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AIDS at 25: A Global Perspective. The early yearsa historical perspective The early yearsa historical perspective AIDS in the developing world AIDS in.

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Presentation on theme: "AIDS at 25: A Global Perspective. The early yearsa historical perspective The early yearsa historical perspective AIDS in the developing world AIDS in."— Presentation transcript:

1 AIDS at 25: A Global Perspective

2 The early yearsa historical perspective The early yearsa historical perspective AIDS in the developing world AIDS in the developing world

3

4 NYC and AIDS Epidemiologic Characterization First reports of First reports of –AIDS –Infants of mothers with AIDS –Heterosexual transmission –IDU Most convincing reports of Most convincing reports of –Lack of transmission by close contact –Low risk for occupational infection GH Friedland, MD

5 Denial, Despair, Discrimination

6 Why AIDS Is Different Nature of the disease itself Nature of the disease itself Young men and women Young men and women Epidemic of death and dying Epidemic of death and dying Fear of transmission Fear of transmission Rooted in intimate behaviors Rooted in intimate behaviors –Stigma, stereotypes, and secrecy Mortality Mortality

7 Denial and Despair, to Therapeutic Optimism, to Therapeutic Balance New York City, NYC Incidence, Prevalence, and Mortality 0 2,000 4,000 6,000 8,000 10,000 12,000 14, Calendar Year Number of Reported AIDS Cases and Deaths 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90, ,000 Number of Reported PLWHA* First cases of PCP, KS reported from NYC, LA AIDS enters the nomenclature AIDS case definition expanded (CD4 <200, 26 OIs) NYS expands AIDS reporting to include HIV 1998 NYS HIV reporting law takes effect HIV identified as causative agent First commercial EIA, screening of US blood supply begins AIDS case reporting mandated by NYS *PLWHA=Persons living with HIV/AIDS CDC AIDS case definition (23 OIs) Reported Persons Living with HIV (non-AIDS) Reported Persons Living with AIDS Deaths Reported AIDS Cases 1987:AZT 1988:PCP prophylaxis 1992:Combination therapy 1994:ACTG 076: AZT reduces perinatal transmission 1995:Protease inhibitors 1996:HAART Clinical Milestones in the History of the HIV/AIDS Epidemic

8 AIDS: The First Quarter Century New York City >150,000 have been diagnosed with AIDS >150,000 have been diagnosed with AIDS –90,000 (60%) have died ~100,000 diagnosed and living with HIV/AIDS ~100,000 diagnosed and living with HIV/AIDS –~35,000 with HIV, ~65,000 with AIDS Remains epicenter of HIV/AIDS epidemic in US 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 >25,000 living with HIV not tested or known to be infected 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 500, ,000 (50%-60%) have died At peak, leading cause of death in young men and women in 15 US cities At peak, leading cause of death in young men and women in 15 US cities Demographic changes Demographic changes Largest population MSM, but increasingly an epidemic of poverty, people of color, women, and heterosexual transmission Largest population MSM, but increasingly an epidemic of poverty, people of color, women, and heterosexual transmission 40,000 new infections per year 40,000 new infections per year

10 Trends in Annual Rates of Death From Leading Causes of Death Among Persons Years Old, USA, *Preliminary 1998 data National Center for Health Statistics, National Vital Statistics System * Year Deaths per 100,000 Population Unintentional injury Cancer Chronic liver disease Stroke Diabetes Heart disease Suicide HIV infection Homicide

11 Social Change and HIV Transmission The Seed and the Wind IV drug route, shooting galleries, cocaine fourth world IV drug route, shooting galleries, cocaine fourth world Sexual behavior/practice Sexual behavior/practice –Gender inequality Migration, urbanization, and detribalization Migration, urbanization, and detribalization International travel International travel Widespread manufacture and distribution of blood components Widespread manufacture and distribution of blood components

12 Lessons in HIV/AIDS Prevention Denial is not a river in Egypt Denial is not a river in Egypt Prevention works but cant start too early Prevention works but cant start too early The goal is not elimination of risk but its reduction The goal is not elimination of risk but its reduction Both communitywide and targeted interventions Both communitywide and targeted interventions Integrate prevention and care, biology and behavior Integrate prevention and care, biology and behavior – Focus on HIV+s and HIV-s – Understand belief, meaning, and practice – Dont beat around the Bush

13 Lessons in HIV/AIDS Care Comprehensiveness Continuity Competence Compassion Colleagueship Cost-effectiveness

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

15 Adults and Children Estimated to Be Living With HIV at the End of 2005 Total: 40.3 (36.7–45.3) million Western & Central Europe720,000(570,000–890,000) North Africa & Middle East510,000 (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) Oceania74,000(45,000–120,000) North America 1.2 million (650,000–1.8 million) Caribbean300,000(200,000–510,000) Latin America 1.8 million (1.4–2.4 million) East Asia870,000 (440,000–1.4 million)

16 Estimated Number of Adults and Children* Living With HIV by Region, 1986–2005 AIDS Epidemic Update, December Oceania North Africa & Middle East Eastern Europe & Central Asia Western and Central Europe and North America Latin America and Caribbean Asia Sub-Saharan Africa Millions Number of people living with HIV * Under 15 years old

17 Challenges Facing the New African Nations Very fragile and volatile links bound myriad ethnic groups within nations Very fragile and volatile links bound myriad ethnic groups within nations Africa was the poorest, least developed region on the planet Africa was the poorest, least developed region on the planet Climate harsh and variable Climate harsh and variable At least 80% of the population engaged in subsistence agriculture without education or health services At least 80% of the population engaged in subsistence agriculture without education or health services Economies had been built to serve colonial interests Economies had been built to serve colonial interests Rapidly enlarging populations and urban migration Rapidly enlarging populations and urban migration

