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HIV in a low endemicity country; country response Turkey Serhat Ünal, M.D, FACP, FEFIM Professor in Medicine Chair Hacettepe University, Faculty of Medicine Department of Infectious Diseases President Hacettepe University HIV/AIDS Treatment and Research Center General Demographic Indicators Turkey 1990 2000 2010 2011 Total Population 56.473.035 67.803.927 73.722.988 74.724.269 Rural Population (%) 48,7 40,8 29,0 28,2 Urban Population (%) 51,3 59,2 71,0 71,8 0-14 y/o Population (%) 35,0 29,8 25,6 25,3 65 y/o and Over Population (%) 4,3 5,7 7,2 7,3 Population Growth Rate Per Year ( ‰) 17,0 13,8 13,0 12,8 Crude Birth Rate ( ‰) 24,1 20,3 17,5 17,3 Crude Mortality Rate ( ‰) 7,1 6,6 6,3 6,3 Total Fertility Rate (Number Of Children Per Woman) 2,9 2,4 2,1 2,1 Source: Turkish Statistical Institute TURKEY - TÜRKİYE HIV/AIDS CASES ACCORDING TO YEARS Ministry of Health, Turkey 1 October 1985 – 31 December 2013 n:6802 1400 1200 1000 800 600 400 200 0 85 87 89 91 93 95 97 99 HIV (+) 2001 AIDS 7000/ 7000000 = 0.1 % 2003 2005 2007 2009 2011 2013 HIV/AIDS CASES ACCORDING TO AGE AND SEX Ministry of Health, Turkey 1 October 2013 1985 – 31 December 2013 n:1313 350 300 250 200 150 100 50 0 0 '1-4 '5-9 '10-14 '15-19 '20-24 '25-29 Male '30-34 Female '35-39 '40-49 '50-59 '60+ HIV/AIDS CASES BY MODE OF TRANSMISSION AND SEX 1985 1 October 2013 – 31 December 2013 n:1313 8.5% 4.5% Homosexual intercourse IDU Heterosexual contact 56% Mother-to-child Nosocomial infection 32,60% Undetermined 1,6% 0% Ministry of Health, Turkey CONDITION OF EPIDEMIC DISEASES AMONG THE GROUPS HAVING BEHAVIOURS OF RISK (TADOC – 2010) Intravenous Drug Users Number % HIV/AIDS 1 1.5 Hepatitis B 2 2.9 Syphilis 1 1.5 Gonorea 1 1.5 Chlamydia 2 2.9 Main Factors That Lead To Increase The Number of HIV/AIDS Cases In Turkey Turkey has a very young population (15-49 ages groups) General knowledge of population regarding HIV/AIDS and sexual transmitted infections are limited Increase in useage of intravenous drugs Growth of the Turkish tourism Large number of Turkish men working abroad Increase in number of commercial sex workers Important Milestones in HIV/AIDS Turkey 1985 1985 1986 1987 1994 1994 Detection of the first AIDS case HIV/AIDS; mandatory notifiable disease HIV testing Serological testing for: • Blood/tissue/organ donors • Registered sex workers • Before major surgical operations Medical treatment became free of charge Coding system for notifications for HIV/AIDS cases 1996 Establishment of National AIDS Commission 2004 Gonorrhea and Chlamydia; mandatory notifiable diseases 2005 “HIV/AIDS Prevention and Support Programme” funded by the Global Fund 2007 Approval of 2007-2011 HIV/AIDS National Strategic Action Plan 2010 Establishment of Sexual Transmitted Diseases Scientific Committee State Institute of Statistics AIDS Prevention Society PM Youth and Sport GD Turkish Family Planning Association PLA Human Resource Development Foundation TGNA Legal Affairs Dep. Religious Affairs Turkish Red Crescent Association Health Professional Associations NATIONAL AIDS COMMISSION Turkish Third Sector Foundation PM Social Services and Child Protection Ministry of Labour and Social Security PODER Association for Combat with AIDS Turkish Radio and Television Higher Education Council State Planning Organisation PM Women’s Status and Issues GD Hacettepe AIDS Prev., Treat. and Research Center Artisans and Entrepreneurs Confederation Ministry of Finance PM – Family Research Institute Ministry of Health Ministry of Interior Ministry of Culture and Tourism TGNA Population and Development Group Turkish Journalists Association Ministry of Defence Ministry of National Education Prime Ministry