The Global AIDS Pandemic Where Do We Go From Here? Paul De Lay, M.D. Chief, HIV/AIDS Division USAID

June 5, 1981 MMWR publishes report on five cases of Pneumocystis carinii pneumonia in previously healthy young men

Spread of HIV over time in sub-Saharan Africa, 1984 to 1999 Estimated percentage of adults (15–49) infected with HIV 20.0% – 36.0% 10.0% – 20.0% 5.0% – 10.0% 1.0% – 5.0% 0.0% – 1.0% trend data unavailable outside region

HIV-Seroprevalence for Pregnant Women in Selected Urban Areas of Africa: Source: US Census Bureau

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

The latest numbers 16 countries in SSA now have general population rates >10%; of these 7 have rates greater than 20% 16 countries in SSA now have general population rates >10%; of these 7 have rates greater than 20% Mortality for women peaks at 30-34, for men at Mortality for women peaks at 30-34, for men at By 2003, it is estimated 3 countries will be experiencing negative population growth. 5 will be experiencing a growth rate of 0 By 2003, it is estimated 3 countries will be experiencing negative population growth. 5 will be experiencing a growth rate of 0 This will produce population pyramids unlike any that we have seen before This will produce population pyramids unlike any that we have seen before

Population of Zimbabwe, With and Without AIDS: 2010 US Census Bureau, World Population Profile Thousands Thousands Males Females Without AIDS With AIDS

3.6 million 15.8 million 30.2 million 18.6 million 18.9 million 14.0 million 22.2 million 34.7 million 44.2 million 1990 AIDS Orphans Orphans of Other Causes TotalOrphans Total Orphans, 34 Study Countries

Socio-Economic Impact Macro-economy Macro-economy Specific Labor Sectors Specific Labor Sectors Agriculture Agriculture Transport Transport Extraction Extraction Skilled workers Skilled workers Community Community Families/Households Families/Households Political Political Security/military Security/military Social Sectors Social Sectors Health

Cambodia Haiti Mozambique Rwanda Côte d'Ivoire Zambia Kenya South Africa Zimbabwe Botswana Life expectancy at birth (years) Predicted life expectancyLoss in life expectancy due to HIV/AIDS Source: U.S. Census Bureau, 2000 Predicted loss in life expectancy due to HIV/AIDS in children born in 2000

Impact of AIDS on Mortality at Kenyatta National Hospital, Nairobi

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

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

Natural History of HIV Infection WeeksYears Source: Fauci AS, et al. Ann Intern Med, 1996;124:654).

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

HIV prevalence rate among teenagers in Kisumu, Kenya, by age Age in years HIV prevalence (%) boys girls Source: National AIDS Programme, Kenya, and Population Council, 1999

The Role of Behavior “Quantitative Behavior” Number of partners Number of partners Number of persons engaging in risk behavior Number of persons engaging in risk behavior Rate of partner exchange Rate of partner exchange Size of and rate of contact between core groups and general population-” bridging” Size of and rate of contact between core groups and general population-” bridging”

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

Infectious Disease Control Basic Principles Modes of transmission Modes of transmission Stages of the epidemic Stages of the epidemic Epicenters/ “hot zones” Concept of “core transmitters” Epicenters/ “hot zones” Concept of “core transmitters” Those most likely to transmit/Those most likely to contract (“TMLTC”) Those most likely to transmit/Those most likely to contract (“TMLTC”)

HIV Transmission Global Summary

Stages of the Epidemic Nascent Nascent Concentrated Concentrated Generalized Generalized Mature Mature

Essential Technical Elements of an HIV/AIDS Program 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 (1996) Voluntary Counseling and Testing (1996) Stigma reduction Stigma reduction Preventing MTCT (1998) Preventing MTCT (1998) Surveillance and M&E Surveillance and M&E Care and Mitigation Palliative care Palliative care Psychosocial support Psychosocial support Treatment of Opportunistic Infections (1995) Treatment of Opportunistic Infections (1995) Orphans and Vulnerable Children (1998) Orphans and Vulnerable Children (1998) Use of Highly Active Anti- Retroviral Therapy (1997) Use of Highly Active Anti- Retroviral Therapy (1997) Other mitigation activities Other mitigation activities

Major goalsfor Prevention Reduce the number of risk acts Reduce the number of risk acts Decrease the efficiency of transmission Decrease the efficiency of transmission

Global Response: Successes At project level, we have evidence of sustained behavior change to reduce the risk of HIV transmission, resulting in decreased HIV and STD prevalence At project level, we have evidence of sustained behavior change to reduce the risk of HIV transmission, resulting in decreased HIV and STD prevalence At national level, we have two categories of success: At national level, we have two categories of success: Preventing a major epidemic Preventing a major epidemic (Senegal, Philippines, Indonesia) Reducing an existing severe epidemic Reducing an existing severe epidemic (Uganda, Thailand, Zambia, Dominican Republic, Cambodia)

