MALAYSIA:MALAYSIA:Taking Stock of Taking Stock of

HIV Prevention HIV Prevention

Dr. Christopher KC LeeDr. Christopher KC LeeInfectious Disease UnitInfectious Disease Unit

Department of MedicineDepartment of MedicineHospital Sungai BulohHospital Sungai Buloh

HIV / AIDS:HIV / AIDS:

The Global BurdenThe Global Burden

Global estimates for adults and children, 2005

• People living with HIV 38.6 million [33.4 – 46.0 million]

• New HIV infections in 2005 4.1 million [3.4 – 6.2 million]

• Deaths due to AIDS in 2005 2.8 million [2.4 – 3.3 million]

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

Global summary of the HIV and AIDS epidemic, 2005

North Africa and Middle EastNorth Africa and Middle East440,000440,000

Sub-Saharan AfricaSub-Saharan Africa24.5 million24.5 million

Eastern Europe and Eastern Europe and Central AsiaCentral Asia 1.4 million1.4 million

OceaniaOceania78,00078,000

North AmericaNorth America1.3 million1.3 million

CaribbeanCaribbean330,000330,000

Southern and Southern and Southest AsiaSouthest Asia

7.6 million7.6 million

Latin AmericaLatin America1.6 million1.6 million

UNAIDS, 2006. Available at: http://www.unaids.org.

Western/Western/Central EuropeCentral Europe

720,000720,000

Adults and Children Estimated to Be Living With HIV, 2005

East AsiaEast Asia680,000680,000

Estimated number of adults and children newly infected with HIV, 2005

Total: 4.1 (3.4 – 6.2) millionTotal: 4.1 (3.4 – 6.2) million

Western & Central Europe

22 00022 000[18 000 – 33 000[18 000 – 33 000]]

North Africa & Middle East

64 00064 000[38 000 – 210 000][38 000 – 210 000]

Sub-Saharan Africa2.7 million2.7 million

[2.3 – 3.1 million][2.3 – 3.1 million]

Eastern Europe & Central Asia

220 000 220 000 [150 000– 650 000][150 000– 650 000]

South & South-East Asia830 000830 000[530 000 – 2.3 million][530 000 – 2.3 million]

Oceania72007200

[3500 – 55 000][3500 – 55 000]

North America43 00043 000

[34 000 – 65 000][34 000 – 65 000]

Caribbean37 00037 000

[26 000 – 54 000][26 000 – 54 000]

Latin America140 000140 000

[100 000 – 420 000][100 000 – 420 000]

East Asia97 00097 000

[55 000 – 290 000][55 000 – 290 000]

Estimated adult and child deaths from AIDS, 2005

Total: 2.8 (2.4 – 3.3) millionTotal: 2.8 (2.4 – 3.3) million

Western & Central Europe

12 00012 000[<15 000][<15 000]

North Africa & Middle East

37 00037 000[20 000 – 62 000][20 000 – 62 000]

Sub-Saharan Africa2.0 million2.0 million

[1.7 – 2.3 million][1.7 – 2.3 million]

Eastern Europe & Central Asia

53 000 53 000 [36 000 – 75 000][36 000 – 75 000]

South & South-East Asia560 000560 000[370 000 – 810 000][370 000 – 810 000]

Oceania34003400

[1900 – 5500][1900 – 5500]

North America18 00018 000

[11 000 – 26 000][11 000 – 26 000]

Caribbean27 00027 000

[19 000 – 36 000][19 000 – 36 000]

Latin America59 00059 000

[47 000 – 76 000][47 000 – 76 000]

East Asia33 00033 000

[20 000 – 49 000][20 000 – 49 000]

Western & Central Europe

200200[<400][<400]

North Africa & Middle East69006900

[3200 – 12 000][3200 – 12 000]

Sub-Saharan Africa470 000470 000

[370 000 – 590 000][370 000 – 590 000]

Eastern Europe & Central Asia

2300 2300 [1400 – 3900][1400 – 3900]

South & South-East Asia44 00044 000[23 000 – 75 000][23 000 – 75 000]

Oceania11001100

[400 – 2800][400 – 2800]

North America500500

[<1000][<1000]

Caribbean37003700

[2100 – 5800][2100 – 5800]

