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Pediatric HIV Infection in Developing Countries Chokechai Rongkavilit Pediatric Infectious Diseases.

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Presentation on theme: "Pediatric HIV Infection in Developing Countries Chokechai Rongkavilit Pediatric Infectious Diseases."— Presentation transcript:

1 Pediatric HIV Infection in Developing Countries Chokechai Rongkavilit Pediatric Infectious Diseases

2 Objectives: Scope and basic information of pediatric HIV epidemic International efforts and research interest to deal with the epidemic

3 BASIC INFORMATION Pediatric HIV Epidemic

4 AdultsChildren (<15 y) % adults who are women Adult prevalence rate (%) Sub-Saharan Africa 26,500,0002,800, South & Southeast Asia 5,800,000240, East Asia & Pacific1,200,0004, Eastern Europe & Central Asia 1,200,00016, Latin America1,500,00045, Western Europe & North America 1,530,00015, Estimated number living with HIV/AIDS by end 2003

5 GlobalAIDS epidemic 1990−2003 Global AIDS epidemic 1990− Millions Number of people living with HIV and AIDS Year % HIV prevalence adult (15-49) Source: UNAIDS/WHO, 2004 Number of people living with HIV and AIDS % HIV prevalence, adult (15-49) 2004 Report on the Global AIDS Epidemic (Fig 1)

6 Karnataka % HIV prevalence Year * Data from consistent sites Median HIV prevalence in antenatal clinic population in Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu, India, 1998−2003* Source: National AIDS Control Organization Andhra PradeshMaharashtraTamil Nadu 2004 Report on the Global AIDS Epidemic (Fig 2)

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8 Estimated number of new HIV infections in Thailand by year and changing mode of transmission Year New HIV infections (number of people, in thousands) Spouse: heterosexual transmission of HIV in cohabiting partnerships; SW: HIV transmission through sex work IDU: HIV transmission through injecting drug use; MTCT: mother to child transmission of HIV Source: Thai Working Group on HIV/AIDS Projections, 2001 SW 90% Spouse 5% IDU 5% Spouse50% IDU 20% SW 15% MTCT 15% 2004 Report on the Global AIDS Epidemic (Fig 4)

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10 Epidemic in sub-Saharan Africa 1985− Millions Number of people living with HIV and AIDS % HIV prevalence adult (15-49) Number of people living with HIV and AIDS % HIV prevalence, adult (15-49) Year Source: UNAIDS/WHO, Report on the Global AIDS Epidemic (Fig 5)

11 Life expectancy at birth in selected most affected countries, 1980 − 1985 to 2005 − 2010 Source: UN Population Division, World Population Prospects: the 2002 Revision 2004 Report on the Global AIDS Epidemic (Fig 12) Years Botswana South Africa Swaziland Zambia Zimbabwe

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13 Central Africa Eastern Africa Southern Africa Western Africa Number of orphans (millions) REGIONS Orphans per region within sub-Saharan Africa, end 2003 Source: UNAIDS, Report on the Global AIDS Epidemic (Fig 15)

14 Problems among children and families affected by HIV/AIDS Source: Williamson, Jan (2004) A Family is for Life (draft), USAID and the Synergy Project. Washington. Deaths of parents and young children HIV infection Children without adequate adult care Economic problems Children may become caregivers Increased vulnerability to HIV infection Discrimination Exploitative child labour Sexual exploitation Life on the street Children withdraw from school Inadequate food Problems with shelter and material needs Reduced access to health-care services Increasingly serious illness Problems with inheritance Psychosocial distress 2004 Report on the Global AIDS Epidemic (Fig 15a)

15 International efforts to deal with the epidemic

16 Bridging the gap between the rich and the poor Prevention/Education Comprehensive prevention & education programs Prevention of mother-to-child transmission (PMTCT Plus) Microbicide (chemical condom) research programs Bill and Melinda Gates Foundation International Working Group on Microbicides HIV Vaccine US NIH, CDC, ANRS International AIDS Vaccine Initiative

17 Prevention of Mother-to-Child Transmission International perinatal HIV studies ACTG 076 Thailand Retro-CI DITRAME PETRA-A PETRA-B PETRA -C HIVNET 012 SAINT NVAZ 14 wk 36 wk labor delivery 1 wk 6 wk Transmission rate 7.6 % 9.5 % 15 % 17 % 8 % 12 % 19 % 12 % 10 % 7.7% AZTAZT+3TCNVP FF BF

