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AIDS at 25: A Global Perspective

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1 AIDS at 25: A Global Perspective

2 AIDS at 25: A Global Perspective
The early years—a historical perspective AIDS in the developing world

3 Friedland, G. “AIDS: The First Quarter Century
Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course.

4 NYC and AIDS Epidemiologic Characterization
First reports of AIDS Infants of mothers with AIDS Heterosexual transmission IDU Most convincing reports of Lack of transmission by close contact Low risk for occupational infection Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course. GH Friedland, MD

5 Denial, Despair, Discrimination
Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course.

6 Why AIDS Is Different Nature of the disease itself Young men and women
Epidemic of death and dying Fear of transmission Rooted in intimate behaviors Stigma, stereotypes, and secrecy Mortality Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course.

7 Denial and Despair, to Therapeutic Optimism, to Therapeutic Balance
NYC Incidence, Prevalence, and Mortality 14,000 100,000 Clinical Milestones in the History of the HIV/AIDS Epidemic Reported Persons Living with 90,000 12,000 1987: AZT HIV (non-AIDS) 1988: PCP prophylaxis 80,000 1992: Combination therapy 1994: ACTG 076: AZT reduces perinatal transmission 10,000 1995: Protease inhibitors 70,000 1996: HAART 60,000 8,000 Reported Persons Living with AIDS Deaths Reported AIDS Cases Number of Reported AIDS Cases and Deaths Number of Reported PLWHA* 50,000 6,000 40,000 4,000 30,000 Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course. 20,000 2,000 10,000 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Calendar Year CDC AIDS case First cases of PCP, KS AIDS case definition (23 OIs) NYS expands AIDS 1998 NYS HIV reporting law reported from NYC, LA reporting reporting to include HIV takes effect mandated First commercial EIA, AIDS case definition AIDS enters the by NYS HIV identified as screening of US blood expanded (CD4 <200, nomenclature causative agent supply begins *PLWHA=Persons living with HIV/AIDS 26 OIs) New York City,

8 AIDS: The First Quarter Century New York City
>150,000 have been diagnosed with AIDS 90,000 (60%) have died ~100,000 diagnosed and living with HIV/AIDS ~35,000 with HIV, ~65,000 with AIDS Remains epicenter of HIV/AIDS epidemic in US Highest AIDS case rate in US, more than Los Angeles + San Francisco + Miami + Washington, DC >25,000 living with HIV not tested or known to be infected Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course. Slide courtesy of Dr. Torian, BHIV Epi Prgm.

9 AIDS and the United States
> 1 million living with HIV/AIDS 500, ,000 (50%-60%) have died At peak, leading cause of death in young men and women in 15 US cities Demographic changes Largest population MSM, but increasingly an epidemic of poverty, people of color, women, and heterosexual transmission 40,000 new infections per year Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course.

10 Trends in Annual Rates of Death From Leading Causes of Death Among Persons Years Old, USA, 40 Unintentional injury 35 Cancer 30 25 Heart disease 20 Suicide Deaths per 100,000 Population 15 HIV infection 10 Homicide Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course. 5 Chronic liver disease 82 84 86 88 90 92 94 96 98* Stroke Year Diabetes *Preliminary 1998 data National Center for Health Statistics, National Vital Statistics System

11 Social Change and HIV Transmission The Seed and the Wind
IV drug route, “shooting galleries,” cocaine “fourth world” Sexual behavior/practice Gender inequality Migration, urbanization, and detribalization International travel Widespread manufacture and distribution of blood components Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course.

12 Lessons in HIV/AIDS Prevention
Denial is not a river in Egypt Prevention works but can’t start too early The goal is not elimination of risk but its reduction Both communitywide and targeted interventions Integrate prevention and care, biology and behavior Focus on HIV+s and HIV-s Understand belief, meaning, and practice Don’t beat around the Bush Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course.

13 Lessons in HIV/AIDS Care
Comprehensiveness Continuity Competence Compassion Colleagueship Cost-effectiveness Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course.

