HIV/AIDS The Epidemic in ANE and E&E So what do we do now? Paul De Lay Senior Advisor on HIV/AIDS Office of HIV/AIDS

Factors that influence the spread of HIV The Virus The Virus The Host The Host The Role of Behavior The Role of Behavior

The Virus Time of introduction into a population Time of introduction into a population HIV subtypes HIV subtypes Levels of viremia Levels of viremia

HIV-Seroprevalence among Pregnant women from Capital or Major Urban Centers in Selected Countries

The Host (Us) The presence of a sexually transmitted disease The presence of a sexually transmitted disease The age of the person The age of the person Immunologic characteristics Immunologic characteristics Male circumcision Male circumcision

Elements of HIV/AIDS Programs Prevention Blood safety Blood safety Universal precautions Universal precautions Sexual risk reduction Sexual risk reduction Harm reduction Harm reduction Condom social marketing Condom social marketing STI management STI management Voluntary Counseling and Testing Voluntary Counseling and Testing Stigma reduction Stigma reduction Preventing MTCT Preventing MTCT Surveillance and M&E Surveillance and M&E Care and Mitigation Palliative care Palliative care Psychosocial support Psychosocial support Improve nutrition Improve nutrition Effective Treatment of Opportunistic Infections Effective Treatment of Opportunistic Infections Use of Highly Active Anti-Retroviral Therapy Use of Highly Active Anti-Retroviral Therapy Orphans and Vulnerable Children Orphans and Vulnerable Children Other mitigation activities Other mitigation activities

Complex Epidemics In Rapidly Changing Societies Serious localized foci

Comparison of average number of clients per sex worker versus % of young men to utilized sex workers Indonesia Philippines Cambodia Thailand

Behavior change interventions IDU IDU Reduce drug use/harm reduction Reduce drug use/harm reduction MSM MSM Stigma, access Stigma, access Commercial sex workers and their clients Commercial sex workers and their clients Stigma, access Stigma, access

Implications In South and South-East Asia, condom promotion and STI interventions for sex workers top priority In South and South-East Asia, condom promotion and STI interventions for sex workers top priority In Central and Eastern Asia, Europe, LAC and North America, programs for injecting drug users, MSM and, to lesser extent sex workers, top priority In Central and Eastern Asia, Europe, LAC and North America, programs for injecting drug users, MSM and, to lesser extent sex workers, top priority

Providing antiretrovirals Of the 40 million persons infected, about 6-7 million would qualify for ARV Rx Of the 40 million persons infected, about 6-7 million would qualify for ARV Rx 250,000 persons in developing world are on combination ARV 250,000 persons in developing world are on combination ARV WHO has set a target of 3 million persons on ARV Rx by 2005 WHO has set a target of 3 million persons on ARV Rx by 2005 Barcelona update Barcelona update

Should USAID be supporting ARV therapy in ANE and E&E countries Better health infrastructure Better health infrastructure ?? Stronger private sector ?? Stronger private sector ?Smaller numbers ?Smaller numbers Drug production capacity Drug production capacity

Preventing Mother-To-Child HIV Transmission (PMTCT) Over 100 programs in 11 countries Issues: stigma stigma controversies over safe infant feeding controversies over safe infant feeding treatment of parents treatment of parents Will MTCT reduce stigma and increase use of VCT, Rx????

The Next Five Years Basic Assumptions Unlikely to have an effective vaccine Unlikely to have an effective vaccine Microbicide candidates will still be in Phase III testing Microbicide candidates will still be in Phase III testing Continued growth of epidemic in some settings in all regions-beware slow growth Continued growth of epidemic in some settings in all regions-beware slow growth Deterioration/collapse of key social and economic sectors in hard hit countries Deterioration/collapse of key social and economic sectors in hard hit countries Massive orphan problem Massive orphan problem Increasing # PWAs needing ARV Rx Increasing # PWAs needing ARV Rx Increasing number of success stories at national level Increasing number of success stories at national level

The Next Five Years Prevention works! Still key to winning the war. Prevention works! Still key to winning the war. Increase care/treatment Increase care/treatment Synergy between strategy elements Synergy between strategy elements Invest in human capacity Invest in human capacity Advances: e.g. microbicides, rapid TB diagnosis Advances: e.g. microbicides, rapid TB diagnosis Impact on health infrastructure and other sectors Impact on health infrastructure and other sectors Improved coordination Improved coordination