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MALAYSIA: Taking Stock of HIV Prevention

MALAYSIA: Taking Stock of HIV Prevention . Dr. Christopher KC Lee Infectious Disease Unit Department of Medicine Hospital Sungai Buloh. HIV / AIDS: The Global Burden. Global estimates for adults and children, 2005. People living with HIV 38.6 million [33.4 – 46.0 million]

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MALAYSIA: Taking Stock of HIV Prevention

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  1. MALAYSIA:Taking Stock of HIV Prevention Dr. Christopher KC Lee Infectious Disease Unit Department of Medicine Hospital Sungai Buloh

  2. HIV / AIDS:The Global Burden

  3. Global estimates for adults and children, 2005 • People living with HIV38.6 million[33.4 – 46.0 million] • New HIV infections in 20054.1 million [3.4 – 6.2 million] • Deaths due to AIDS in 20052.8 million[2.4 – 3.3 million]

  4. Global summary of the HIV and AIDS epidemic, 2005 Total 38.6 million [33.4 – 46.0 million] Adults 36.3 million [31.4 – 43.4 million] Women 17.3 million [14.8 – 20.6 million] Children under 15 years 2.3 million [1.7 – 3.5 million] Total 4.1 million [3.4 – 6.2 million]Adults 3.6 million [3.0 – 5.4 million]Children under 15 years 540 000 [420 000 – 670 000] Total 2.8 million [2.4 – 3.3 million]Adults 2.4 million [2.0 – 2.8 million]Children under 15 years 380 000 [290 000 – 500 000] Number of people living with HIV in 2005 People newly infected with HIV in 2005 AIDS deaths in 2005

  5. Adults and Children Estimated to Be Living With HIV, 2005 Eastern Europe and Central Asia 1.4 million Western/ Central Europe 720,000 North America 1.3 million East Asia 680,000 North Africa and Middle East 440,000 Caribbean 330,000 Southern and Southest Asia 7.6 million Sub-Saharan Africa 24.5 million Latin America 1.6 million Oceania 78,000 UNAIDS, 2006. Available at: http://www.unaids.org.

  6. Estimated number of adults and children newly infected with HIV, 2005 Eastern Europe & Central Asia 220 000 [150 000– 650 000] Western & Central Europe 22 000 [18 000 – 33 000] North America 43 000 [34 000 – 65 000] East Asia 97 000 [55 000 – 290 000] North Africa & Middle East 64 000 [38 000 – 210 000] Caribbean 37 000 [26 000 – 54 000] South & South-East Asia 830 000 [530 000 – 2.3 million] Sub-Saharan Africa 2.7 million [2.3 – 3.1 million] Latin America 140 000 [100 000 – 420 000] Oceania 7200 [3500 – 55 000] Total: 4.1 (3.4 – 6.2) million

  7. Estimated adult and child deaths from AIDS, 2005 Eastern Europe & Central Asia 53 000 [36 000 – 75 000] Western & Central Europe 12 000 [<15 000] North America 18 000 [11 000 – 26 000] East Asia 33 000 [20 000 – 49 000] North Africa & Middle East 37 000 [20 000 – 62 000] Caribbean 27 000 [19 000 – 36 000] South & South-East Asia 560 000 [370 000 – 810 000] Sub-Saharan Africa 2.0 million [1.7 – 2.3 million] Latin America 59 000 [47 000 – 76 000] Oceania 3400 [1900 – 5500] Total: 2.8 (2.4 – 3.3) million

  8. Estimated number of children (<15 years) newly infected with HIV, 2005 Eastern Europe & Central Asia 2300 [1400 – 3900] Western & Central Europe 200 [<400] North America 500 [<1000] East Asia 2300 [1000 – 4100] North Africa & Middle East 6900 [3200 – 12 000] Caribbean 3700 [2100 – 5800] South & South-East Asia 44 000 [23 000 – 75 000] Sub-Saharan Africa 470 000 [370 000 – 590 000] Latin America 5000 [3500 – 8000] Oceania 1100 [400 – 2800] Total: 540 000 (420 000 – 670 000)

  9. Over 11 000 new HIV infections a day in 2005 • More than 95% are in low and middle income countries • About 1500 are in children under 15 years of age • About 10 000 are in adults aged 15 years and older • of whom: • almost 50% are among women • over 40% are among young people (15-24)

