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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
1930s
Leap to
Humans
Origins of HIV-1
HIV remained unnoticed in
isolated populations.
1930s –leap to human
from chimpanzees ~
1st human case from
Kinshasa 1959
In 1960s-70s; 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
4.0
3.0
1.9
Source: The World Health Report 2000, WHO
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
19821st 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
2.4
• 10 Maternal conditions
Source: The World Health Report 2000, WHO
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
% HIV prevalence
20
15
Women
Men
10
5
0
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
• 2nd 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
1980
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
0
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
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
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
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
St. Petersburg, Russia, Rate of HIV
per 100,000 Population
250
200
Rate per 150
100,000
population 100
50
0
1996
1997
1998
1999
Year
2000
2001
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 age 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
Low or no risk
males
Multiple interlinked
& interrelated
epidemics in higher
risk populations
and their immediate
sex partners
MSM
IDUs
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
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