Transcript HIV Epidemiology Update and Transmission Factors : IAC Plenary

XVI International AIDS Conference
Toronto
HIV Epidemiology Update
based on Plenary Presentation
Chris Beyrer MD, MPH
Johns Hopkins Bloomberg School of Public Health
Global HIV epidemic, 1990‒2005
Number of people
living with HIV (millions)
% HIV prevalence,
adult (15‒49)
50
5.0
• 38.6 million living with HIV
[33 to 46 million]
40
4.0
30
3.0
20
2.0
10
1.0
0
0.0
1990
1995
2000
2005
Number of people living with HIV
% HIV prevalence, adult (15-49)
Bar indicates the range around the estimate
Source: UNAIDS 2006
• 24.5 million in SS Africa
[21.6 to 27.4 million]
IMPORTANCE OF PREVENTION
(estimates 2005)
4.9 million
new HIV
infections
40.3 million
people living
with
HIV/AIDS
In 06/2006 1.65million on
ART
3.1 million
AIDS related
Deaths
Prevalence main determinant of
incidence
4.9 million
New HIV
infections
40 million
People living
with
HIV/AIDS
3.1 million
AIDS related
deaths
A global view of HIV infection, 2005
1.5 million
200,000 in ‘05
IDU
7.6 million
830,000 in ‘05
Heterosexual
MSM
IDU
12.1 million
1.3 million in ‘05
Heterosexual
Source: UNAIDS 2006 Report on the Global AIDS Pandemic
States with at least one site with HIV
prevalence > 20% in IDU in 2006
Emergent Epidemics
•
•
•
•
•
•
Belarus
Estonia
Kazakhstan
Russia
Ukraine
Serbia & Montenegro
Established Epidemics
•
•
•
•
•
•
•
•
Iran
•
•
•
•
Nepal
Indonesia
•
•
•
•
•
Libya
Mauritius
•
•
•
•
Kenya, Tanzania, Ghana,
Nigeria**
•
Burma
China
India
Malaysia
Thailand
Vietnam
Italy
Netherlands
Portugal
Spain
Argentina
Brazil
Uruguay
Canada
Puerto Rico
USA
**African States with at least one published report of IDU risks
Adapted from : Aceijas, et al, AIDS 2004 18:2295-2302
Individual Level Determinants for
Parenteral HIV Infection
Needle sharing
Higher frequency of injection
Cocaine injection
Lack of opioid analogue therapy
MSM-IDU history
Injection use while incarcerated
Reported HIV cases in the Russian Federation
and Ukraine, 1987–2005
Reported HIV cases
in the Russian Federation
Reported HIV cases
in Ukraine
120 000
400 000
Russian Federation
350 000
105 000
Newly reported cases
300 000
90 000
Cumulative (previous years)
250 000
75 000
Ukraine
200 000
60 000
Newly reported cases
150 000
45 000
Cumulative
100 000
30 000
50 000
15 000
0
0
1987
1989
1991
1993
1995
1997
1999
2001
2003
Adapted from : Russian Federal AIDS Centre; Ukranian AIDS Centre and Ministry of Health of Ukraine, UNAIDS
2006 Report on the Global AIDS Pandemic
2005
What are the Structural Drivers of
Spread Across Eurasia?
Driver # 1
Geographic proximity to overland drug trafficking routes
Driver # 2
Limited use of HIV prevention measures with
demonstrated efficacy for IDU transmission
Driver # 3
Punitive and legalistic approaches to IDUs
Opiate seizures in Asia in 2004
Source : UNODC World Drug Report 2006
21
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Percent (%)
IDUs Reached by NSEP, Select FSU Countries, 2005
UNAIDS recommends 60% coverage for effective HIV prevention among IDUs
Sources: IDU Estimates: UNODC HIV/AIDS unit, September 2005; WHO/UNAIDS October 2005. Published in Harm Reduction
Developments 2005. International Harm Reduction Development Program (IHRD) of the Open Society Institute
Structural limits on
prevention & care for IDU
•
US continues ban on federal funding for Needle Syringe
Exchange Programs (NSEP) in US and globally
•
Methadone Maintenance Therapy (MMT) remains illegal
in many countries Ex: Russian Federation
•
Across 50 developing countries,
34,000 IDU on ARV: 30,000 were in Brazil
Source: Aceijas, et al, Addiction, 2006
Photo: Hans Jürgen Burkard
MSM Trends in High and Low
Income Country Settings
Estimated Number of HIV/AIDS Diagnoses, by
Transmission Category — 33 States, 2001–2004.
% Δ / year
20000
HIV / AIDS
MSM
2.7
15000
−3.9*
HC
10000
IDU
−9.1*
5000
MSM/IDU
−3.4*
0
2001
2002
2003
2004
Year of Diagnosis
* Statistically significant
Source: Espinoza, CDC, 2005
Trends HIV among MSM
mid ’90- now

