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HIV/AIDS after 25 Years Global Pandemic Local Disparities

HIV/AIDS after 25 Years Global Pandemic Local Disparities. EVMS/ODU MPH Seminar Series Edward C. Oldfield, III, M.D. March 9, 2007. Worst of Times: 25 Years, 25 Million Dead. Spreading Global Epidemic. “The greatest challenge of our generation.”. UN Secretary General Kofi Annan

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HIV/AIDS after 25 Years Global Pandemic Local Disparities

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  1. HIV/AIDS after 25 YearsGlobal PandemicLocal Disparities EVMS/ODU MPH Seminar Series Edward C. Oldfield, III, M.D. March 9, 2007

  2. Worst of Times:25 Years, 25 Million Dead Spreading Global Epidemic

  3. “The greatest challenge of our generation.” UN Secretary General Kofi Annan UN Special Session on AIDS 2 June 2006

  4. Global HIV Epidemiology, 2006 • 40 million people infected with HIV in the world at the end of 2005 (cumulative 75 million total). • 5.0 million new infections in 2005, 13,000 every day. • 25 million have died since the beginning of the pandemic, 3.1 million in 2005. www.unaids.org/Epi2005/doc/report.html

  5. AIDS Global Epidemic “When 80% of persons dying from AIDS are between 20 and 50 years of age, societies are left with the young and the old, with few to support them.” President William J. Clinton 10th CROI Boston Feb 2003. “A catastrophe far worse by orders of magnitude than any problem or crisis we have on the face of the earth right now…..a catastrophe far worse than terrorism.” Colin Powell, U.S. Secretary of State, April 23,2002.

  6. AIDS in Africa • AIDS is the number one killer in Africa (10% of the world population, 60% of global AIDS burden). • A 15 year old boy in Botswana has an 85% probability of dying of AIDS in his lifetime. • In Zambia, 2,000 teachers die of AIDS each year, equivalent to all the new teachers trained each year. • 50% of all hospitalized patients in South Africa.

  7. Africa: Health Disparities • 24% of the world’s disease burden, 3% of the world’s health workforce. • U.S. has 1 physician for every 390 individuals; Mozambique has 1 for every 33,000. • U.S. has 1 nurse for every 107 individuals; Tanzania has 1 for every 2,700. • Angola has 24 Pharmacists for 12 million people. Mullan F. JAMA 2007;297:744-6.

  8. AIDS Pandemic “Africa is the tip of the iceberg.” “We are just at the beginning of a pandemic the likes of which we have not seen in this century, and in the end will probably never have been seen in history”. Sandra Thurman, Co Chairwoman Office of National AIDS Policy, 2000. • 50 million new infections by 2010 in China, Ethiopia, India, Nigeria and Russia alone.

  9. Global HIV Trends • India has the largest number of HIV infected people; 5.7 million of 1.1 billion (0.9%). • South Africa has 5.5 million infected of 47 million (19%). • For Haiti, 9% of pregnant women were HIV (+) in 1993 vs. 4% in 2003-04 • AIDS remains the leading cause of death in the Caribbean. UNAIDS Report, 30 May 2006.

  10. Global HIV Trends • 120 million projected to die in the next 25 years; becoming the #3 killer worldwide after heart disease and stroke. • Even if new infections decrease and access to HAART is increased, 89 million will die. Mathers C. PLoS Nov 2006.

  11. HIV/AIDS, U.S. • As of December 2004, 944,306 people had been diagnosed with AIDS and 529,113 had died. • CDC estimates there are 1.2 million people in the U.S. infected with HIV; about 300,000 are undiagnosed. • More than half of all new HIV infections are transmitted by people who are unaware they are infected.

  12. HIV Infection in the US, 2003 • 1,100,000 HIV positive. • 335,000 (30%) undiagnosed. • 363,000 (33%) diagnosed, no care. • 499,000 (37%) diagnosed under physicians care.

  13. HIV/AIDS, Virginia thru 12/05 • 27,001 unduplicated HIV/AIDS. • 77% men; 23% women. • 59% black, 35% white, 4% hispanic.

  14. HIV/AIDS Cases thru 12/05 • Northwest 7% • Northern 28% • Southwest 8% • Central 24% • Eastern 33%

  15. STD Statistics, 2002 Virginia Norfolk EMA (%) • 1/2nd Syphilis 71 31 (44%) • Chlamydia 18,832 5,871 (31%) • Gonorrhoea 10,550 4,648 (44%) Source: VDH

  16. HIV/AIDS Proportion of AIDS Cases by Race and Year of Report, United Stated, 1985-2001 Source: CDC/NCHSTP 2001 HIV/AIDS Surveillance Report

  17. AIDS: Quiet, Deadly Scourge for Blacks • 1 of every 50 black Americans is infected with HIV. • AIDS is the leading cause of death for African American women between the ages of 25 and 34 and men 35 to 44 years old. • The rate of new HIV infections is 7 times higher for black men than white men and 21 times higher for black women than white women. • Older blacks are 10-15 times more likely than whites of the same age to be HIV (+).