18 Sub-Saharan Africa South & South- East Asia Latin America & the Caribbean Eastern Europe & Central Asia Note:For each region, the percentage is shown for countries with low, median and high values % Percentage of young women (15−24 years old) with comprehensive HIV and AIDS knowledge, by region, by 2003 Source: United Nations Development Programme (2002), Botswana AIDS Impact Survey (BAIS 2001): Survey Results and Indicators Summary Report. Gaborone; UNICEF, Multiple Indicator Survey (2000); FHI, Behavioural Surveillance Survey (2001) and; Measure DHS+, Demographic and Health Surveys, ( ) 2004 Report on the Global AIDS Epidemic (Fig 32)

19 * Cameroon, Democratic Republic of Congo, Kenya, Malawi, Rwanda, South Africa, Uganda, Zambia and Zimbabwe ** Cumulative through June Voluntarily counselled Tested (of those voluntarily counselled) Received results (of tested) HIV+ women (of tested) Mothers on Nevirapine (of HIV+ women) Babies on Nevirapine (of those born to HIV+ women) % Source: Elizabeth Glaser Pediatric AIDS Foundation Pregnant women attending antenatal clinics, served by 'Call to Action' programme in Africa*, 2000−2003** (N = 416,498) 2004 Report on the Global AIDS Epidemic (Fig 28)

20 Voluntarily counselled Tested (of those voluntarily counselled) Received results (of tested) HIV+ women (of tested) Mothers on Nevirapine (of HIV+ women) Babies on Nevirapine (of those born to HIV+ women) % * Dominican Republic, Georgia, India and Thailand ** Cumulative through June 2003 Source: Elizabeth Glaser Pediatric AIDS Foundation Pregnant women attending antenatal clinics, served by 'Call to Action' programme outside Africa*, 2000−2003** (N = 243,103) 2004 Report on the Global AIDS Epidemic (Fig 29)

21 MTCT-Plus Initiative MTCT = mother-to-child transmission A new major program to combine prevention and treatment for HIV-infected women and their families Coalition of private foundations, UN and Columbia University $100 million funding for 5 years Targets: MTCT centers or programs worldwide Family-centered care and treatment –Service package: education, counseling, psychosocial support, antiretroviral therapy, prophylaxis and treatment of HIV complications Community outreach

22 Bridging the gap between the rich and the poor Treatment Anti-HIV therapy Improves rates of morbidity & mortality Prolongs lives Improves quality of life Revitalises communities Transforms perception of AIDS from a deadly disease to a manageable, chronic illness However, less than 7% of those in developing world have access to the drugs (half of these live in one country, Brazil)

23 400,000 people on treatment: 7% coverage % Source: UNAIDS/WHO, 2004 Antiretroviral therapy coverage for adults, end 2003 AfricaAsiaLatin America and the Caribbean Eastern Europe and Central Asia North Africa and Middle East 2004 Report on the Global AIDS Epidemic (Fig 33)

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25 TRIPS safeguards TRIPS = WTO Agreement on Trade Related Aspects of Intellectual Property Rights TRIPS gives patents on medicine for a certain period of time (monopoly to patent-holders)

26 TRIPS safeguards Countries can counter TRIPS by building TRIPS-compliant safeguards –Compulsory Licensing Break patents and grant licensing for local production of drugs in case of national public health threat (Doha Declaration) –Parallel importation Allows a country to shop around for the best price of a branded drug on the global market

27 Global Effort in HIV Therapy Global Fund to Fight HIV, TB and Malaria President’s Emergency Plan for AIDS Relief Clinton Foundation WHO “3 by 5”

28 Global Fund to Fight AIDS, TB and Malaria Scale up antiretroviral therapy in resource-limited settings Collaborative effort United Nations: UNAIDS, UNICEF, UNESCO WHO Family Health International (FHI) World Bank Local governments Non-government organizations (NGO) and private sectors Philanthropic foundations

29 Global Fund to Fight AIDS, TB and Malaria Initiated by UN Secretary General Kofi Annan in 2001 A financial instrument to complement existing programs addressing AIDS, TB and malaria It concentrates on generating additional resources and making them available at the community and country levels. 60% supports HIV/AIDS prevention and treatment programs (including purchasing HIV drugs).

