HIV AIDS State of the Epidemic HIV AIDS State by Piecebypiece

VIEWS: 121 PAGES: 7

									                                                                        HIV/AIDS – State of the Epidemic
            HIV/AIDS – State of the
                                                                     • Global estimates and measurement
                  Epidemic                                           • Epidemiologic parameters and their
                                                                       interpretation
                                                                     • Descriptive epidemiology by region
                                                                     • Descriptive epidemiology – United States
                      Kevin M. De Cock, MD
                                                                     • Determinants of heterogeneity
                     World Health Organization
                                                                     • Responding to HIV/AIDS
                     IAS-USA, March 14, 2008
                                                                     • Apologies for too many slides




                   The Cycle of HIV Disease

                          1. Incidence of HIV
                          Infection


                                                    3. Incidence
                                                    AIDS
2. Prevalence of
  HIV Infection



                   4. Prevalence of
                     AIDS

                                      5. Mortality from AIDS




                                                                       Estimated adult (15–49 years) HIV prevalence rate (%)
                                                                          globally and in Sub-Saharan Africa, 1990–2007
  Global Distribution of HIV Infections
  Sub-Saharan Africa      68%
                                                                            8

  Asia                    14%
                                                                            7                               Sub-Saharan Africa
                                                                            6

  The Americas            11%                                               5
                                                                   Adult HIV
                                                                   preval    4
                                                                   ence (%)
  Europe                   7%                                               3
                                                                            2                                            Global
  North Africa, ME         1%                                               1
                                                                            0
                                                                                 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
  Oceania                 <1%
                                                                                                                           Year




                                                                                                                                                                             1
   Estimated number of people living with HIV globally,                                                                              Estimated number of people newly infected with
                      1990–2007                                                                                                                 HIV globally, 1990–2007

                                                                                                                                                            6




                                                                                                                                                 Millions
                 40
       Million




                                                                                                                                                            5

                 30                                                                                                                                         4
Number                                                                                                                                                                                                                                                                                   Upper range
                                                                                                                                     Number                 3
of people 20                                                                                                                         of people
living                                                                                                                                                                                                                                                                                   Estimate
                                                                                                                                     newly
with HIV                                                                                                                                                    2
                                                                                                                                     infected
          10                                                                                                                                                                                                                                                                             Lower range
                                                                                                                                     with HIV
                                                                                                                                                            1

                  0                                                                                                                                         0
                       199019911992199319941995199619971998199920002001200220032004200520062007                                                                 1990 1991 1992 1993 19941995 1996 1997 1998 19992000 2001 2002 2003 2004 2005 2006 2007
                                                         Year                                                                                                                                                             Year


                          This bar indicates the range




    Estimated number of adult and child deaths
         due to AIDS globally, 1990–2007                                                                                                                    Global HIV Epidemiology
                 3.0                                                                                                                  Sub-Saharan Africa                                                                      Rest of the World
       Million




                 2.5
                                                                                                                                      -   68% global HIV incidence and                                                        -   Concentrated epidemics
                                                                                                                                          prevalence                                                                              affecting IDU, MSM, sex
Number 2.0
                                                                                                                                                                                                                                  workers and their partners
of adult
and child 1.5                                                                                                                         -   76% global AIDS mortality
deaths due                                                                                                                                                                                                                    -   Clusters possible, generalized
to AIDS 1.0                                                                                                                                                                                                                       epidemics unlikely
                                                                                                                                      -   Almost 90% global HIV in
                 0.5                                                                                                                      children
                                                                                                                                                                                                                              -   Caribbean most heavily
                  0                                                                                                                   -   One third of global burden in                                                           affected, adult HIV prevalence
                       199019911992199319941995199619971998199920002001200220032004200520062007                                           southern Africa; adult HIV                                                              1%
                                                         Year                                                                             prevalence >15% in 8
                                                                                                                                          countries
                          This bar indicates the range




                                                                                                                                          Changing Surveillance Practice –
  Monitoring the HIV/AIDS Pandemic
                                                                                                                                                  United States
     HIV and AIDS case reporting
                                                                             The Cycle of HIV Disease
     Countries with generalized                                                                                                                                                                                          90                                                                 450
     epidemics:                                                                       1. Incidence of HIV Infection                                                                                                      80                                        Persons living           400
                                                                                                                                                                                                                                                                                                  Persons Living with AIDS




