25 Years of HIV Africa and beyond

25 Years of HIV – Africa and beyond Carol Ciesielski, MD Centers for Disease Control and Prevention Chicago Dept of Health

Origins of HIV-1 Simian Immunodeficiency Virus (SIVcpz ) HIV-1 1930 s Leap to Humans

Origins of HIV-1 HIV remained unnoticed in isolated populations. 1930 s –leap to human from chimpanzees ~ 1 st human case from Kinshasa 1959 In 1960 s-70 s; changing social structures, migrations to cities from rural areas, building roads, commercial trucking, wars, jobs far from home. Transmission amplified by urbanization: reuse of needles in health care settings, sex workers along truck routes, job migrations

Already 30% gay men in San Francisco HIV+

Leading causes of death globally, 2001 Rank % of total • 1 Ischaemic heart disease 12. 7 • 2 Cerebrovascular disease 9. 9 • 3 Acute lower respiratory infections 7. 1 • 4 HIV/AIDS 4. 8 • 5 Chronic obstructive pulmonary disease 4. 8 • 6 Perinatal conditions 4. 2 • 7 Diarrhoeal diseases • 8 Tuberculosis • 11 Malaria Source: The World Health Report 2000, WHO 4. 0 3. 0 1. 9

HIV Transmission Sexual: Heterosexual ♂♀ >> ♀ ♂ Male to male Blood: blood or blood/tissue products Injection drug use Medical injections Perinatal (Vertical): mother to child

Highest Risk Populations • Men who have Sex with Men (MSM) • Injecting Drug Users • Sex workers and their clients Concentrated vs generalized epidemics • Concentrated (low level) HIV concentrated in high risk groups • Generalized - >1% of population HIV+; HIV penetrated into general population (mostly heterosexual spread)

Sexual Transmission • Accounts for ~ 75% of infections worldwide • Probability of infection through sexual contact lower than through other routes • Infectiousness and duration of infectiousness important in epidemic spread

Factors Facilitating HIV Pandemic Long Period between Infection and Symptoms (average 10 -12 years) • Individual: long period of silent infection & infectivity • Community: Prevalence >> incidence resulting in an insidious epidemic • HIV persists for life time of human host

Global Spread ~65 million persons have been infected ~25 million deaths

Global HIV Epidemic, 2005

HIV Prevalence -# of persons HIV infected (38. 6 million) HIV Incidence (Number of new infections each year) 4. 1 million HIV related deaths 2. 8 million

A Global View of HIV Infection 38. 6 million people living with HIV 4. 1 million new infections 2005

HIV Epidemic in Sub-Saharan Africa, 1985 -2005 2. 7 million new infections, 2 million deaths 1982 - 1 st AIDS case

38. 6 million 4. 1 million 2. 8 million

Leading causes of death in Africa, 2001 Rank % of total • 1 HIV/AIDS • 2 Acute lower respiratory infections • 3 Malaria 9. 1 • 4 Diarrhoeal diseases 7. 3 • 5 Perinatal conditions 5. 9 • 6 Measles 4. 9 • 7 Tuberculosis 3. 4 • 8 Cerebrovascular disease 3. 2 • 9 Ischaemic heart disease 3. 0 20. 6 10. 3 • 10 Maternal conditions The World Health Report 2000, WHO 2. 4 Source:

HIV Prevalence (%) in Adults in Africa, 2005 Adult Prevalence Rate

HIV prevalence among 15– 24 year-old men and women, selected countries in sub-Saharan Africa, 2001– 2005 Women 15 Men 10 5 02 ba bw e 20 01 / 20 04 th o Zi m Le so h A fr ic a 20 02 m bi a 20 03 a en y K Za So ut U ga nd a 20 04 /0 5 on 20 04 20 03 er o ni a am Ta nz a al M 20 03 so i 2 00 1 C Bu rk i na Fa ha na 20 03 0 G % HIV prevalence 20 Sources: Demographic and Health Surveys. ORC Macro (Ghana, Burkina Faso, Mali, United Republic of Tanzania, Cameroon, Lesotho, Kenya, Zambia); Department of Health, Uganda HIV/AIDS sero-behavioural survey 2004/2005 (Uganda); Ministry of Health and Child Welfare, Zimbabwe National Family Planning Council, National AIDS Council , and CDC, The Zimbabwe Young Adult Survey 2001 -2002 (Zimbabwe); Pettifor AE, et al. HIV and sexual behaviour among young South African: a national survey of 15 -24 year olds (South Africa). AIDS epidemic update, December 2005. Fig 3

Southern Africa • Global epicenter All 7 countries in Southern Africa have adult prevalence rates near or above 20% (Swaziland >33%). 33% of HIV infected persons 43% of all HIV + children <15 live here 52% of all HIV + women (>14 years of age) 1/3 of all AIDS deaths

HIV Prevalence (%) among pregnant women attending antenatal clinics in Southern Sub-Saharan Africa, 1997 -2004

Africa -Economic Impact of HIV in Hardest Hit Countries • Annual per capita growth in half of the countries is falling by 0. 5 -1. 2%. • By 2010 GDP may drop by 8%. • By 2020 GDP could drop more than 20%. • In several countries, 53% of all illnesses among workers are AIDS-related. • 7 million farm workers have died from AIDS. • 85% of teacher deaths are from AIDS.

