Reframing HIV and AIDS
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7423.1101 (Published 06 November 2003) Cite this as: BMJ 2003;327:1101Data supplement
Summary of possible disaster phases, objectives, and activities for the AIDS epidemic under a disaster management approach
Phase I (predisaster) Phase II (early warning) Phase III (emergency/ disaster) State of alert Green Yellow Red Hazard
(seroprevalence)<1% ?10% >10% Vulnerability
(See comment)Key objectives Mitigation (risk reduction) Heightened mitigation Focus on relief, rehabilitation, and reconstruction (mitigation and preparedness do not cease) Preparedness Heightened preparedness Key activities Targeting high risk populations for prevention Expanded prevention activities Scaled up, simplified treatment programmes focused on saving existing lives Treatment Provision of more AIDS education Emergency establishment and rehabilitation of treatment infrastructure Surveillance for increase in seroprevalence and vulnerable populations Focus on reducing sexually transmitted diseases and other risk factors Rehabilitation and reconstruction of social and economic infrastructure Build-up of prevention and treatment infrastructure Treatment Increased surveillance Planning for possible progression to emergency phase Role of nation Balance key activities with national and health priorities Prioritise key activities in relation to other national agendas Declare a state of emergency Focus attention across sectors on efficiently mobilising resources for HIV/AIDS disaster Role of global community Provide financial assistance, according to need Debt relief Increased phase II activities Low or no interest loans Αssist in rehabilitation and reconstruction activities Direct funding for HIV/AIDS activities Increased attention to health and public health infrastructure HIV/AIDS, which has a long (approximately 10 years) latency period from infection to death, is comparable to other so-called "slow onset disasters" (e.g. famine) that often have an insidious onset, but can have death rates and secondary consequences no less devastating than classic acute onset disasters (e.g. floods). Under a formal disaster management approach, societies are usually classified into three slow onset disaster phases: Phase I: Pre-disaster phase, Phase II: Early Warning Phase and Phase III: Emergency or Disaster Phase.[1] Each phase is linked with key objectives, which remain the same across all disasters, and activities which vary according to the nature of the disaster. These objectives and activities have the potential to provide simple guidelines to countries and the international community for priority setting and resource allocation in the context of a disaster.
Under a standard disaster management framework, societies are categorized into phases according to the risk or potential impact that a given event could have on that society. The risk is defined as a combination of the current level of hazard to a society as well as the vulnerability of the society to the disaster. Hazard is a proxy measure of the inherent level of threat an event poses to a society (e.g. the deficit of rain in a drought leading to a famine). Vulnerability refers to the susceptibility or predisposition of a society to a threat (e.g. nations in arid regions are more susceptible to famine from drought). Vulnerability in a disaster management construct also encompasses the excess effects endured by societies that do not have resources to adequately protect themselves from the threatening event (e.g. poorer nations may not have the resources to purchase food or irrigation systems when faced with a drought and may suffer excess mortality and morbidity.)
In the table above, which is shown for illustrative purposes only, it is proposed that nations should be sorted first by hazard and then moved up a phase if appropriate according to their vulnerability to HIV/AIDS epidemic. Hazard is defined as sero-prevalence and is likely a good estimate for the current level of threat. Vulnerability could be defined using a number of different measures in HIV/AIDS and it is likely that a composite measure including socio and economic indicators pre-disposing societies to the epidemic may be most acceptable. Admittedly, no data can absolutely measure vulnerability and many countries would resist any measure of vulnerability that may place them in an unfavourable category. However, this type of composite data, as imperfect as it is, has been used in measuring human development (e.g. Human Development Index), is accepted globally and is a source of positive competition amongst nations. Alternatively, vulnerability to the HIV/AIDS disaster could be approximated by HIV infection incidence rates and female mortality rates 15-45, which reflect both the susceptibility and "excess effect" components of vulnerability.
The objectives suggested in the above table are those recommended for all slow-onset disasters. The proposed activities illustrate the potential differences in priority setting and resource allocation that could be considered by nations and the international community according to the level of risk a society is facing. For instance, it is suggested that those countries in Phase II of the epidemic, which are not yet facing a significant disruption of their society due to HIV/AIDS but are extremely vulnerable to the disaster, should heighten their mitigation and preparedness activities. They should focus their priority and efforts on scaling up prevention, building up their infrastructure for prevention and treatment. However, they should balance this response with other national and health priorities. On the other hand, it is recommended that countries in Phase III, which are experiencing a significant disruption to their societies, should launch an immediate multi-sectoral "social salvage operation" focusing on saving existing lives.
Treatment is proposed as appropriate and imperative in each phase because of its importance in saving existing lives, its positive impact on prevention and its role in the reduction in stigma.[2] However, the focus on the rate of scaling up treatment, resources allocated and its balance with other national activities should be different across the phases. It is recommended that prevention activities should not cease in any phase, but these activities should be decreased in terms of priority and relative resource allocation in Phase III.
1 UNDP. An Overview of Disaster Management 1992. http://undmtp.org/modules_e.htm (accessed 15 May 2003).
2 Farmer, P. "Introducing ARVs in Resource-Poor Settings: Expected and Unexpected Challenges and Consequences." http://www.pih.org/library/essays/IntroducingARVs/plenarytalk.pdf. (accessed 5 October 2003).
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