Source: National STD/AIDS Control Programmes, Senegal and Uganda Armed Forces Research Institute of Medical Sciences, Thailand HIV prevalence (%) Kampala, <20 year old ANC Thailand, 21 year old military conscripts Dakar, all ages ANC Trends in HIV prevalence in selected populations in Kampala, Uganda; Dakar, Senegal; and Thailand; 1989 to 1999

HIV prevalence rate among 13 to 19-year-olds, Masaka, Uganda, 1989 to /901990/911991/921992/931993/941994/951995/961996/97 girls boys Source: Kamali et al. AIDS 2000, 14: HIV prevalence (%)

Percentage of sexually experienced by current age ( years old) in 1989 and 1995

Key Elements of the Uganda Response to HIV/AIDS Strong political commitment starting in 1986 which encouraged all political leaders to speak out on AIDS at all opportunities Strong political commitment starting in 1986 which encouraged all political leaders to speak out on AIDS at all opportunities Free press encouraged to print candid, powerful articles on AIDS-intense ongoing use of mass media (radio, TV, soap operas, etc) Free press encouraged to print candid, powerful articles on AIDS-intense ongoing use of mass media (radio, TV, soap operas, etc) Reliable ongoing national seroprevalence data which was routinely disseminated Reliable ongoing national seroprevalence data which was routinely disseminated Derived from E. Marum-USAID/CDC

Key Elements of the Uganda Response to HIV/AIDS Public figures openly discussed HIV status (Philly Bongole Lutaya, Major Ruranga) Public figures openly discussed HIV status (Philly Bongole Lutaya, Major Ruranga) TASO established in 1987-has served 50,000 clients TASO established in 1987-has served 50,000 clients AIDS Information Centers established in 1990-have served 500,000 clients (same day results and “post test clubs”) AIDS Information Centers established in 1990-have served 500,000 clients (same day results and “post test clubs”) Strong religious networks established for both care and prevention (Islamic Medical Association, Protestants, Catholics) Strong religious networks established for both care and prevention (Islamic Medical Association, Protestants, Catholics) Derived from E. Marum-USAID/CDC

Key Elements of the Uganda Response to HIV/AIDS Condom social marketing program was initially resisted by government, now openly endorsed Condom social marketing program was initially resisted by government, now openly endorsed Multiple “AIDS in the workplace” programs (implemented by Federation of Ugandan Workers-banks, breweries, military, police, etc.) Multiple “AIDS in the workplace” programs (implemented by Federation of Ugandan Workers-banks, breweries, military, police, etc.) Derived from E. Marum-USAID/CDC

Key Elements of the Uganda Response to HIV/AIDS Consistent outreach to young people (use of radio, Straight Talk clubs, etc.) Consistent outreach to young people (use of radio, Straight Talk clubs, etc.) Orphans program with strong commitment to keep children in communities and not support institutions, includes microenterprise efforts. Orphans program with strong commitment to keep children in communities and not support institutions, includes microenterprise efforts. Staffing for AIDS programs was strongly supported, attracting the best and the brightest Staffing for AIDS programs was strongly supported, attracting the best and the brightest Derived from E. Marum-USAID/CDC

Key Elements of the Uganda Response to HIV/AIDS Active, well supported research programs with international collaborations (AIDS vaccines, mother to child transmission, TB, pneumococcal vaccine, Vitamin A, mass STD Rx, etc) Active, well supported research programs with international collaborations (AIDS vaccines, mother to child transmission, TB, pneumococcal vaccine, Vitamin A, mass STD Rx, etc) Ongoing, consistent, reliable donor support, averaging $18 million/year Ongoing, consistent, reliable donor support, averaging $18 million/year Derived from E. Marum-USAID/CDC

2001 Why hasn’t there been more impact on the epidemic?

The major challenges for an expanded, comprehensive response Resource levels Resource levels What are we trying to achieve? What are we trying to achieve? Political will Political will Strategic planning Strategic planning Scaling up new activities Scaling up new activities Urgent need for new technologies Urgent need for new technologies

USG Resources for HIV/AIDS

Reduce HIV prevalence rates among those years of age by 50% in high prevalence countries Reduce HIV prevalence rates among those years of age by 50% in high prevalence countries Maintain prevalence below 1% among year olds in low prevalence countries Maintain prevalence below 1% among year olds in low prevalence countries Ensure that at least 25% of HIV/AIDS infected mothers in high prevalence countries have access to interventions to reduce HIV transmission to their infants “Shared” Targets for the Year 2007