  18. “HIV has increasingly become a disease of color.One of the greatest crises threatening the black community.”“It’s the life and death of black people.” Battling a Black Epidemic Claudia Kalb. Newsweek, May, 15 2006.

  19. African Americans and HIV HIV/AIDS % African American U.S. 51% Virginia 62% Norfolk 72%

  20. HIV and Adolescent Girls • 71% of the fathers of children born to unwed teenage mothers were an average of 5 years older than the mother. • HIV prevalence among teenage girls is 2-4x higher than among teenage boys (closer to rates in adult males). Cheng L. JAMA 1996;276:282.

  21. Age at first intercourse Used condom first intercourse Condom at last intercourse Used condoms consistently Had been pregnant First Sexual Partner >3 yrs olderAbout same age 13.8 14.6 63% 82% 29% 44% 37% 56% 38% 12% Older Men and Younger WomenSurvey of Black and Hispanic Teens

  22. Gonorrhea Gonorrhea Rates by Age, 2001 Source: CDC/NCHSTP 2001 STD Surveillance Report

  23. HIV, Women and the South • Only 29% of women live in the South, but 76% of new HIV cases in women were reported from the South between 1999 and 2003. • 8% of new HIV diagnoses in the South are in girls 13-19 years old; 4 times higher than the rest of the country. 2005 National HIV Prevention Conference.

  24. HIV and Women • Worldwide, 80% of women newly infected with HIV are practicing monogamy within a marriage or a long term relationship. ABC: Abstain, Be faithful, Condoms. “For millions of married women, abstinence is unrealistic, being faithful is insufficient and the use of condoms is not under her control.” Melinda Gates, Newsweek, May 15,2006.

  25. Survey of 1000 Women age 18-70 by the American Medical Women’s Association • 84% said they were not concerned about contracting an STD. • Those at highest risk – women 18 to 24, those with multiple sexual partners, and those whose current partners have had multiple sexual partners – were the least likely to consider themselves at risk. • 49% said they relied on monogamy for protection against STD’s. “I see so much sadness here because women want to believe their relations are mutually monogamous”.

  26. Vaginal Microbicides • Female controlled method to prevent or reduce HIV risk. • Nonoxynol-9: anion surfactant developed as a contraceptive spermicide, disrupts viral membrane, but also caused vaginal inflammation/ulceration. • 2 phase III trials of cellulose sulphate recently halted. • Tenofovir gel: Antiretroviral incorporated in vaginal gel. Weber J. PLoS 2005;2:0392-0395.

  27. HIV and MSM, 2005 • Systematic sample of 2,261 men at venues where MSM congregate in Baltimore, Miami, NY, LA and San Francisco from 6/04-4/05. • 25% were HIV (+); highest in Baltimore (40%). • 46% of blacks, 21% of whites and 17% of Hispanics were HIV (+). Sifakis F. MMWR 2005;54:597-600.

  28. Unrecognized HIV Infection • Data from the CDC Young Men’s Survey in 7 U.S. cities found that 16% of young black men who have sex with men (BMSM), who agreed to be tested, were HIV (+). • 93% were unaware that they were HIV (+). • Of those with unrecognized infection, 71% reported there was no chance or it was unlikely that they were infected. • 42% perceived themselves to be at low risk of ever becoming infected. MMWR 2002;51:733-6.

  29. HIV and the Internet • Survey of 2,934 MSM who frequent internet chat rooms. • 82% said they met sex partners online. • 60% participated in unprotected anal intercourse. • HIV (+) men were 1.5X more likely to participate in unprotected sex than HIV (-). Chaisson M. 10th CROI Feb 2003 Ab#37.

  30. “Serosorting” • Serosorting: HIV (+) men are likely to have unprotected receptive anal intercourse (URAI) with men who are also HIV (+). McConnell J. 10th CROI Feb 2003. Ab# 41. URAI HIV (-) Partner of HIV (+) 7% Partner Status Unknown 34% Both Partners HIV (+) 90% • Also increased “seropositioning.”

  31. On The Down LowJ.L.King with Karen Hunter New York Times Nonfiction Best Sellers June 13, 2004 #6

  32. “On the Down Low” • Men on the “down low” may serve as a bridge to infection from gay men to heterosexual women. “I treat every man as bisexual because I don’t want to end up as the sister with HIV.” Linda Villarosa, New York Times, 5 April 2004. “Among black folks, no matter who you are or who you think you are, you are not safe from HIV.” Phill Wilson, Executive Director, Black AIDS Institute, Los Angeles.