14 AIDS at 25: A Global Perspective
The early years—a historical perspective AIDS in the developing world

15 Adults and Children Estimated to Be Living With HIV at the End of 2005
Western & Central Europe 720,000 (570,000–890,000) North Africa & Middle East 510,000 (230,000–1.4 million) Sub-Saharan Africa 25.8 million (23.8–28.9 million) Eastern Europe & Central Asia 1.6 million (990,000–2.3 million) South & Southeast Asia 7.4 million (4.5–11.0 million) Oceania 74,000 (45,000–120,000) North America 1.2 million (650,000–1.8 million) Caribbean 300,000 (200,000–510,000) Latin America 1.8 million (1.4–2.4 million) East Asia 870,000 (440,000–1.4 million) Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course. Total: 40.3 (36.7–45.3) million

16 Number of people living with HIV
Estimated Number of Adults and Children* Living With HIV by Region, 1986–2005 Millions 45 Oceania 40 North Africa & Middle East 35 Eastern Europe & Central Asia 30 Western and Central Europe and North America 25 Number of people living with HIV Latin America and Caribbean 20 Asia 15 Sub-Saharan Africa 10 Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course. 5 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 * Under 15 years old AIDS Epidemic Update, December 2005.

17 Challenges Facing the New African Nations
Very fragile and volatile links bound myriad ethnic groups within nations Africa was the poorest, least developed region on the planet Climate harsh and variable At least 80% of the population engaged in subsistence agriculture without education or health services Economies had been built to serve colonial interests Rapidly enlarging populations and urban migration Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course.

18 Challenges Facing the New African Nations
Drastic shortage of skilled workforce Adult literacy at 16% Of 200 million people, only 8000 secondary school graduates, half from Ghana and Nigeria Most states had fewer than 200 students in university training, none in former French colonies At independence, 75% of higher level personnel in government and business were foreigners Kinship and ethnicity became the route to power Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course.

19 In 50 African Countries in 1989
Opposition parties were illegal in 32 states Almost all were one-party states or military dictatorships In 29 countries, 150 elections held between 1960 and 1989 never allowed a single seat to go to the opposition parties Only Senegal, Botswana, and Gambia maintained multiparty politics with regular elections … A survey of 20 African countries in 1995 revealed that half had 25 or fewer fully qualified accountants in the entire public sector Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course.

20 Developing World: Emerging Results of ART Trials
A summary of 28 articles and abstracts up to February 2005 of ART in Africa shows: Median sample size of 139 monitored for about 6 months 74.5% received 2 NRTIs and an NNRTI Mean CD4 increase was cells/µl over a mean of 10.4 months Among 21 studies assessing VL, a median of 73% of patients achieved undetectable VL Participants achieving >95% adherence ranged between 68% and 99% In 5 studies assessing resistance, at least 1 mutation was detected in 10.1% Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course. Akileswaran C, et al. CID. 2005;41:

21 Developing World: Emerging Results of ART Trials
Experience in 8 clinics in western Kenya enrolling 2059 adults between November 2001 and February 2005 With median f/u of 40 weeks, 5.4% died and 24.5% lost to f/u CD4 increase was 160, 225, and 297 cells/µl at 12, 24, and 36 months Adherence in 1766 patients was perfect in 78% Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course. Wools-Kaloustian K, et al. AIDS. 2006;20:41-8.

22 Developing World: Emerging Results of ART Trials
Efficacy of ART in the first 1004 consecutive ART-naive patients in Haiti enrolled over 14 months starting March 2003 Initial median CD4 was 131 cells/µl 87% alive 1 year after initiating therapy At 12 months median CD4 increase was 163 cells/µl 11% experienced treatment-limiting toxicity Of subgroup of 100 patients followed weeks, 76% had VL <400 copies/mL Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course. Severe P, et al. NEJM. 2005;353:

23 Developing World: Emerging Results of ART Trials
In an urban public clinic in Gaborone 153 ART-naive patients with median CD4 69 cells/µl initiated therapy: 2/3 with DDI, d4T, and either EFV or NVP Mean CD4 increase was 149 cells/µl at 24 weeks, 204 cells/µl at 48 weeks HIV RNA was <400 copies/mL in 87% at 24 weeks and 79% at 48 weeks1 In an urban public clinic in Kampala 137 ART-naive patients on continuous ART for at least 12 weeks 66% had VL <400 copies/mL after median of 38 weeks 22% of patients on NNRTIs developed resistance; treatment interruption due to finances and drug availability occurred2 Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course. 1. Wester CW, et al. JAIDS. 2005;40: 2. Spacek LA, et al. CID. 2006;42:252-9.