Help local institutions provide basic care and support services to at least 25% of HIV infected persons Help local institutions provide basic care and support services to at least 25% of HIV infected persons Provide community support services to at least 25% of children affected by AIDS in high prevalence countries Provide community support services to at least 25% of children affected by AIDS in high prevalence countries

Political Will Resource allocation Resource allocation Use of State controlled media Use of State controlled media Removing taxes and duties on the import of public health commodities Removing taxes and duties on the import of public health commodities Willingness to work with NGOs Willingness to work with NGOs Use of the Education sector Use of the Education sector Prevention activities in the Military Prevention activities in the Military Surveillance activities Surveillance activities

National Strategic Plans Inadequate funding Inadequate funding Inadequate biologic and risk behavior surveillance Inadequate biologic and risk behavior surveillance Not very strategic Not very strategic

Resource Allocation in Strategic Plans

Country Strategic Planning Brazil South Africa Thailand Cote d’Ivoire Kenya Malawi Mozambique Uganda Zaire High prevalence MexicoDominican Republic Ghana Honduras Senegal Low prevalence Non-donor-drivenDonor-driven

Targeting Countries è Three Country Designations: Rapid Scale Up (4 countries) Rapid Scale Up (4 countries) Intensive Focus (16 countries) Intensive Focus (16 countries) Basic Programs (25 countries) Basic Programs (25 countries) Intensive Focus Countries Rapid Scale Up Countries HIV/AIDS Basic Programs Countries

Criteria for Rapid Scale-Up & Intensive Focus Countries The relative severity of the epidemic The relative severity of the epidemic The magnitude of epidemic The magnitude of epidemic The impact on economic and social sectors The impact on economic and social sectors Enabling environment Enabling environment The risk of a rapid increase in prevalence The risk of a rapid increase in prevalence Availability of other sources of funding Availability of other sources of funding Return on investment Return on investment Security and safety issues Security and safety issues National Interest National Interest

Adding New Components to an Expanded Comprehensive Response Care Care Preventing Mother to Child Transmission Preventing Mother to Child Transmission Children Affected by AIDS Children Affected by AIDS

PYRAMID OF HIV/AIDS CARE AND SUPPORT PRIORITIES Prevention*, Human Rights* Prevent Opportunistic Infections Anti Retroviral Drugs Cost and Complexity People Served Strengthen Communities to support affected persons* Improve health care systems*TB* *These programs serve the community as well as PLHA’s Palliative Care, Psycho-Social Care* USAID 1998

ARV Treatment: What Does It Involve: Potentially complex regimens Potentially complex regimens Need for trained HCWs and improving lab support Need for trained HCWs and improving lab support Life long intervention Life long intervention Concerns about multi-drug resistance Concerns about multi-drug resistance Equity of access Equity of access Need for prevention remains Need for prevention remains

Drug Access/Drug Prices Advocates Compulsory licensing Compulsory licensing Parallel importing Parallel importing Expanded definition of generics (CIPLA) Expanded definition of generics (CIPLA)Pharmaceuticals Drug donations Drug donations Individual negotiations Individual negotiations Merck announcement (Crixovan: $600/yr, Stocrin $500/yr) Merck announcement (Crixovan: $600/yr, Stocrin $500/yr)

Mother to Child HIV Transmission (MCT) Risk of HIV Transmission: Conception Birth1 Yr2 Yrs 34% Overall 14%20% } }

Preventing Mother-To-Child HIV Transmission Current Activities/Issues 2 programs: Kenya, Zambia- expanding to 6 in 2001 Issues: Extremely slow scale up due to: stigma stigma controversies over breast feeding controversies over breast feeding lack of synergy lack of synergy

Children Affected by AIDS Current Activities/Issues 18 country programs, 40 individual projects Issues: Integrating PL 480 Food Programs Integrating PL 480 Food Programs Overwhelming demands compared to resources Overwhelming demands compared to resources Orphanages Orphanages

Urgent need for new Technologies Microbicides Microbicides Preventive and Therapeutic Vaccines Preventive and Therapeutic Vaccines Diagnostics Diagnostics Improved male and female condoms Improved male and female condoms Simpler, more affordable treatments Simpler, more affordable treatments ?Curative therapies ?Curative therapies

The Next 20 Years What will happen in Asia, E&E What will happen in Asia, E&E Long term demographic impact Long term demographic impact Societal changes (+&-) Societal changes (+&-) Chronic, treatable disease vs ongoing drug resistance Chronic, treatable disease vs ongoing drug resistance Further mutations Further mutations

Indonesia HIV infection rates 24.5% SW = sex worker IDUs = injecting drug users