%

MSM-IDU Other

Figure 6. Modes of Transmission in the US

57%

Intravenous drug users (IDU)

4% Other

9%

Figure 7. Modes of Transmission in Turkey

In Turkey, according to the Ministry of Health, heterosexual intercourse is the mode of transmission that contributes most greatly to HIV/AIDS, at 57%, followed by MSM at 9%, and intravenous drug users at 4% ("Narrative Report: Turkey"). According to Dr. Hayat Kumbasar KaraosmanoÄ&#x;lu’s study, 96% of women in her Istanbul study were monogamous housewives who acquired HIV from their husbands, who were in homosexual relationships, or were sleeping with sex workers who are infected with HIV (Karaosmanoglu, Aydin and Nazlican). Another 7|Page

study conducted for the entire country of Turkey revealed that 89% of women with HIV were monogamous housewives (Celikbas et al.). HIV is seen as a homosexual disease in Turkey, and because of the lack of awareness of the true nature of transmission, monogamous housewives have a false sense of security against the disease. Among men, less educated, uneducated, or poor men were the main target of HIV infection by foreign women who had HIV. Truck drivers and blue collar workers were the most common professions with HIV. Being a hub for immigrants all over Eastern Europe and the Middle East, Turkey has a greater likelihood than other countries in the same region with fewer immigrants of introducing and transmitting new cases of HIV. Many sex workers in Turkey come from Russia or Eastern Turkey (which is more impoverished than Western Turkey) and are more likely to be unregistered. But by being unregistered, these sex workers do not have access to regular screenings and health care services that are available to registered sex workers, putting many clients and clients’ families at risk.

In Malawi, unprotected heterosexual intercourse is also the predominant mode of transmission, with 80% of new infections occurring among partners in stable relationships, mainly because of multiple and concurrent sexual partners and discordance in long-term couples (MalawiGovernment). The second common mode of transmission, responsible for the continual spread of HIV, is mother-to-child transmission (MTCT) ("2008 Country Profile: Malawi"). In 2010, 10.6% of pregnant women were HIV-positive, which was formerly 22.8% in 1999. As of 2011, only 28% of HIV-exposed children in Malawi undergo antiretroviral therapy, making the HIV transmission through MTCT a large problem in the country, a problem that is insignificant in both the US and Turkey.

Regions of HIV Concentration For all three countries, HIV is more prevalent in urban areas than in suburban or rural areas. In the United States, the coastal areas (which usually have the most immigrants and tourists) have the highest prevalence, ranging from 319.4-428.0 per 100,000 in California, Nevada, Texas, Illinois, Pennsylvania, Virginia, Tennessee, North Carolina, Mississippi and Alabama, to 428.1-3,365.2 per 100,000 in New York, District of Columbia, Maryland, New Jersey, Delaware, Connecticut, South Carolina, Georgia, Louisiana, and Florida in 2008. In 2010, the Northeast reported the highest incidence rate of AIDS diagnoses (14.2/100,000), followed by the South (13.0/100,000), the West (8.8/100,000), and the Midwest (6.3/100,000) ("Hiv and Aids in the United States by Geographic Distribution").

In Turkey, according to Dr. Karaosmanoğlu, the highest concentration of HIV/AIDS is, likewise, in urban areas such as Istanbul, followed by Ankara and İzmir, mainly because these big cities are hubs for sex workers who have emigrated from Eastern Turkey and Eastern Europe.

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In Malawi, HIV prevalence in urban areas is also more prevalent. 20.4% of people aged 15-49 in urban areas are infected with HIV, compared to 17.0% in semi-urban areas and 13% in rural areas ("2008 Country Profile: Malawi").

Cost of Care In the United States, the average cost of HIV treatment per year is more than $20,000 per person ("An Overview of Hiv in Texas"). Upon diagnosis, the annual cost will continue for the rest of the patient’s life as HIV is a chronic disease. However, free or low-cost care is available for low-income and uninsured individuals.

In Turkey, all HIV patients’ health care is covered by the government under their recently modified universal health care system.

In Malawi, the cost of care itself is heavily subsidized by the government; however, the brunt of the cost for care is travel-related expenses. For those who receive centralized care (in urban hospitals or clinics), 60% pay to use a mini-bus to reach the clinic, while among those who receive decentralized care (such as in rural clinics), only 4% use a mini-bus and 96% remainder travel by foot or bicycle (Pinto et al.). Participants in both centralized care and decentralized care clinics report having other out-of-pocket costs for food (100% and 88%, respectively) and for missing work (9% and 16%, respectively).