24 Developing World: Emerging Results of ART Trials
In Cape Town, South Africa, all in-program deaths among ART-naive patients in ART program were evaluated between September 2002 and March 2005 A high pretreatment mortality rate of 35.6 deaths/100 person-years decreased to 2.5/100 person-years at 1 year among those who received ART Risk of death independently associated with CD4 count and WHO clinical stage Within the first 90 days from enrollment, 66% of the deaths occurred in patients not yet on ART; 80% had stage IV disease or CD4 count <50 cells/µl Utilizing only on-treatment analysis underestimates early mortality Most deaths were attributed to wasting syndrome, tuberculosis, acute bacterial infections, malignancy, and immune reconstitution disease Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course. Lawn SD, et al. AIDS. 2005;19:

25 Developing World: Current Quandaries
Point of therapy initiation Detection and treatment of OIs, especially in advanced patients before initiation of therapy Dilemmas with current first regimens Monitoring for efficacy and toxicity Switching therapy for failure—how and to what Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course.

26 Developing World: Current Quandaries
Critical consequences of underdevelopment Critical shortages of capable healthcare professionals Need for expedient and practical initial and ongoing training Incentives to retain capable professionals within their countries and providing care to patients Lack of infrastructure capacity to support care delivery Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course.

27 The “Three Ones” of UNAIDS
International Tactical Plan to Maximize Use of Limited Resources Within Individual Nations The “Three Ones” of UNAIDS One comprehensive national AIDS framework fully negotiated, endorsed, and costed by key stakeholders One national AIDS coordinating authority, recognized in law and with multisectorial support and technical capacity One national monitoring and evaluation system integrated into the national AIDS framework Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course.

28 “Traps and Legacies: The Whirlpool”
“…it will be difficult to make a difference in the AIDS epidemic if HIV is viewed in isolation from its root social, economic, and political context; or if it is seen only as a medical problem or as an issue of individual behavior change…” Disunity, denial, stigma, and competing sources of power and authority undermine capacity for response Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course.

29 “Tough Choices— Africa Takes a Stand”
“…while there are enormous odds to overcome, there is much that countries in Africa can do with their own resources to grow their economies, to prioritize developmental objectives, to lay the foundation for future growth and development, and to reduce the incidence and prevalence of AIDS.” African countries on their own efficiently build capacity within overall health structures, recognizing AIDS as indication of overall crisis of underdevelopment, poverty, and poor governance. Sustained increases in international aid falters. Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course.

30 “Times of Transition: Africa Overcomes”
“Pan-African solidarity and high levels of regional co-operation…put public good before private office. AIDS acts as an international catalyst for the formation of a new global covenant, involving security and human rights agendas brought together in a coherent international framework that encompasses economics, trade, social justice, and political reform.” National autonomy is promoted, African resources are consistently amplified in ways that do not engender dependency, and marked strides in healthcare development are possible. Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course.

31 Potential Outcomes for Scenarios
Adults and Children, Scenario: Times of Transition Traps and Legacies Tough Choices Indicator Cumulative program cost (US$ billion) 195 98 70 Cumulative deaths from AIDS ( , million) 67 75 83 Harris, C. “HIV Management in Resource-Limited Settings.” From HIV Management 2006: The New York Course. Cumulative new infections (million) 46 65 89 Cumulative infections averted (million) 43 24 UNAIDS, AIDS in Africa Scenarios Project; historical data: UNAIDS, 2004 Report on the Global AIDS Epidemic

32 Progress Toward "3 by 5" Targets
Sudan 20 countries with the highest ARV need China Botswana TARGET MET People receiving ARV therapy Russian Federation Cameroon As of June 2004 Côte d'Ivoire June to December 2004 Uganda Thailand TARGET MET January to June 2005 Malawi Zambia People still needing treatment to reach "3 by 5" target Republic of Congo Mozambique Kenya Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course. Ethiopia Tanzania Brazil TARGET MET Zimbabwe Nigeria India South Africa 50K 100K 150K 200K 250K 300K 350K 400K 450K 500K WHO, 2005

33 HIV/AIDS: The Next 25 Years— The Long Haul
HIV/AIDS will be with us for the rest of human history Transmission and disease burden will increase, with attendant personal and societal danger and disruption More resources/sustaining current resources More focus on human rights New and more effective prevention strategies Vaccine, microbicides, structural, behavioral Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course.

34 HIV/AIDS: The Next 25 Years— The Long Haul
Growth of comprehensive systems of care Integration of prevention with care HIV and TB Substance abuse and HIV New, more potent, and less expensive drugs Equity—provision of prevention, care, and treatment worldwide New generation of unsung heroes and heroines Friedland, G. “AIDS: The First Quarter Century.” From HIV Management 2006: The New York Course.


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