HAART introduced, resulting in dramatic improvement of
survival of AIDS patients, as well as reduction in AIDS
cases

HIV/AIDS becomes a “chronic disease” and “less
visible”

Rise in “unsafe sex” and STI , including outbreaks of
Syphylis and LGV
Sexual orientation of male syphilis cases
registered in the sentinel network of
clinicians, Belgium, Oct 2000 - Jan 2003
25
Number of
active
20
syphilis cases
MSM
Het.men
15
10
5
0
Oct 2000-Jan 2001 Oct 2001-Jan 2002 Oct 2002-Jan 2003
Period of registration
From: IPH, Belgium
Possible explanations for
increased risk behaviour

HAART changed the face of the epidemic: less
AIDS and less deaths

Prevention fatigue: challenge of maintaining safe
sex for an extended period

Changing environment : internet as new way of
recruiting partners

Young MSM (<20y) sexually active earlier , and
never exposed to AIDS as a killer disease
HIV prevalence among MSM in low prevalence settings
MSM Prevalence
Adult Prevalence (2006 UNAIDS Estimate)
Uk
ra
in
e
a
ge
nt
in
Ar
ru
Pe
de
r
Bo
r
na
i
US
-M
ex
ico
ng
a
Si
Ch
en
po
r
e
nd
ila
Th
a
dia
bo
Ca
m
Se
ne
g
al
30%
25%
20%
15%
10%
5%
0%
Source: Wade et al. 2005; Girault et al. 2004; van Grievsven et al. 2005; Action for AIDS Singapore, 2006, Go et al.
2004; Pando et al. 2006; UNAIDS, 2006; Caceres et al, 2005, Strathdee, et al, 2006. CENSIDA, CA State Office of
AIDS; Patterson et al, IAS, 2006; Strathdee et al, pers. comm; Viani et al, 2006
HIV prevalence among MSM, Bangkok, Thailand
2003
40
2005
HIV Prevalence (%)
35
30.5
29.7
30
25
22.3
20
15
28.3
20.8
17.5
17.3
12.9
10
5
0
Age (years)
≤22
23-28
≥29
Overall
N = 194/1,121; 113/399
p-values all < 0.05
Source: Van Griensven, et al, MMWR. 2006
MSM structural risk contexts
• Criminalization and stigma limit MSM access to HIV
prevention, treatment and care
• MSM understudied in emerging contexts: MSM not
included in national HIV surveillance in Thailand,
Vietnam, Senegal
• Only one African study (Wade, et al) of MSM risk and
HIV rates
• Fewer than 1 in 10 MSM worldwide have access to
necessary prevention services
Sources: UNAIDS; USAID, 2004; Wade 2005; Go 2006 personal communication; HRW; UNAIDS 2006
HIV prevalence in adults in Africa
Source : UNAIDS, 2006
Adult HIV prevalence in Sub-Saharan Africa, 2003 and 2005.
Region
SOUTH
EAST
WEST
HORN
Country
Populationbased survey
prevalence (%)
(year)
Adjusted
2003 HIV
prevalence
(%) in current
report
2005 HIV
prevalence (%)
in current
report
Trend in prevalence
Botswana
25.2 (2004)
24.0
24.1
Stable
Lesotho
23.5 (2004)
23.7
23.2
Stable
South Africa
16.2 (2005)
18.6
18.8
Increasing
Burundi
3.6 (2002)
3.3
3.3
Decline in capital city
Rwanda
3.0 (2005)
3.8
3.1
Decline in urban areas
Tanzania
7.0 (2004)
6.6
6.5
Stable
Uganda
7.1 (2004-5)
6.8
6.7
Stable
Burkina Faso
1.8 (2003)
2.1
2.0
Decline in urban areas
Cameroon
5.5 (2004)
5.5
5.4
Stable
Ghana
2.2 (2003)
2.3
2.3
Stable
Guinea
1.5 (2005)
1.6
1.5
Stable
Senegal
0.7 (2005)
0.9
0.9
Stable
Sierra Leone
1.5 (2005)
1.6
1.6
Stable
Ethiopia
1.6 (2005)
(1.0-3.5)
(0.9-3.5)
Source: UNAIDS 2006 Report on the Global AIDS Epidemic
Decline in urban areas
HIV prevalence by age and gender
South Africa 2005
HIV Positive (%)
45
40
Males
35
Females
30
33.3
23.9
25
20
12.1
15
10
5
9.4
6.0
3.2
0
15 – 19
20 – 24
25 – 29
Age group (years)
Source: South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2005
Ecological Model for HIV Risk in Southern Africa
Condom Usage, Circumcision, HSV-2/GUD, Viral Load, Acute
Infection, Age of Coital Debut, Marriage, ARV Status
Individual Risks for HIV Infection
Widening Risk Contexts for HIV Infection
Beyrer & Baral, 2006