1. 25 Years of HIV – Africa and beyond Carol Ciesielski, MD
Centers for Disease Control and Prevention
Chicago Dept of Health

2. Simian Immunodeficiency Virus (SIVcpz )
Origins of HIV-1
Simian Immunodeficiency Virus (SIVcpz )
HIV-1
1930s
Leap to Humans

3. Origins of HIV-1 HIV remained unnoticed in isolated populations.
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
1930s –leap to human from chimpanzees ~
1st human case from Kinshasa 1959

4. Already 30% gay men in San Francisco HIV+

5. Leading causes of death globally, 2001
Rank % of total
1 Ischaemic heart disease
2 Cerebrovascular disease
3 Acute lower respiratory infections
4 HIV/AIDS
5 Chronic obstructive pulmonary disease
6 Perinatal conditions
7 Diarrhoeal diseases
8 Tuberculosis
11 Malaria
12.7
9.9
7.1
4.8
4.2
4.0
3.0
1.9
Source: The World Health Report 2000, WHO

6. HIV Transmission Sexual: Blood: blood or blood/tissue products
Heterosexual ♂♀ >> ♀ ♂
Male to male
Blood: blood or blood/tissue products
Injection drug use
Medical injections
Perinatal (Vertical): mother to child

7. 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)

8. 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 1

9. Factors Facilitating HIV Pandemic
Long Period between Infection and Symptoms (average years)
Individual: long period of silent infection & infectivity
Community: Prevalence >> incidence resulting in an insidious epidemic
HIV persists for life time of human host

10. Global Spread ~65 million persons have been infected
~25 million deaths

11. Global HIV Epidemic, 2005

12. HIV Prevalence -# of persons HIV infected (38.6 million)
HIV Incidence (Number of new infections each year)
HIV related deaths
4.1 million
2.8 million

13. Estimated HIV prevalence in Adults,by Global Region (2005)
HIV cases Epidemic
(estimate) began
Australia, Europe, N America million s, 80s
Latin America, Caribbean million s, 80s
Africa million s,80s
Asia million late 1980s
Eastern Europe million s
Global Total million

17. A Global View of HIV Infection 38.6 million people living with HIV
4.1 million new infections 2005

18. HIV Epidemic in Sub-Saharan Africa, 1985-2005
2.7 million new infections, 2 million deaths
st AIDS case

19. 38.6 million
4.1 million
2.8 million

20. Leading causes of death in Africa, 2001
Rank % of total
1 HIV/AIDS
2 Acute lower respiratory infections
3 Malaria
4 Diarrhoeal diseases
5 Perinatal conditions
6 Measles
7 Tuberculosis
8 Cerebrovascular disease
9 Ischaemic heart disease
10 Maternal conditions
20.6
10.3
9.1
7.3
5.9
4.9
3.4
3.2
3.0
2.4
Source: The World Health Report 2000, WHO

21. HIV Prevalence (%) in Adults in Africa, 2005
Adult Prevalence Rate

22. HIV prevalence among 15–24 year-old men and women, selected countries in sub-Saharan Africa, 2001–2005
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 (Zimbabwe); Pettifor AE, et al. HIV and sexual behaviour among young South African: a national survey of year olds (South Africa). 5 10 15 20
Ghana 2003
Burkina Faso 2003
Mali 2001
Tanzania 2003
Cameroon 2004
Uganda 2004/05
Kenya 2003
Zambia 2002
South Africa 2002
Lesotho 2004
Zimbabwe 2001/02
% HIV prevalence
AIDS epidemic update, December Fig 3
Women
Men

24. 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

25. HIV Prevalence (%) among pregnant women attending antenatal clinics in Southern Sub-Saharan Africa,

26. Africa -Economic Impact of HIV in Hardest Hit Countries
Annual per capita growth in half of the countries is falling by %.
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.

27. South Africa 57% are women
2nd highest number of persons living with HIV/AIDS in the world ~ 5.5 million/population 45 million;
~19% HIV+
60%-70% military HIV+
57% are women
in year olds, females are 3 x more likely to be infected than males

28. HIV prevalence among pregnant women in South Africa, 1990 to 20015 10 15 20 25 30
HIV prevalence (%)
1990
‘91
‘92
‘93
‘94
‘95
‘96
‘97
‘98
‘99
‘01
2000
Source: Department of Health, Republic of South Africa

29. Number of people who died from HIV/AIDS
in sub-Saharan Africa,
2,500
Thousands
2,000
1,500
1,000
500
1980
1983
1986
1989
1992
1995
1998
2001
Source: UNAIDS, 2002

32. Projected population structure with and
without the AIDS epidemic, Botswana, 2020 80
Projected population
structure in 2020 75 70
Males
Females 65
Deficits due to AIDS 60 55
Age in years 50 45 40 35 30 25 20 15 10 5
140
120
100 80 60 40 20 20 40 60 80
100
120
140
Population (thousands)
Source: US Census Bureau, World Population Profile 2000

34. 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

35. Has Epidemic Peaked in Sub Saharan Africa?
Adult prevalence stable in many countries
Stable or declining prevalence ? Leveling off vs increase in deaths

36. World’s fastest growing epidemic- started in late 1990’s— 1
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

37. 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

38. Russia: 860,000 infected
Predictions of 5-8 million infected by 2010

39. Newly diagnosed HIV infections per million population
in Eastern European and Central Asian countries,
1996—2003
Source: (1) HIV /AIDS Surveillance in Europe, EuroHIV mid-year report 2003, no (2) AIDS Foundation East West
200
400
600
800
1,000
1,200
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
New HIV
infection
per million
population
Estonia
Russian Federation
Ukraine
Belarus
Moldova, Republic of
Latvia
Kazakhstan
Uzbekistan
Kyrgyzstan
2004 Report on the Global AIDS Epidemic (Fig 9)

40. St. Petersburg, Russia, Rate of HIV per 100,000 Population

42. 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 to

43. Prevalence of syphilis among pregnant women
attending antenatal clinics in the Moscow region,
1993 to 1997
800
700
600
Prevalence per 100,000
500
400
300
200
100
1993
1994
1995
1996
1997
Source: Borisenko KK et al. Int J STD & AIDS, 1999, 10:

44. 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.