  33. Heterosexual MSM • 12% of NYC men have had sex with a man in the last year. MSM who self identify as heterosexual are more likely to: • Belong to minority racial/ethnic group. • Be foreign born. • Lower income/education • Married (70% married, 10% of all married men had sex with a man in the preceding year). Pathela P. Ann Intern Med 2006;145:416-25.

  34. HIV and College Students • 84 newly infected college students in North Carolina (11% of all new HIV infections in the state) from 1999-2002. • New HIV cases were found in 37 colleges in NC or surrounding states with a sexual partner network linking 21 colleges often via internet chat rooms. • 87% were African American, 92% were MSM. • College students were 3X more likely to be bisexual than other newly infected with HIV (40% admitted to sex with men and women). Hightow L. J AIDS 2005;38:531-7.

  35. Oral Sex Safe? No Way • 14% of all syphilis cases appear transmitted by oral sex, especially among MSM (20% of cases). MMWR 2004;53:966-68. • 5% of MSM in San Francisco have (+) throat swabs for gonorrhea, over a median of 2 years 18% developed new infections. • 92% had no symptoms. Morris S. Clin Infect Dis 2006;43:1284-9.

  36. Stigma and Discrimination Perpetuate the Epidemic

  37. “Many of the people interviewed said it mattered a great deal if they thought they might be harmed or rejected because of disclosure.Fear and terror often shaped their decisions.”

  38. Decrease the Spread • Number of new HIV infections has remained the same since 1998 (40,000). • Transmission of HIV is 3.5-fold higher in those who are unaware that they are HIV positive. • Unsafe sex decreases by 2/3 in those who are aware of their diagnosis.

  39. Fear and Denial • 25% of those infected with HIV do not know that they are positive (more than 250,000). • 30% know they are positive, but are not in care. • 39% first test positive for HIV within 1 year of an AIDS diagnosis.

  40. Missed Opportunities • During 2001-2005, 4,315 HIV infections were reported in South Carolina. • 41% developed AIDS within 1 year of diagnosis (late testers), 17% within 30 days. • 73% had visited health care facilities between 1997-2005, median 4 visits and 2.5 years prior to HIV diagnosis. • Only 20% of diagnosis might suggest HIV risk. MMWR 2006; 55:1269-72.

  41. HIV Testing: New Guidelines • HIV screening is recommended for patients aged 13-64 years in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). • Persons at high risk should be screened at least annually . • Separate written consent for HIV testing should not be required. • Prevention counseling should not be required. MMWR 2006;55 (No. RR-14):1-13.

  42. It’s the Law in Virginia: Informed Consent/Counseling “A test subject shall be given an oral or written explanation of the meaning of the test. The test subject shall then be given informed consent to the testing.” “Every HIV test subject shall be given the opportunity to have the test results disclosed on an individual face-to-face basis and with appropriate counseling.” Va. Code 32.1-37.2

  43. Repeat HIV Testing Annual testing for high risk: • IVDA and sex partners. • Persons who exchange sex for money or drugs. • Partners of HIV infected persons. • Persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test. HCW should encourage patients and their prospective partners to be tested before initiating a new sexual relationship.

  44. HIV and Pregnancy • In southeastern Virginia, about 70 HIV(+) women become pregnant each year. • Transmission to the child with current antiretrovirals is 0-2% each year. • Dr. Bonnie Dattel in the EVMS Maternal Fetal Medicine Division manages almost all local HIV(+) pregnancies. • No infected children from HIV (+) pregnant women in her program since 1999.

  45. Global Mother-to-Child Transmission • In the US, transmission peaked at 945 children, then declined 95% to 48 in 2004. • Globally, estimated 2 million children born each year to HIV infected women in resource poor settings. • 700,000 infected annually. • >90% in sub-Saharan Africa, >50% die before their second birthday.

  46. Adult Circumcision and HIV • South African men 18-24 y.o. were randomized to immediate circumcision or wait 20 months. • After 21 months, 51 new HIV infections occurred in the controls vs. 18 in the circumcised group, a 65% reduction. Auvert B. 3rd IAS, Rio de Janeiro, 2005 Ab# TuOa0402. • Circumcision reduced the rate of HIV infection in female partners by 30%. Quinn T. CROI 2006.

  47. Adult Circumcision and HIV • 4,996 men 15-49 y.o. in rural Uganda ranomized to immediate or delayed circumcision (24 months). • As treated efficacy: 55% reduction; no change in behaviors.Gray R. Lancet 2007;369:657-66. • 2,784 men 18-24 y.o. in Kenya randomized to immediate or delayed circumcision. • As treated efficacy: 60% reduction; no behavioral risk compensation. Bailey R. Lancet 2007;369:643-56.

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