  10. 2006 International AIDS Conference: Time to Deliver “Between 2003 and 2005 . . . for each new person who got treatment for HIV, about 10 people became infected. Even during our greatest advance, we are falling behind.” - Bill Gates “If you oppose the distribution of condoms, something is more important to you than saving lives.” “Let’s agree that every life has equal worth, and saving lives is the highest ethical act.” - Melinda Gates “Empowering women to protect themselves seems so elemental, and yet when I hear people pontificating against AIDS and acting as if we can do everything through abstinence, I think they don't know what most women are up against in too many parts of the world today.” - Bill Clinton

  11. 2006 International AIDS Conference: Time to Deliver “The (South African) government has a lot to atone for. I’m of the opinion they can never attain redemption.” Stephen Lewis “Today, we have a real opportunity to deliver like never before . . yet still the epidemic continues to outpace us . . . We must demand action over rhetoric and research over ideology” - Helene Gayle,MD “Indeed, we will have failed unless we dramatically and rapidly expand by millions the numbers of people around the world with access to antiretroviral drugs and simultaneously scale up prevention.” - Mark Wainberg, PhD

  12. Burden of HIVin Malaysia

  13. MALAYSIA • First HIV case detected in 1986 • as of 31st. December, 2005 : 70.559 cases notified to Ministry of Health numbers 1992 to 2005, years Malaysia 31/12//05

  14. Cummulative HIV infectionsMalaysia 1993-2005 Year

  15. Cummulative AIDS casesMalaysia 1993 - 2005 Year

  16. Yearly AIDS DeathsMalaysia 1993 - 2005 Cummulative AIDS deaths: 8179(31st. Dec, 2005) Year

  17. Gender Male 65,345 (92.6%) Female 5,214 (7.4%) TOTAL 70,559 (100%) Malaysia 31/12/05

  18. HIV in MalaysiaProportion of Men / Women by Year percentage

  19. Age Distribution 78.5% : ages 20 - 39 yrs. numbers Age groups in years Malaysia 31/12/05

  20. HIV : Routes of transmission No. % • Homo / bisexuals 1025 1.5% • IV drug users 52407 74.3% • Heterosexuals 10124 14.3% • Blood / blood products 28 0.04% • Mother-to-child 541 0.8% • Unknown 6431 9.1% Malaysia 31/12/05

  21. HIV Proportion by route of transmission percentage

  22. Percentages of IDUs reactive for HIV by year % Year

  23. Medically: What happens to those infected? • 50% will have flu-like illness for about 2-6 weeks after exposure (Primary HIV illness) • Will recover & enter a long asymptomatic phase (the latent period) • Prolong asymptomatic period; Average period from infection to AIDS 8-10 years • Viral load, plasma HIV RNA, remain at steady state. • CD4 T-lymphocyte count fairly stable; rate of decline dependant on viral load • CD4 cell count : production almost = destruction for sustained period of time

  24. CD4 counts & Opportunistic Infections Asymptomatic CD4 counts Mildly symptomatic AIDS-defining illness Years : mean survival ~ 10 yrs.

  25. Candidiasis: oesophagus, trachea, lungs Cervical ca., invasive Cryptococcosis, extrapulmonary Cryptosporidiosis: diarrhoea > 1 month CMV: except liver, spleen & lymph nodes Herpes simplex: ulcer > 1 month, lung, oesophagus HIV dementia HIV wasting (wt. loss> 10 %) Kaposi’s sarcoma Lymphoma, non-Hodgkins My. avium , disseminated My. tuberculosis PCP Pneumonia, recurrent, Salmonella septicaemis, recurrent Toxoplasmosis, internal organ Examples of AIDS- defining Illness (ADI)

  26. Implications of growing AIDS population • Increasing strain on health sector esp. hospital based services - hospital beds - human resource - finances • Social & developmental implications: - impact on families, communities, countries - political uncertainty / national threat

  27. Infection PrevalenceRate Tuberculosis 40%-68% Toxoplasmosis 10%-66% Oropharyngeal candidiasis 58%-60% Cryptosporidiosis 4%-11% Cryptococcosis 5%-8% Systemic candidiasis 4%-8% Pneumocystis carinii pneumonia 0.4% Isosporiasis 0.3% Kaposi's sarcoma 0.27% Prevalence of Opportunistic Infections among AIDS patients in India S. Singh, AIDS Reader 7(3);101-106, 1997

  28. Health Sector Under Stress • Care & treatment for PLWHAs heavily taxing public health services in developing countries. • Rwanda, 1990s – treatment consumed 66% of public health spending. • 1997 – Public health spending for AIDS > 2% of GDP in 7/19 African countries (total health spending - 3-5% GDP) • AIDS take up 50% beds in Provincial Hospital, Chiang Mai; 39% - Hospital Kenyatta, Nairobi, & 70% in Prince Regent Hospital, Bujumbura, Burundi UNAIDS Photo Library

  29. Health Sector Under Stress • Other patients do not get beds in hospitals & die due to late treatment. • TB – rapidly increasing, kills 1/3 PLWHAs, increases TB risk in community at large • World Bank – 25% of HIV-negative people who die of TB in the future would not have been infected with the bacillus in the absence of AIDS. • New AIDS therapies – increases health sector expenditure in infrastructure, drugs, training and personnel.