Ministry of Justice HIV/AIDS National Strategic Action Plan Targets & Strategies Prevention & Support VCT Diagnosis and Treatment Supportive Environment Monitoring & Evaluation Social support Intersectoral Collaboration Vulnerable Populations Commercial Sex Workers Men Having Sex With Man Intravenous Drug Users Prisoners HIV/AIDS (+) Refugees and asylum seekers………. HIV/AIDS Prevention and Support Programme of Turkey Donor Organisation Grant Number Principal Recipient Program Duration Start- End Dates Budget The Global Fund TUR-405-G01-H Ministry of Health 36 Months August 2005 - 15 June 2008 USD 3,891,762 85% out of the total budget has been disbursed Programme cities Ankara, Istanbul, Izmir, Gaziantep and Trabzon Goal To prevent the further spread of HIV through active preventive interventions, especially among the most vulnerable populations, like IDUs, MSM, CSWs and detainees of penitentiary institutions and to support and empower vulnerable populations including PLWHA Objectives To increase the access of CSWs, MSMs, IDUs to health centers for preventive HIV/AIDS services To increase the access of general population to VCT services and carry out their instituationalisation To improve the access of psychosocial support services for PLHA and improve national legislative framework To improve preventive HIV services in prisons and detention centers To improve national STIs/HIV/AIDS monitoring and evaluation system Activities Awareness raising activities for NGOs Training of outreach workers Training of police officers 14 VCT centers, VCT Training for health staff Produce and distribution of outreach services and VCT materials (brochures, posters, VCT guidelines, outreach guidelines) Procurement and distribution of rapid HIV tests, condoms, lubricants Monitoring and evaluation Behavioural Survey 13 NGOs; including PLA and PODER, 16 projects, 1,8 million US Dollar Workshop on IDU and HIV/AIDS Workshop on HIV/AIDS and Human Rights Workshop on the Evaluation of VCT Services VCT Media Campaign Voluntary Councelling and Test Centers Turkey Begin to provide service in 2007 to high risk and critical groups in terms of HIV/AIDS • Information about transmission routes and protection from HIV/AIDS • Free and confidential HIV testing, • Pre and post test councelling • Guidance to a healthcare center for treatment HIV/AIDS Tests in Turkey HIV test groups HIV Test Number in Years (2002-2013*) a) Blood donors (mandatory) b) Sex workers (mandatory) c) Volentary Councelling & Test Centers d) Pre-marital councelling e) After risky behavior, f) Pre surgery *Until Oct 2013 Diagnosis Time in Turkey 60,0% CD4+ Hücre/mm3 <200 50,0% 40,0% 30,0% 20,0% n=59 200-500 n=55 n=36 n=33 n=39 n=15 10,0% 0,0% <2006 ≥2006 Şekil. Vakaların CD4+ Hücre Sayılarına Göre İki Döneme Göre Dağılımları >500 Barriers to Testing in Turkey • • • • • • • Lack of awareness Stigmatisation- social isolation Cost No quidelines Low numbers of centers for testing Social aspect – patient privacy Homosexual men Hard ro reach groups Sex workers Injecting drug users Prisoners Refugees , illegal immigrants HIV/AIDS TANI TEDAVİ REHBERİ – TÜRKİYE HIV/AIDS Diagnose and Treatment Guideline Turkey 2013 KLİNİK KATEGORİ CD4 T HÜCRESİ SAYISI ÖNERİLEN Semptomatik hasta Herhangi bir değer Tedavi başlanmalı Asemptomatik hasta <350 hücre/mm3 Tedavi başlanmalı 350-500 hücre/mm3 Tedavi başlanması yararlıdır. Hastanın özel koşullarına göre tedavi önerilir. Asemptomatik hasta Asemptomatik hasta >500 hücre/mm3 Tedavi başlanabilir. Hastanın özel koşulları değerlendirilerek, istekli ve hazırsa tedavi önerilebilir. Turkish Ministry of Health 2013 TURKEY - TÜRKİYE People newly infected with HIV UNAIDS global AIDS epidemic report 2012 Slide 33