IV.

Conclusions and Implications

The cross-comparative analysis of the prevalence, incidence, dominant modes of transmission, and cost of care of HIV/AIDS in the United States, Turkey, and Malawi, provides enlightening evidence of how an infectious disease can afflict core, semi-periphery, and periphery countries. From the results above, I will evaluate why such disparities exist.

Malawi As of 2009, Malawi has a high HIV prevalence rate of 11%, meaning more than 1 out of every 10 individuals in the country has HIV (National Foreign Assessment Center (U.S.) and United States. Central Intelligence Agency.). Though Malawi has the smallest population out of the three, it faces a HIV prevalence rate significantly higher than those of Turkey and the U.S. The virus is an epidemic in Malawi, which is why more research and efforts are needed to alleviate the disease burden. Among the many reasons that contribute to high prevalence include knowledge insufficiency regarding HIV, stigma associated with HIV, cost of transportation for medical care, and availability of quality medical care.

Knowledge Insufficiency In the Central District of Malawi, only 66% of surveyed women between 15-49 knew that condoms can be prevent HIV transmission, only 83% knew that limiting sexual intercourse to one uninfected partner can prevent HIV transmission, and only 76% knew that abstaining from 9|Page

sex can prevent HIV (Malawi. National Statistical Office. and ICF Macro (Firm)). Among all surveyed men in the Central District, 73% knew that condoms can prevent HIV, 83% knew that limiting sexual intercourse to one uninfected partner can prevent HIV, and only 74% knew that abstinence can prevent HIV. Regarding MTCT, only 72% of women and 58% of men in the Central District knew that HIV can be transmitted by breastfeeding and risk of MTCT can be reduced by the mother taking drugs during pregnancy. Thus, this lack of knowledge may result in parents not taking their children to health care facilities even if they knew they had HIV and/or even if they had the means to get antenatal care for their HIV-exposed children.

Cost of Transportation Additionally, as mentioned in the Results section, cost of transportation or loss of workdays can often stop HIV-exposed adults, pregnant women, and children from accessing the care needed for proper prevention, treatment, and education.

Lack of Medical Care Furthermore, another dire problem is the lack of enough healthcare providers in Malawi.

According to the World Health Organization, there are only 2 physicians and 38 nurses per 100,000 people, thus severely limiting access to HIV healthcare (World Health Organization).

Turkey Reasons for low prevalence and incidence Compared to HIV in Malawi and the United States, HIV in Turkey is almost negligible.

Below are some reasons that could explain the low numbers: 1. Islam, the predominant religion in Turkey, promotes conservative sexual practices among its believers, which could lead to more monogamous sexual relationships in the country.

2. Healthcare of HIV patients is completely covered. The Haseki Training and Research Hospital in Istanbul, among many other hospitals that care for HIV patients, provide both medical care and emotional counseling for their patients. Meetings with HIV patients can go anywhere between 20 minutes to 1 hour, depending on how much patients want to share. Instead of simply asking what their sexuality is, physicians at the Haseki Training and Research Hospital will ask about their behavioral patterns and lifestyle choices in considering the sexuality, especially because many men who have sex with men will deny homosexuality.

3. Some HIV data could be underreported or not reported. However, in Izmir, the third most populous city in Turkey, a study proved that the HIV notification rate was 100%, indicating that underreporting may not be a problem (Durusoy and Karababa).

Notification rates in other cities and rural areas have yet to be studied.

4. The reason behind why Turkey has a lower prevalence than the United States could be that Turkey’s immigrants are mainly from the Eastern European and Asian continents, whereas American immigrants come from all over the world, thereby Turkey has a lower chance of introducing the virus.

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Though HIV transmission in Turkey is minimal compared to that of Malawi, the number of new HIV cases in Turkey over the course of two decades has increased exponentially. Though it is not as pressing as other infectious diseases such as Hepatitis B, it is not an issue that should be ignored due to its small magnitude, but an issue of concern that should be watched over and publicized so that future spread can be mitigated. Below, I will discuss risk factors for increased spread of HIV in Turkey.

Knowledge insufficiency The fact that the 96% of women with HIV in an Istanbul study were monogamous women in heterosexual relationships is an indication that the main problem lies within the lack of awareness of the nature of HIV. The belief that HIV is a homosexual disease prevents larger numbers of monogamous women to deny HIV status, not get tested, and not question their husband’s behavior.