45. 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

46. Epidemic in Eastern Europe is Maturing
Increasing sexual transmission (6% infections in % 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

47. 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

48. High Proportion of Men who Inject Drugs are also Clients of Sex Workers. Most do not Use Condoms

49. 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).

50. Transmission of HIV in Asia
Most infections occur through unsafe commercial sex
injecting drugs with contaminated equipment

51. What do Asian epidemics look like?
FSW
Clients
MSM
IDUs
Low or no risk
males
Low or no risk
females
Multiple interlinked & interrelated epidemics in higher risk populations and their immediate sex partners
In Africa, HIV has spread mainly through casual heterosexual relationships in the population at large. In contrast, Asian epidemics consist almost entirely of multiple interlinked and interrelated epidemics in higher risk populations and their immediate sexual partners.
The key populations involved include:
Injecting drug users – epidemics among injectors have played a key role in China, Vietnam, and Malaysia
Men who have sex with men – while this has been largely an ignored epidemic in Asia, recent HIV surveys in Jakarta, Bangkok and Phnom Penh have all found roughly one in seven of these men infected with HIV.
Sex workers and their clients – this is by far the largest component of the epidemics in Asia and the source of most male heterosexual infections.
And finally we have the “low risk” female partners of these higher risk men. It is worth noting that over 80% of women infected in Asia have no risk behavior at all by conventional definitions – they contracted HIV in what they thought was a “monogamous” relationship with their husbands.
The term “general population spread” (by which I mean the “boyfriend-girlfriend” driven transmission we see in Africa) really doesn’t apply in Asia, because female sexuality is extremely constrained.
 But does this concentration of HIV in higher risk populations and their immediate partners mean that Asian epidemics will naturally be quite limited in their extent?
~10% Asian men go to sex workers

52. HIV prevalence in Asia, 2003 Spread through IDUs, sex workers
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
When it comes to the HIV/AIDS epidemic, Asia is a land of true diversity and contrast. A number of countries, for example Burma, Cambodia and Thailand shown in darker blue here, have high adult HIV levels of 2 to 3 percent. Others such as Bangladesh, Laos and the Philippines have some of the lowest rates of HIV in the world. But as time goes on, fewer and fewer countries fall in this category and several countries such as China, Indonesia and Vietnam have epidemics in transition – they have experienced recent and dynamic changes in their epidemics after an extended period of low prevalence.
But despite strong evidence that HIV continues to spread in most Asian countries, complacency seems to be setting in. Outside of Thailand and Cambodia surveillance is often poor or incomplete, national responses to the epidemic remain weak, and the coverage of prevention programs is extremely limited.
In the next few minutes, I’d like to speak with you about:
•What drives Asian epidemics and why we see major differences around the region,
•Where these epidemics are likely to go, and
•What analysis of epidemic dynamics tells us we should do about it.
Spread through IDUs, sex workers

53. 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

54. Expanding HIV/AIDS Epidemic in China
1985
1995
1989
1998
Source: UNAIDS
650,000 HIV+ in 2004; 80% IDU & commercial sex

55. Estimated that ~10% of Asian Men Buy 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

57. 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

58. Focusing on persons 25 to 44 years old emphasizes the importance of HIV disease among causes of death. Compared with rates at other ages, the rate of death due to HIV disease is relatively high in this age group, but rates of death due to other causes are relatively low. Of all deaths due to HIV disease, about 70% have occurred among persons 25 to 44 years old.
HIV disease was the leading cause of death among persons 25 to 44 years old in 1994 and In 1995, HIV disease caused about 32,000 deaths, or 20% of all deaths in this age group (based on ICD-10 rules for selecting the underlying cause of death). The rank of HIV disease fell to 5th place from 1997 through 2000, and to 6th place in 2001 and The spike in the rate of death due to homicide in 2001 resulted from the terrorist attack on September 11. In 2002, HIV disease caused about 7,500 deaths, or 6% of all deaths in this age group.

59. HIV/AIDS Treatment Antiretroviral Therapy (ART), available 1996 by 1997, death, hospitalizations, OIs declined by 60-80%

60. Antiretroviral therapy coverage for adults, Developing World, end 2005
1.3 million people on treatment: 10 20 30 40 50 60 %
Source: UNAIDS/WHO, 2004
Antiretroviral therapy coverage for adults, Developing World, end 2005
Africa
Asia
Latin
America and
the Caribbean
Eastern
Europe and
Central Asia
North
Africa and
Middle East
2004 Report on the Global AIDS Epidemic (Fig 33)

61. 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

63. 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

64. Percentage of young people aged 15–24 years
who correctly identified major ways
of preventing the sexual transmission of HIV*, 2003 10 20 30 40 50 60 %
Source: Demographic and Health Surveys. ORC Macro (Burkina Faso, Cameroon, Ghana, Kenya, Madagascar, Mozambique and Nigeria); Tanzania HIV/AIDS
Indicator Survey , TACAIDS, NBS, and ORC Macro (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.
Burkina Faso
Cameroon
Ghana
Kenya
Madagascar
Mozambique
Nigeria
UR Tanzania
AIDS epidemic update, December Fig 4
Female
Male

65. 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