  30. From “Health Issue” to “Development Crisis” • Destruction of social capital • Knowledge base of society • Production sectors: agriculture, industry • Weakening of institutions • Governance, civil service, judiciary, armed forces, education, health • Inhibition of private sector growth • Wider, deeper poverty

  31. Economic Growth Impact of HIV (1990-97) Growth Impact of HIV (1990-97) (80 developing countries) 0 -0.2 -0.4 -0.6 -0.8 Reduction in growth rate GDP per capita (%, per year) -1 -1.2 -1.4 -1.6 0 5 10 15 20 25 30 35 HIV Prevalence Rate (%) Source: R. Bonnel (2000) Economic Analysis ofHIV/AIDS, ADF2000 Background paper, World Bank

  32. AIDS - Developmental Crisis Demographic Impact of AIDS • Botswana 2020 – More adults aged 60 – 70 yrs than 40 – 50 yrs • Small number of young adults support large number of young & old people Projected population structure with & without the AIDS epidemic, Botswana 2020 Source: US Census Bureau, World Population Profile 2000

  33. Household Impact • Survey: Impact of family member with AIDS – households suffer in income. • Leads to fewer purchases & savings • Thailand • 1/3 family affected by AIDS • 50% in agricultural output – threatens food security • 15% forced to take children out of school. • > 50% elderly left to care for themselves.

  34. AIDS Orphans • Children who lose their mothers or both parents to AIDS < age of 15 yrs • 13.2 mil AIDS orphans; 95% in developing countries • Before AIDS - 2% of children in developing countries were orphans. • 1997, 7 – 11% of children were orphans • AIDS orphans – raised by elderly or left on their own. • UNICEF/UNAIDS, 1999 – • AIDS orphans - high risk of malnutrition, illness, abuse, sexual exploitation by others. • Also face stigma and discrimination.

  35. HIV is hurting business • Impact of AIDS in sugar estate, Kenya a)Absenteeism(8,000 days of labour lost due to sickness between ’95-97) b)Lower productivity (50%  in the ratio of processed sugar from raw cane from ’93-97) c)Higher overtime costs when healthy workers fill in for sick colleagues d) Spending on funerals  5 times between ’89-97 e) Health costs > 10 times (3/4 HIV-related illness) • HIV-related illness & death – main reason people leaving company

  36. Current Status: the HKL cohort > 2800 patients registered since `92 • New patients per year: ~ from 150 (1993) to about 565 (2005) patients • 82% Malays IV drug users • 78% Chinese infected through sex • 70% education level : < Form 3 • Employment: 79% blue-collared workers CLee,IDclinic,HKL

  37. Is there any Good News ?

  38. HIV Prevalence among antenatal women, Cambodia 1997-2000 (%) 3.2 3.0 2.8 2.6 2.4 2.2 1997 1998 1999 2000 Source : MOH Cambodia

  39. 5 HIV prevalence (%) 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Trend in HIV prevalence in 21 year old military conscripts in Thailand Prevention Works! Source: Armed Forces Research Institute of Medical Sciences, Thailand

  40. Prevention Strategies • Has to be individualised for countries, districts, communities, etc. • Targetted vs Generalised • Objective: Behavioural Change • Community sensitive • Gender sensitive • Obstructive policies need to be addressed • Multisectoral involvement often required

  41. What has worked …? • HIV Education programs for schoolchildren – various models • Harm Reduction programs: - methadone maintenance treatment - needle exchange programs • Targeted Condom promotion • Women specific & sensitive programs • Involvement of civil society – religious, community leaders, corporate sector

  42. H.A.A.R.T. Highly Active Anti- Retroviral Therapy

  43. Declining morbidity & mortality among patients with advanced HIV infection 100 75 50 ARV therapy including protease inhibitors Deaths per 100 person yrs 25 0 ‘94 ’95 ‘96 ‘97 Pallella FJ et al, HIV Outpatient Study Investigations, N Engl J Med 1998; 338:853-860

  44. ARV drug Prices in Malaysia Ringgit per month * Expected new prices

  45. Thank You “Do What you Can with what you Have Where you Are !” Theodore Roosevelt

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