South Africa • 2 nd highest number of persons living with HIV/AIDS in the world ~ 5. 5 million/population 45 million; • ~19% 15 -49 HIV+ • 60%-70% military HIV+ • 57% are women – in 15 -24 year olds, females are 3 x more likely to be infected than males

HIV prevalence among pregnant women in South Africa, 1990 to 2001 HIV prevalence (%) 30 25 20 15 10 5 0 1990 ‘ 91 ‘ 92 ‘ 93 ‘ 94 ‘ 95 ‘ 96 ‘ 97 ‘ 98 ‘ 99 2000 ‘ 01 Source: Department of Health, Republic of South Africa

Thousands Number of people who died from HIV/AIDS in sub-Saharan Africa, 1980 -2001 2, 500 2, 000 1, 500 1, 000 500 0 1983 Source: UNAIDS, 2002 1986 1989 1992 1995 1998 2001

Age in years Projected population structure with and without the AIDS epidemic, Botswana, 2020 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 Projected population structure in 2020 Males 140 120 100 80 Females 60 40 20 40 60 80 100 120 140 Population (thousands) Source: US Census Bureau, World Population Profile 2000 Deficits due to AIDS

Sub-Saharan Africa • Poverty –health care infrastructure and accessibility • Migration for jobs –miners, long distance truck drivers • Young girls having relationships with older men (more likely to be HIV+) • Armed conflicts/displacements • Political leadership – • Successes in several countries including Uganda, Botswana, Nigeria • Severe economic consequences –loss of skilled and nonskilled workers, farmers, decreased food supply, lack of educational opportunities

Has Epidemic Peaked in Sub Saharan Africa? • Adult prevalence stable in many countries • Stable or declining prevalence ? Leveling off vs increase in deaths

World’s fastest growing epidemic- started in late 1990’s— 1. 6 million living with HIV, 270, 000 newly infected in 2005 75% infections in persons <30 years of age Eastern Europe

Eastern Europe Most affected countries are Russia and Ukraine 0. 8% population infected Fueled by large numbers of IDUs’—estimated 1% 2% population injects drugs (up to 3, 400, 000) 5%-8% men <30 have injected drugs Inject in groups, promoting multiple reuse of injecting equipment and transmission of HIV

Russia: 860, 000 infected Predictions of 5 -8 million infected by 2010

St. Petersburg, Russia, Rate of HIV per 100, 000 Population

Drug Use in Saratov Oblast • Drug use was a major problem in May 2000. • The drug market is expanding rapidly as dealers enlist younger people into use and distribution. • Over the past four years the average of drug initiation reportedly has dropped from 15 -16 to 12 -13.

Prevalence of syphilis among pregnant women attending antenatal clinics in the Moscow region, 1993 to 1997 Prevalence per 100, 000 800 700 600 500 400 300 200 100 0 1993 1994 1995 1996 1997 Source: Borisenko KK et al. Int J STD & AIDS, 1999, 10: 665 -668

Sex Workers in St. Petersburg Russia Observations Motivations: quick money for survival needs, including food, lodging and medicine; obtain money for luxuries; support a drug habit; to travel abroad and meet potential marital partners. Initiation into sex work usually through friends and occasionally through applications to Internet agencies. Sex work in Russia in high demand, widespread and reaches deep into society. The social backgrounds of sex workers are highly varied; some from very poor backgrounds; others from high socioeconomic status families.