30 The Global Fund to Fight AIDS, Tuberculosis and Malaria Pledges and contributions received, as of December 31, 2003 EC 11% Italy 9% Germany 7% U.K. 6% Other Govt’s 7% Japan 5% Netherlands 3% Canada 2% Corporate/Private* 2% France 14% U.S. 33% EC 19% Italy 10% Germany 2% U.K. 6% Other Govt’s 10% Japan 8% Netherlands 2% Canada 2% Corporate/Private* 5% France 6% U.S. 30% Total pledges: US$ 4,966 million Total contributions received: US$ 2,104 million *Foundations and Non-for-profit organizations, Corporations, and Individuals, Groups and Events Source: THE GLOBAL FUND ANNUAL REPORT 2003, January 1 - December 31, Report on the Global AIDS Epidemic (Fig 42)

31 Global resources needed for prevention, orphan care, care and treatment and administration and research 2004−2007 (in US$ millions) PreventionOrphan careCare & treatmentAdmin & Research 0 5,000 10,000 15,000 20, US$ millions 2004 Report on the Global AIDS Epidemic (Fig 36)

32 President Bush’s Emergency Plan for AIDS Relief Focusing significant new resources in 15 countries ($9 billion) Commitment to provide prevention and treatment services ABC Model: Abstinence, Be faithful, Condoms US Global AIDS Coordinator: coordinate all US government HIV/AIDS activities worldwide

33 The Clinton HIV/AIDS Initiative (CHAI) Developing "business plans" for bringing integrated care, treatment, and prevention programs to large numbers of people Assisting in presenting the plan to donor governments, foundations, multilateral organizations, and private corporations to help mobilize the financial resources Negotiating supplier agreements for low-priced drugs and medical equipment Primary focus: Africa, Caribbean and China

34 Reducing the price of HIV drugs Encouraging generic competition This is one of the most powerful tools that country policymakers have to lower prices. Brazil d4T + 3TC + NVP $712 $347 Galvão J. Lancet.

35 Source: UNAIDS/WHO, Price US$ Jun 00 Oct 00 Feb 01 Apr 01 Dec 00 Nov 00 Jul 01 Mar 03 Sep 98 Aug 98 Jul 98 Oct 03 Jun 98 Sep 03 Jan 01 May 01 Aug 01 Mar 10 Jun 01 Launch of Accelerating Access Initiative (AAI) Negotiatiations with R & D Pharma within AAI Generic companies’ offer of price reduction to Uganda Further price reductions by AAI companies Further discussion with generic companies Negotiations by William J. Clinton Foundation with 4 generic companies Mar 01 Apr 01 Oct 03 Jun 01 May 01 Feb 01 Jan 01 Dec 00 Nov 00 Jul Price US$ Prices (US$/year) of a first-line antiretroviral regimen in Uganda: 1998− Report on the Global AIDS Epidemic (Fig 34)

36 WHO 3 by 5 Initiative Providing antiretroviral treatment to three million people living with AIDS in developing countries and by the end of WHO and UNAIDS will focus on five critical areas: Simplified, standardized tools to deliver antiretroviral therapy. A new service to ensure an effective, reliable supply of medicines and diagnostics. Rapid identification, dissemination and application of new knowledge and successful strategies. Urgent, sustained support for countries. Global leadership, strong partnership and advocacy.

37 0 3,000 6,000 9,000 12,000 15, Before ART 2002 ART started Khayelitsha: Availability of decentralized antiretroviral therapy (ART) access, advocacy, and multi-disciplinary support services dramatically increases demand for testing and counselling HIV tests Support groups Source: WHO, 2004 (courtesy of Dr. Fareed Abdullah) 2004 Report on the Global AIDS Epidemic (Fig 27)

38 Pediatric treatment guidelines USAEUWHOThailand When to start ARV Symptomatic A,B,C CD4 <25% All <1 y For >1 y +asymp -VL 100,000 -Dropping CD4 Symptomatic B,C CD4 <20% ?All <1 y For >1 y+asymp -VL 100,000 -CD4 <20% <18 mo -WHO stage III -(CD4 <20%) >18 mo -WHO stage III -(CD4 <15%) What to start 2NRTI+LPV 2NRTI+NFV 2NRTI+RTV 2NRTI+EFV 2NRTI+NVP 2NRTI+PI 2NRTI+EFV 2NRTI+NVP ZDV+3TC+NVP ZDV+3TC+EFV ZDV+3TC+ABC Stage A,B and CD4 >15% -2NRTI+PI -2NRTI+NNRTI -2NRTI Stage C or CD4 <15% -2NRTI+PI -2NRTI+NNRTI Monitoring CD4 VL q 3 mo Resistance CD4 VL Resistance TDM Clinical Growth CD4 Clinical Growth CD4

39 Many questions remain… How will an HIV drug program affect or change stigmatization and perception of HIV in community levels? What will the effect of HIV care be on community in regard to prevention practices? What monitoring tools can be used in the resource-limited setting? What are the determinants of adherence to ARV therapy and what is necessary to develop sustainable adherence practices? What is an affordable household expenditure for HIV care with ARV therapy? How will an HIV drug program affect drug resistance dynamics and other co-morbidity such as TB in community/country levels? And many many more…

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