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AIDS at 25: A Global Perspective

AIDS at 25: A Global Perspective. AIDS at 25: A Global Perspective. The early years—a historical perspective AIDS in the developing world. NYC and AIDS Epidemiologic Characterization. First reports of AIDS Infants of mothers with AIDS Heterosexual transmission IDU

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AIDS at 25: A Global Perspective

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  1. AIDS at 25: A Global Perspective

  2. AIDS at 25: A Global Perspective • The early years—a historical perspective • AIDS in the developing world

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

  4. Denial, Despair, Discrimination

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

  6. Deaths Reported AIDS Cases Reported Persons Living with AIDS Denial and Despair, to Therapeutic Optimism, to Therapeutic Balance NYC Incidence, Prevalence, and Mortality 14,000 100,000 Clinical Milestones in the 90,000 History of the HIV/AIDS Epidemic Reported Persons Living with HIV (non-AIDS) 12,000 1987: AZT 1988: PCP prophylaxis 80,000 1992: Combination therapy 1994: ACTG 076: AZT reduces perinatal transmission 10,000 70,000 1995: Protease inhibitors 1996: HAART 60,000 8,000 Number of Reported PLWHA* 50,000 Number of Reported AIDS Cases and Deaths 6,000 40,000 30,000 4,000 20,000 2,000 10,000 0 0 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 1981 1982 1983 1984 1985 1986 2001 2002 2003 Calendar Year CDC AIDS case AIDS case First cases of PCP, KS NYS expands AIDS 1998 NYS HIV reporting law definition (23 OIs) reporting reported from NYC, LA reporting to include HIV takes effect First commercial EIA, mandated AIDS case definition AIDS enters the HIV identified as screening of US blood by NYS expanded (CD4 <200, *PLWHA=Persons living with HIV/AIDS nomenclature causative agent supply begins 26 OIs) New York City, 1981-2003

  7. AIDS: The First Quarter Century New York City • >150,000 have been diagnosed with AIDS • 90,000 (60%) have died • ~100,000 diagnosed and living with HIV/AIDS • ~35,000 with HIV, ~65,000 with AIDS • 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 Slide courtesy of Dr. Torian, BHIV Epi Prgm.

  8. AIDS and the United States > 1 million living with HIV/AIDS • 500,000-600,000 (50%-60%) have died • At peak, leading cause of death in youngmen and women in 15 US cities • Demographic changes • Largest population MSM, but increasinglyan epidemic of poverty, people of color,women, and heterosexual transmission • 40,000 new infections per year

  9. Unintentional injury Cancer Heart disease Suicide HIV infection Homicide Chronic liver disease Stroke Diabetes Trends in Annual Rates of Death From Leading Causes of Death Among Persons 25-44 Years Old, USA, 1982-1998 40 35 30 25 20 Deaths per 100,000 Population 15 10 5 0 82 84 86 88 90 92 94 96 98* Year *Preliminary 1998 data National Center for Health Statistics, National Vital Statistics System

  10. Social Change and HIV TransmissionThe Seed and the Wind • IV drug route, “shooting galleries,” cocaine “fourth world” • Sexual behavior/practice • Gender inequality • Migration, urbanization, and detribalization • International travel • Widespread manufacture and distribution of blood components

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

  12. Lessons in HIV/AIDS Care • Comprehensiveness • Continuity • Competence • Compassion • Colleagueship • Cost-effectiveness

  13. AIDS at 25: A Global Perspective • The early years—a historical perspective • AIDS in the developing world

  14. Eastern Europe & Central Asia 1.6 million (990,000–2.3 million) Western & Central Europe 720,000 (570,000–890,000) North America 1.2 million (650,000–1.8 million) East Asia 870,000 (440,000–1.4 million) North Africa & Middle East 510,000 (230,000–1.4 million) Caribbean 300,000 (200,000–510,000) South & Southeast Asia 7.4 million (4.5–11.0 million) Sub-Saharan Africa 25.8 million (23.8–28.9 million) Latin America 1.8 million (1.4–2.4 million) Oceania 74,000 (45,000–120,000) Adults and Children Estimated to Be Living With HIV at the End of 2005 Total: 40.3 (36.7–45.3) million

