Global HIV/AIDS epidemiology Anna Mia Ekstrm Karolinska Institutet Professor, Infectious Disease Clinician The HIV/AIDS & Global Health Research group Part I: HIV, the virus, the epidemic, new infections, prevalence and risk/safe behaviours What is HIV? Virus attacking a type of white blood cells/immune defense T-cells CD positive, important coordinators Hiv destroys T-cells when making new copies Immune defense weakens over time if no treatment 10,000,000,000 new particles made/destroyed every day T1/2= 30 min-6 h. Vad r AIDS? AIDS= Acquired Immuno-Deficiency Syndrome A few months25+ yrs after infection Immunodeficiency symptoms/illnesses= AIDS Opportunistic infections Natural course of HIV (without treatment) Before 1996 Photo by Therese Frare, LIFE magazine 1990 People living with HIV: 35.3 million 2/3 in SSA, 19 million dont know they have HIV People living with HIV in the world Anna Mia Ekstrm Source: UNAIDS 2011 New infections and ADS related deaths People New HIV infections AIDS-related deaths Peaked in 1997 Peaked in million in million deaths in 2013 Anna Mia Ekstrm Source: UNAIDS, World AIDS Day Report 2012 Prevalence vs. Incidence PREVALENCE (proportion HIV& now) Death INCIDENCE (new HIV cases/pop) Prevalence is influenced by: Speed at which new cases are infected Duration/Survival People living with HIV, by country 2013 New HIV infections continue to decline in most regions 2.1 million people were newly infected in 2013 44% decline in among adults (aged 15 to 49) in >2/3 new HIV infections are in sub-Saharan Africa 15 countries account for 75% PLHIV & >75 % of new infections (2013). Key populations especially high prevalence (MSM, IDUs, sex workers) 2/6/2016 Name Surname 15 New HIV infections, by country 2013, The global decline is not uniform In Indonesia, new infections increased by 48% since 2005 Middle East and North Africa by 31% since 2001 Western Europe and North America 6% since Also increases in Eastern Europe (Kazakhstan, Kirgizstan, Georgia), but Russia and Ukraine account for 85% of all PLHIV in the region 2/6/2016 Name Surname 17 Young girls and women= of all new infections in SSA 2/6/2016 Name Surname 18 Anna Mia Ekstrm, KI 19 1 million new infections 2013 among < 24 years 60% are women 80% is infected by someone who doesnt know his/her status 50% by someone newly infected HIV among young people in southern Africa Age at first sexual intercourse by education status in Swaziland, 2007 Sources: Central Statistical Office & Macro International (2008). Figure Women < 15 yrs Women < 18 yrs Men < 15 yrs Men < 18 yrs No education Lower primary Higher primary Secondary High School Tertiary % Voluntary male circumcision cuts risk of HIV infection by 60% 2/6/2016 Name Surname 22 HIV-incidence ( ) Increasing>25% Stable Decreasing>25% Insufficient data Anna Mia Ekstrm Source: UNAIDS 2011 MDG6a (reverse the spread): Behind the success story Incidence data inherently uncertain! Biggest decline in SSA but leveled off at VERY high level Southern Africa Part II: HIV and health systems: Antiretroviral treatment, TasP, adherence and coverage ART= Miracle drugs! 2/6/2016 Name Surname 27 Before and 90 days after ART Antiretrovirals: miracle drugs but still costly, require perfect lifetime adherence & have potential serious side effects 2/6/2016 Name Surname 30 Target 6. Access to life saving treatment has increased! 12 million on ART in LMIC 2014 Antiretroviral treatment reduces risk of infection in discordant couples by 96% = TasP Treatment as Prevention New infections vs % on ART Treatment as Prevention (TasP) Figure 1. The percentage of all HIV-infected people taking antiretrovirals, by country Andrew Hill et al. World AIDS Conference 2014 [LBPE29] 2/6/2016 Name Surname 35 Fragmenterade hlsosystem pverkar tillgngen till behandling Exempel frn Tanzania Source: MOHSW & WHO. Courtesy of Don de Savigny Ugandans die as ARVs expire in govt stores Esther Nakkazi The East African magazine Sep , 2006 Weak health systems harm treatment effcacy =22% 90% Efficacy X Access X Stock-outs X Patient retention X Patient adherence Effectiveness X 83% X 70% X 77% X 54% Health system factors Poor adherence Insufficient drug exposure Virologic failure ART =wild-type virus Treatment failure Virologic suppression Viral load After Spizter, 2004 HIV cure? Intensive research Early treatment before established infection Chronic infection: kick, kill, contain 2/6/2016 Name Surname 44 2/6/2016 Name Surname 45 Reduce sexual transmission of HIV by 50% Halve transmission of HIV among drug users Eliminate HIV transmission to children 15 million people should access ART Halve TB deaths among HIV-positive Reduce resource gaps on HIV and AIDS Eliminate gender inequality in HIV Eliminate HIV-related stigma & discrimination Eliminate HIV-related travel restrictions Stronger integration of HIV into other health / medical fields Local political leadership is key to success Impact of three scenarios on HIV infection in sub-Saharan Africa, 2003 Year Treatment-centered Prevention-centered Baseline Comprehensive response Number of new HIV infections (millions) Source: Salomon JA et al. (2005). Integrating HIV prevention and treatment: from slogans to impact 6.1 HIV/AIDS: how will we reach the targets? Health systems must be strengthened to reduce the risk of drop-out and resistance Reduction in the incidence through prevention (partner reduction, male circumcision, TasP) ART cannot replace prevention when 1.6 new infected for every person entering treatment Combating stigma, gender segregation and violence against women should be intensified 2/6/2016 Name Surname 47 Thank you!