Get documents about "HIV AIDS State of the Epidemic HIV AIDS State
Document Sample
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
Related docs