     - antenatal sentinel                                                                                                                                                                                                70                                        with AIDS                350
                                                                                                                                                                                                   AIDS Cases & Deaths




                                                                                                                                                                                                                              AIDS Cases
     surveillance                                                                                                                                                                                                        60                                                                 300
                                                                                                                                                                                                      (Thousands)




                                                                                                                                                                                                                                                                                                        (Thousands)




                                                                                                                 3. Incidence AIDS
                                                          2. Prevalence of
                                                                                                                                                                                                                         50                                                                 250
     - population surveys                                    HIV Infection
                                                                                                                                                                                                                         40                                                                 200

                                                                                                                                                                                                                         30                                                                 150

     Countries with concentrated                                              4. Prevalence of AIDS
                                                                                                                                                                                                                         20                                                                 100

     epidemics:                                                                                                                                                                                                          10                                  Deaths                         50
                                                                                                      5. Mortality from AIDS
     - sentinel populations (CSW,                                                                                                                                                                                         0
                                                                                                                                                                                                                          1985    1987   1989   1991   1993 1995    1997   1999   2001
                                                                                                                                                                                                                                                                                            0
                                                                                                                                                                                                                                                                                         2003
     STI etc)                                                                                                                                                                                                                                             Years




     HIV incidence is critical but
     difficult to measure




                                                                                                                                                                                                                                                                                                                             2
       Heterogeneity of HIV/AIDS                                                                        Impact of HIV/AIDS in Africa

                                                                                                           Family, social, and demographic disruption
                                                                                                           Epidemic of orphans
                                                                                                           Adverse economic effects
                                                                                                           Worsening food security
                                                                                                           Worsening of public services, including health
                                                                                                           care
                                                                                                           Threatened stability and security
                                                                                                           Secondary epidemic of tuberculosis




Tuberculosis Trends in East and                                                                         HIV Incidence, Prevalence and
       Southern Africa                                                                                      Mortality in Zimbabwe

                         800                          Swaziland
                                                      Lesotho
                         700                          Botswana
                                                      South Africa
                         600                          Zambia
       per 100,000 pop




                                                      Zimbabwe
                         500                          Kenya
                                                      Malawi
                         400                          UR Tanzania
                                                      Uganda
                         300

                         200

                         100

                          0
                               80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3
                                                              Year




                 AIDS in Asia at End-2007                                                               AIDS in Europe at End-2007
•   4.9 million persons living with HIV; SE Asia most heavily affected                               • Eastern Europe most heavily affected, 90% HIV
                                                                                                       infections in Russia and Ukraine; most in IDU
•   Epidemics driven by IDU and commercial sex; increasing
    awareness of MSM
                                                                                                     • Central Europe – low level epidemic
•   Cambodia, Myanmar, Thailand show declining prevalence;
    Indonesia, Viet Nam increasing                                                                   • Western Europe very heterogeneous, heterosexual
                                                                                                       transmission predominates; African immigrants affected
•   India – approximately 2.5 million HIV-infected; commercial sex in
    south, IDU in north
                                                                                                     • High or increasing rates in MSM
•   China – approximately half infections in IDU; earlier outbreak in
    commercial blood donors
                                                                                                     • Declining rates in IDU in southern Europe




                                                                                                                                                                3
    HIV/AIDS in the Americas at End-
                  2007
•   US most heavily affected industrialized country - 1,039,000 -
    1,185,000 HIV-infected

•   1.6 million HIV-infected in Latin America, one third in Brazil

•   Transmission predominantly sexual in Latin America, MSM in many
    countries

•   Caribbean – 230,000 HIV-infected, adult HIV prevalence 1%

•   Three quarters of infections in Haiti and Domican Republic

•   Predominantly heterosexual transmission, IDU in Puerto Rico and
    Bermuda




                                                                      4
Basic Reproductive Rate (Number)
                                 • Number of secondary
                                   cases generated from
                                   one primary case