Furthermore, the stigma of HIV in Turkey is so significant that many patients do not even share the news with their family or friends. From her experiences interacting with her 350 HIV patients and at the hospital, Dr. Karaosmanoğlu says many patients turn to her and her colleagues and not their family or friends to share their feelings and thoughts—“We [physicians] are family to them” (Karaosmanoğlu).

Stigma due to Cultural Attitudes Though Turkey has become more industrialized and urbanized, it is still a traditional and patriarchal society. As a result, conversation about sexuality and sexually transmitted diseases is considered mostly taboo, both outside and inside the family. Additionally, homosexuality is not received well, and many men who have sex with men (MSM) will pursue heterosexual relationships without claiming to be homosexual (Ay and Karabey).

Attitudes of healthcare workers Because HIV/AIDS prevalence is low in Turkey, many health professionals also have misconceptions about the disease and may either not know how to care for HIV/AIDS patients and/or even refuse to care for perform surgery or deliver their babies (Karaosmanoğlu). Without proper education of healthcare workers, HIV patients may remain sick and untreated for some conditions and suffer higher mortality rates. Thus, Dr. Karaosmanoğlu and her colleagues at the Haseki Training and Research Hospital are part of an “Action Against HIV” group in Istanbul which consist of several research hospitals which meet every month and make presentations to physicians about HIV/AIDS to further spread the word about proper treatment and care for HIV/AIDS patients.

United States In the United States, the majority of new HIV cases in the United States derive from homosexual relationships, while the predominant mode of transmission in both Turkey and Malawi is heterosexual relationships. This discrepancy is partially due to the fact that the people in Turkey and Malawi are not as well-informed about HIV, and often associate HIV with homosexuals, whereas in the United States, sexual education starting usually starting from late 11 | P a g e

elementary school or middle school years teach students about safe sex or abstinence practices.

The relatively better education most likely lowers the rate of heterosexual transmission compared to the rates in Turkey or Malawi. HIV stigma is definitely still existent in the United States; however, the presence of sexual education and public awareness efforts has reduced misconceptions about the disease.

However, the number of individuals living with HIV in the US is still relatively high. In examining Figure 8 made by the WHO, the United States has a similar range of HIV infected individuals as many Sub-Saharan countries and India. The reason behind such a high number is that more and more HIV patients in the United States are living longer because of greater technology and medications that have increased their life expectancies. Unfortunately, HIV patients in sub-Saharan African countries have not witnessed the same advances.

Figure 8. Estimated number of people in the world living with HIV/AIDS ((UNAIDS)) Concluding Thoughts The differences in modes of transmission and attitudes toward HIV imply that different methods must be employed to address HIV in each of these countries. For the US, more education and attention needs to be directed to homosexual populations; for Turkey, more education and attention needs to be directed to heterosexual couples; and for Malawi, more education, attention, and medical resources need to be available for heterosexual couples and pregnant or potentially pregnant women. Further research should be conducted to address how policies, education efforts, and healthcare reform can be shaped to address the problems that each country faces.

Yet in the end, the most fundamental and consistent solution for all three countries is to educate all individuals about what is HIV, how to prevent HIV, and what can be done to treat HIV at a young age. By educating members of society at a young age, people learn to address HIV at each stage of disease, whether it is prevention, testing, or treatment for themselves and their friends and family. By talking more openly about HIV, people will not only be more aware, but the stigma of the disease will gradually diminish.

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Acknowledgements This research project would not have been possible without the support of many people. I would like to thank Ipek Martinez, the Associate Dean of Rice University’s Social Sciences Department and Director of the Gateway Program and Abbey Godley, the Gateway Administrator, who both coordinated the Global Urban Lab class and made my trip to Istanbul, Turkey incredibly unique and inspiring. I also wish to thank Dr. Michael Emerson, my faculty mentor, who provided valuable insights and feedback throughout every stage of my research project. I am also incredibly grateful to Dr. Pınar Ay, a public health physician at the Marmara Üniversitesi Tıp Fakültesi (School of Medicine) in Istanbul for sharing with me her frontline HIV research and Dr. Hayat Kumbasar Karaosmanoğlu, an infectious diseases physician at the Haseki Training and Research Hospital in Istanbul for sharing with me her firsthand experiences of her patient encounters.

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