Ukraine Estimated HIV prevalence 1. 4% of population, Fueled by IDUs, sex workers High proportion of sex workers HIV+ • 42% newly diagnosed HIV in 2004 were females

Epidemic in Eastern Europe is Maturing • Increasing sexual transmission (6% infections in 2001 -25% in 2004) • HIV + in pregnant women increased from <0. 01% in 1998 to 0. 11% 2003. • Recent surveys ->80% male IDUs didn’t use condoms regularly in last month • Continued growth sex industry, rising number women migrating for work

How HIV Spreads out of High Risk Populations • IDUs are sexually active • Many sex workers also inject drugs • Most male clients of sex workers have other sexual partners, including wives & steady girlfriends • HIV infection filters gradually from injecting drug users & commercial sex workers to their regular sex partners who may have no other risk of exposure to the virus

High Proportion of Men who Inject Drugs are also Clients of Sex Workers. Most do not Use Condoms

HIV/AIDS in Asia 60% of world’s population 8. 3 million infected There is no “Asian HIV epidemic”; much diversity in the nature, pace, and severity of the HIV epidemic across Asia, between and within countries. Areas of rapid increases in HIV (China, Vietnam, Indonesia); Areas of sustained epidemic levels (India, Myanmar); areas of HIV declines (Thailand, Cambodia), and low prevalence countries (Laos, Pakistan, Sri Lanka, Phillippines).

Transmission of HIV in Asia • Most infections occur through unsafe commercial sex • injecting drugs with contaminated equipment

What do Asian epidemics look like? FSW Clients MSM IDUs Low or no risk males Multiple interlinked & interrelated epidemics in higher risk populations and their immediate sex partners Low or no risk females ~10% Asian men go to sex workers

HIV prevalence in Asia, 2003 2. 0% – 5. 0% 1. 0% – 2. 0% 0. 5% – 1. 0% 0. 1% – 0. 5% 0. 0% – 0. 1% trend data unavailable outside region Spread through IDUs, sex workers

Southeast Asia adult HIV prevalence, 2003 Myanmar 1. 2% (330, 000) Vietnam 0. 4% (220, 000) Laos 0. 1% (1, 700) Thailand 1. 5% (570, 000) Cambodia 2. 6% (170, 000) Malaysia 0. 4% (52, 000) Singapore 0. 2% (4, 100) Adult HIV prevalence (Numbers of HIV+ cases) Source: WHO

Expanding HIV/AIDS Epidemic in China 1985 1989 Source: UNAIDS 1995 1998 650, 000 HIV+ in 2004; 80% IDU & commercial sex

Percent of Men Buying Sex in Previous 12 Months among Men in High Risk Occupations and the General Population Estimated that ~10% of Asian Men Buy Sex High risk occupations =truck drivers, police, sailors, migrant workers

• HIV in Asia vs. Africa –Prevalence in Asia lower but populations larger • 1 percent in India or China = 10 million people –Effective intervention “easier” in Asia • Focus on IDUs, MSM, sex workers and clients –Lower prevalence and growing economies make early identification (testing) and effective treatment (HAART) possible

HIV/AIDS Treatment Antiretroviral Therapy (ART), available 1996 by 1997, death, hospitalizations, OIs declined by 60 -80%

Antiretroviral therapy coverage for adults, Developing World, end 2005 1. 3 million people on treatment: 60 50 40 % 30 20 10 0 Africa Source: UNAIDS/WHO, 2004 Report on the Global AIDS Epidemic (Fig 33) Asia Latin America and the Caribbean Eastern Europe and Central Asia North Africa and Middle East

Challenges • HIV testing -only 10% of 39 million persons HIV + are aware of their infection • Affordable HIV treatment • HIV prevention • Education and awareness • Overcome stigma and discrimination

Impact of HAART-Behaviors • HIV is now a manageable chronic illness, no longer a death sentence • HIV+ persons less concerned about transmitting HIV to HIV - partners — mistaken belief that nondetectable viral load means that they are not infectious to others • ↑ in unprotected sex, ↑ in STIs and ↑ in HIV transmission

Percentage of young people aged 15– 24 years who correctly identified major ways of preventing the sexual transmission of HIV*, 2003 60 50 Female Male 40 % 30 20 10 0 Burkina Faso Cameroon Ghana Kenya Madagascar Mozambique Nigeria UR Tanzania *Using condoms and limiting sex to one faithful, uninfected partner, who reject the two most common local misconceptions about HIV transmission, and who know that a healthy looking person can transmit HIV. Source: Demographic and Health Surveys. ORC Macro (Burkina Faso, Cameroon, Ghana, Kenya, Madagascar, Mozambique and Nigeria); Tanzania HIV/AIDS Indicator Survey 2003 -04, TACAIDS, NBS, and ORC Macro (UR Tanzania). AIDS epidemic update, December 2005. Fig 4

Factors Facilitating Pandemic of HIV Long Period between Infection and Symptoms • Individual: long period of silent infection & infectivity • Community: Prevalence >> incidence resulting in an insidious epidemic • HIV persists for life time of human host Stigma/Discrimination • • Modes of transmission (sex and drugs) High case fatality rate Fear of contagion Linked to poverty -competing priorities