                                 • For HIV, depends on:
                                    - Rate of partner change
                                    - Transmissibility
                                    - Duration of infectiousness




Risk Estimates of HIV Infection in Patients Infected                         Impact of MC on HIV incidence:
           with HSV-2 – Meta Analysis                                 Evidence from observational studies and RCTs
              (Wald and Link, 2002)
                                                                                                                               Effect size
                                                                     Study                                                     (95% CI)


                                                                     Overall                                                   0.42 ( 0.34, 0.52)

                                                                     High-risk groups                                          0.29 ( 0.20, 0.42)

                                                                      General Population                                       0.56 ( 0.44, 0.71)

                                                                      South Africa                                             0.40 ( 0.24, 0.67)

                                                                     Kenya                                                     0.41 ( 0.24, 0.70)

                                                                     Uganda                                                    0.49 ( 0.28, 0.86)



                                                                                 .15    .2   .3   .4   .5            1       1.5
         (Longitudinal and nested case control studies)                                                          Effect size




            Universal Access                                            The Health Sector's Contribution to
                                                                           Achieving Universal Access
            2005 G8 Summit at Gleneagles, Final Communiqué:
            “…working with WHO, UNAIDS and other international
            bodies to develop and implement a package of HIV                                                                                   S
            prevention, treatment and care, with the aim of as                                                                                 T
                                                                                 Expanding testing and counseling                              R
            close as possible to universal access to treatment for                                                                             A
                                                                                                                                               T
            all those who need it by 2010.”                                                                                                    E
                                                                                                                                               G
                                                                               Maximising                      Accelerating                    I
                                                                                                                                               C
                                                                               prevention                   treatment scale up
                                                                                                                                                I
                                                                                                                                               N
                                                                                                                                               F
                                                                                                                                               O
                                                                                                                                               R
                                                                                     Strengthening health systems                              M
                                                                                                                                               A
                                                                                                                                               T
                                                                                                                                               I
                                                                                                                                               O
                                                                                                                                               N




                                                                                                                                                    5
                                                                                                                                                                                                                           Recent Guidelines on HIV Testing
       HIV Testing in France and UK
                                                                                                                                                                                                                                  in Clinical Settings
United Kingdom, 2005                                                         France, 2004

                                                      •                      Second highest HIV testing
•   43% of HIV-infected MSM left                                             rate in W. Europe
    STI clinic undiagnosed
                                                      •                      40,000 (circa one third) of
                                                                             HIV-infected persons
•   32% of 63,500 PLHA in UK                                                 unaware
    were undiagnosed
                                                      •                      40% of new HIV diagnoses
•   34% of new HIV diagnoses at                                              at AIDS or CD4 <200 per mcl
    CD4 <200 per mcl




                 HIV in MSM, 2008…….                                                                                                                                                                                     Prevention of mother-to-child transmission
                                                                                                                                                                                                                                 The four-pronged strategy
                                                          HIV case reports in MSM, UK
                                                                                                                                                                                                                                                                                                • Primary prevention of HIV
                                              2500                                                             HIV                AIDS                Deaths
                                                                                                                                                                                                                                                                                                • Prevention of unwanted
                                              2000
                                                                                                                                                                                                                                                                                                  pregnancies
                                  Number      1500
                                     of
                                  diagnoses
                                              1000
                                                                                                                                                                                                                                                                                                • Prevention of
                                               500
                                                                                                                                                                                                                                                                                                  transmission from HIV-
                                                 0
                                                                                                                                                                                                                                                                                                  infected mother to infant
                                                                                                                                                                                                                                                                                                • Appropriate treatment
                                                 81


                                                         83


                                                                                                                 85


                                                                                                                             87


                                                                                                                                         89


                                                                                                                                                 91


                                                                                                                                                          93


                                                                                                                                                                      95


                                                                                                                                                                                  97


                                                                                                                                                                                           99


                                                                                                                                                                                                    01


                                                                                                                                                                                                            03


                                                                                                                                                                                                                    05
                                              19


                                                      19


                                                                                                              19


                                                                                                                          19


                                                                                                                                      19


                                                                                                                                              19


                                                                                                                                                       19


                                                                                                                                                                   19


                                                                                                                                                                               19


                                                                                                                                                                                        19


                                                                                                                                                                                                 20


                                                                                                                                                                                                         20


                                                                                                                                                                                                                 20




                                                                                                                                                      Year of diagnosis
                                                                                                                                                                                                                                                                                                  and care