  15. Estimated Number of Adults and Children* Living With HIV by Region, 1986–2005 Millions 45 Oceania 40 North Africa & Middle East 35 Eastern Europe & Central Asia 30 Western and Central Europe and North America 25 Number of people living with HIV Latin America and Caribbean 20 Asia 15 Sub-Saharan Africa 10 5 0 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 * Under 15 years old AIDS Epidemic Update, December 2005.

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

  17. Challenges Facing the New African Nations • Drastic shortage of skilled workforce • Adult literacy at 16% • 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 • At independence, 75% of higher level personnel in government and business were foreigners • Kinship and ethnicity became the route to power

  18. In 50 African Countries in 1989 • Opposition parties were illegal in 32 states • 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 • 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

  19. 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 • 74.5% received 2 NRTIs and an NNRTI • Mean CD4 increase was 165.9 cells/µl over a mean of 10.4 months • Among 21 studies assessing VL, a median of 73%of patients achieved undetectable VL • Participants achieving >95% adherence ranged between 68% and 99% • In 5 studies assessing resistance, at least 1 mutation was detected in 10.1% Akileswaran C, et al. CID. 2005;41:376-85.

  20. 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 • CD4 increase was 160, 225, and 297 cells/µl at 12, 24, and 36 months • Adherence in 1766 patients was perfectin 78% Wools-Kaloustian K, et al. AIDS. 2006;20:41-8.

  21. 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 • 87% alive 1 year after initiating therapy • At 12 months median CD4 increase was 163 cells/µl • 11% experienced treatment-limiting toxicity • Of subgroup of 100 patients followed 48-56 weeks, 76% had VL <400 copies/mL Severe P, et al. NEJM. 2005;353:2325-34.

  22. Developing World: Emerging Results of ART Trials • 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 weeks1 • 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 occurred2 1. Wester CW, et al. JAIDS. 2005;40:336-43. 2. Spacek LA, et al. CID. 2006;42:252-9.

  23. 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 • 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 • Utilizing only on-treatment analysis underestimates early mortality • Most deaths were attributed to wasting syndrome, tuberculosis, acute bacterial infections, malignancy, and immune reconstitution disease Lawn SD, et al. AIDS. 2005;19:2141-8.

  24. Developing World: Current Quandaries • Point of therapy initiation • Detection and treatment of OIs, especially in advanced patients before initiation of therapy • Dilemmas with current first regimens • Monitoring for efficacy and toxicity • Switching therapy for failure—how and to what

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

  26. 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 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

  27. “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…” • Disunity, denial, stigma, and competing sources of power and authority undermine capacity for response

  28. “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.” • 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.

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

  30. Potential Outcomes for Scenarios Adults and Children, 2003-2025 Scenario: Traps and Legacies Times of Transition Tough Choices Indicator Cumulative program cost (US$ billion) 195 98 70 Cumulative deaths from AIDS (1980-2025, million) 67 75 83 Cumulative new infections (million) 46 65 89 Cumulative infections averted (million) 43 24 0 UNAIDS, AIDS in Africa Scenarios Project; historical data: UNAIDS, 2004 Report on the Global AIDS Epidemic

  31. HIV/AIDS: The Next 25 Years—The Long Haul • 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 • More resources/sustaining current resources • More focus on human rights • New and more effective prevention strategies • Vaccine, microbicides, structural, behavioral

  32. HIV/AIDS: The Next 25 Years—The Long Haul • Growth of comprehensive systems of care • Integration of prevention with care • HIV and TB • Substance abuse and HIV • New, more potent, and less expensive drugs • Equity—provision of prevention, care,and treatment worldwide • New generation of unsung heroes and heroines

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