18 Challenges Facing the New African Nations Drastic shortage of skilled workforce Drastic shortage of skilled workforce Adult literacy at 16% Adult literacy at 16% Of 200 million people, only 8000 secondary school graduates, half from Ghana and Nigeria 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 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 At independence, 75% of higher level personnel in government and business were foreigners Kinship and ethnicity became the route to power Kinship and ethnicity became the route to power

19 In 50 African Countries in 1989 Opposition parties were illegal in 32 states Opposition parties were illegal in 32 states Almost all were one-party states or military dictatorships 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 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 … 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 A survey of 20 African countries in 1995 revealed that half had 25 or fewer fully qualified accountants in the entire public sector

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 Median sample size of 139 monitored for about 6 months 74.5% received 2 NRTIs and an NNRTI 74.5% received 2 NRTIs and an NNRTI Mean CD4 increase was cells/µl over a mean of 10.4 months 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 Among 21 studies assessing VL, a median of 73% of patients achieved undetectable VL Participants achieving >95% adherence ranged between 68% and 99% Participants achieving >95% adherence ranged between 68% and 99% In 5 studies assessing resistance, at least 1 mutation was detected in 10.1% In 5 studies assessing resistance, at least 1 mutation was detected in 10.1% 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 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 CD4 increase was 160, 225, and 297 cells/µl at 12, 24, and 36 months Adherence in 1766 patients was perfect in 78% Adherence in 1766 patients was perfect in 78% 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 Initial median CD4 was 131 cells/µl 87% alive 1 year after initiating therapy 87% alive 1 year after initiating therapy At 12 months median CD4 increase was 163 cells/µl At 12 months median CD4 increase was 163 cells/µl 11% experienced treatment-limiting toxicity 11% experienced treatment-limiting toxicity Of subgroup of 100 patients followed weeks, 76% had VL <400 copies/mL Of subgroup of 100 patients followed weeks, 76% had VL <400 copies/mL Severe P, et al. NEJM. 2005;353:

23 Developing World: Emerging Results of ART Trials In an urban public clinic in Gaborone 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 weeks 1 In an urban public clinic in Kampala 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 occurred 2 1. Wester CW, et al. JAIDS. 2005;40: 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 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 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 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 Utilizing only on-treatment analysis underestimates early mortality Most deaths were attributed to wasting syndrome, tuberculosis, acute bacterial infections, malignancy, and immune reconstitution disease Most deaths were attributed to wasting syndrome, tuberculosis, acute bacterial infections, malignancy, and immune reconstitution disease Lawn SD, et al. AIDS. 2005;19:

25 Developing World: Current Quandaries Point of therapy initiation Point of therapy initiation Detection and treatment of OIs, especially in advanced patients before initiation of therapy Detection and treatment of OIs, especially in advanced patients before initiation of therapy Dilemmas with current first regimens Dilemmas with current first regimens Monitoring for efficacy and toxicity Monitoring for efficacy and toxicity Switching therapy for failurehow and to what Switching therapy for failurehow and to what

26 Developing World: Current Quandaries Critical consequences of underdevelopment Critical shortages of capable healthcare professionals Critical shortages of capable healthcare professionals Need for expedient and practical initial and ongoing training Need for expedient and practical initial and ongoing training Incentives to retain capable professionals within their countries and providing care to patients Incentives to retain capable professionals within their countries and providing care to patients Lack of infrastructure capacity to support care delivery Lack of infrastructure capacity to support care delivery

27 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 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 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 One national monitoring and evaluation system integrated into the national AIDS framework

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… …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 Disunity, denial, stigma, and competing sources of power and authority undermine capacity for response

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. …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. 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.

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. 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. National autonomy is promoted, African resources are consistently amplified in ways that do not engender dependency, and marked strides in healthcare development are possible.

31 Potential Outcomes for Scenarios Adults and Children, Indicator Tough Choices Times of Transition Traps and Legacies Scenario: Cumulative program cost (US$ billion) Cumulative deaths from AIDS ( , million) Cumulative new infections (million) Cumulative infections averted (million) UNAIDS, AIDS in Africa Scenarios Project; historical data: UNAIDS, 2004 Report on the Global AIDS Epidemic 65

32 Progress Toward "3 by 5" Targets WHO, K100K150K200K250K300K350K400K450K500K South Africa India Nigeria Zimbabwe Brazil Tanzania Ethiopia Kenya Mozambique Republic of Congo Zambia Malawi Thailand Uganda Côte d'Ivoire Cameroon Russian Federation Botswana China Sudan 20 countries with the highest ARV need As of June 2004 June to December 2004 January to June 2005 People still needing treatment to reach "3 by 5" target People receiving ARV therapy TARGET MET

33 HIV/AIDS: The Next 25 Years The Long Haul HIV/AIDS: The Next 25 Years The Long Haul HIV/AIDS will be with us for the rest of human history 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 Transmission and disease burden will increase, with attendant personal and societal danger and disruption More resources/sustaining current resources More resources/sustaining current resources More focus on human rights More focus on human rights New and more effective prevention strategies New and more effective prevention strategies –Vaccine, microbicides, structural, behavioral

34 HIV/AIDS: The Next 25 Years The Long Haul HIV/AIDS: The Next 25 Years The Long Haul Growth of comprehensive systems of care Growth of comprehensive systems of care Integration of prevention with care Integration of prevention with care –HIV and TB –Substance abuse and HIV New, more potent, and less expensive drugs New, more potent, and less expensive drugs Equityprovision of prevention, care, and treatment worldwide Equityprovision of prevention, care, and treatment worldwide New generation of unsung heroes and heroines New generation of unsung heroes and heroines


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