     Towards HIV-Free Survival                                                                                                                                                                                             Unmet treatment need in low- and middle-income
                                                                                                                                                                                                                            countries according to region, December 2006
                                                                           Rate of Gastroenteritis Hospitalizations in
                                                                           Early vs Delayed Weaning:

                                                                                                                                                                                                                                                    5 000 000
                                                              GE rate per 100 infants in age group observed




                                                                                                              8

                                                                                                              7
                                                                                                                                                                                                                                                    4 500 000                     68% of the total unmet need
                                                                                                              6
                                                                                                                                                                                                                                                    4 000 000
                                                                                                              5                                                                                                                                                                                                 Unmet need ARV
                                                                                                                                                                                                     GE rate VT                                     3 500 000                                                   therapy
                                                                                                              4
                                                                                                                                                                                                     GE rate KiBS                                                                                               Receiving ARV
                                                                                                                                                                                                                                 Number of people




                                                                                                              3                                                                                                                                     3 000 000                                                   treatment in Dec 2006
                                                                                                              2
                                                                                                                                                                                                                                                    2 500 000
                                                                                                              1
                                                                                                                                                                                                                                                    2 000 000
                                                                                                              0
                                                                                                                      0    1      2     3     4   5     6      7    8      9     10    11   12
                                                                                                                                                                                                                                                    1 500 000

                                                                                                                                                                                                                                                    1 000 000
                                                      •                    Prolonged breast feeding is
                                                                           associated with increased HIV                                                                                                                                             500 000
                                                                           transmission; early weaning with
                                                                                                                                                                                                                                                           0
                                                                           increased infant mortality. HIV-                                                                                                                                                     Sub-Saharan   Latin America   East, South and      Europe and     North Africa and
                                                                           free survival seems unchanged.                                                                                                                                                          Africa        and the      South-East Asia      Central Asia    the Middle East
                                                                                                                                                                                                                                                                                Caribbean



     Louis Gallait (1810 -1887)
       The Unhappy Mother
     PVSK Museum, Antwerp




                                                                                                                                                                                                                                                                                                                                                     6
  Children's access to HIV treatment,                      WHO guidance on use of ARV
               June 2006
  • Africa        • L. America     • Asia
  Median: 8%      Median: 8%       Median: 5 %




Evolving Challenges in Global Guidance and            Is too much money spent on AIDS?
        Practice on HIV/AIDS-2008

 • Optimal regimens for PMTCT, including for      OP-ED CONTRIBUTOR

   breast-feeding women                           Putting a Plague in Perspective
                                                  By DANIEL HALPERIN
 • When to start pediatric ART                    Published: January 1, 2008
 • Guidance on HIV testing in children
 • When to start ART in adults                    Last year, for instance, as the United States spent
                                                  almost $3 billion on AIDS programs in Africa,
 • Moving away from stavudine                     it invested only about $30 million in traditional
 • Optimal approaches to monitoring ART           safe-water projects. This nearly 100-to-1
                                                  imbalance is disastrously inequitable…..
 • Pharmacovigilance
 • Access to second and third line ART regimens   The Global Fund's director, Michel Kazatchkine,
                                                  has acknowledged, "We are not a global fund that
 • Retention and adherence                        funds local health."

                                                  (New York Times, Herald Tribune)




         Investing in Strategic                           Progress towards Universal Access at December
                                                                              2006
              Information                                    WHO/UNAIDS/UNICEF report, April 2007

                                                      •    Antiretroviral treatment
                                                      •    Preventing mother-to-child transmission
• "What gets measured gets done"                      •    HIV testing and counselling
  (Margaret Chan)                                     •    Interventions for injecting drug users
                                                      •    STI control
                                                      •    HIV surveillance
• "Surveillance is the conscience of any              •    Target-setting
  epidemic"
  (James W. Curran)




                                                                                                          7

								
To top