Latin America50005000

[3500 – 8000][3500 – 8000]

East Asia 23002300

[1000 – 4100][1000 – 4100]

Total: 540 000 (420 000 – 670 000Total: 540 000 (420 000 – 670 000)

Estimated number of children (<15 years) newly infected with HIV, 2005

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)

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

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

Burden of HIVBurden of HIVin in

MalaysiaMalaysia

MALAYSIAMALAYSIA• First HIV case detected in 1986First HIV case detected in 1986

• as of 31as of 31stst. December, 2005 : 70.559 cases notified to . December, 2005 : 70.559 cases notified to Ministry of HealthMinistry of Health

0

1000

2000

3000

4000

5000

6000

700092

93

94

95

96

97

98

99

2000

2001

2002

2003

2004

2005

num

ber

sn

umb

ers

1992 to 2005, years1992 to 2005, yearsMalaysiaMalaysia31/12//0531/12//05

Cummulative HIV infectionsMalaysia 1993-2005

780511198

1539619993

2391728541

3323338340

4427851256

5801264439

70559

0

10000

20000

30000

40000

50000

60000

70000

80000 1993199419951996199719981999200020012002200320042005Year

Cummulative AIDS casesMalaysia 1993 - 2005

227 332 565 9121480

2355

3555

4723

6025

72188294

9442

10663

0

2000

4000

6000

8000

10000

12000 1993199419951996199719981999200020012002200320042005Year

Yearly AIDS DeathsMalaysia 1993 - 2005

55 80165

271

473

689

874 882975

881

700

1065984

0

200

400

600

800

1000

1200 1993199419951996199719981999200020012002200320042005

Cummulative AIDS deaths: 8179 (31st. Dec, 2005)

Year

GenderGender MaleMale 65,345 65,345 (92.6%)(92.6%)

FemaleFemale 5,214 5,214 (7.4%) (7.4%)

TOTALTOTAL 70,559 70,559 (100%)(100%)

Malaysia 31/12/05

HIV in MalaysiaHIV in MalaysiaProportion of Men / Women by Proportion of Men / Women by

YearYear

0102030405060708090

100

MenWomen

per

cen

tag

e

Age DistributionAge Distribution

0

5000

10000

15000

20000

25000

30000

35000

<1313-1920-2930-3940-49>50unknown

num

bers

num

bers

Age groups in yearsAge groups in years

78.5% : ages 20 - 39 yrs.78.5% : ages 20 - 39 yrs.

Malaysia 31/12/05Malaysia 31/12/05

HIV : Routes of transmissionHIV : Routes of transmission

•Homo / bisexuals 1025 1.5%Homo / bisexuals 1025 1.5%

•IV drug users 52407 74.3%IV drug users 52407 74.3%

•Heterosexuals 10124 14.3%Heterosexuals 10124 14.3%

•Blood / blood products 28 0.04%Blood / blood products 28 0.04%

•Mother-to-child 541 0.8%Mother-to-child 541 0.8%

•Unknown 6431 9.1%Unknown 6431 9.1%

No.No. %%

MalaysiaMalaysia31/12/0531/12/05

HIV Proportion by route of HIV Proportion by route of transmissiontransmission

0

10

20

30

40

50

60

70

80

90

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

IDUHeteroHomo/Bip

erc

enta

ge

Percentages of IDUs reactive for HIV by year

0

5

10

15

20

25

30

89 90 91 92 93 94 95 96 97 98 99 2000Year

%

Medically: What happens to those Medically: What happens to those infected?infected?

• 50% will have flu-like illness for about 2-6 weeks 50% will have flu-like illness for about 2-6 weeks after exposure (Primary HIV illness)after exposure (Primary HIV illness)

• Will recover & enter a long asymptomatic phase Will recover & enter a long asymptomatic phase (the latent period)(the latent period)

• Prolong asymptomatic period; Average period from Prolong asymptomatic period; Average period from infection to AIDS 8-10 yearsinfection to AIDS 8-10 years

• Viral load, plasma HIV RNA, remain at steady state. Viral load, plasma HIV RNA, remain at steady state.

• CD4 T-lymphocyte count fairly stable; rate of CD4 T-lymphocyte count fairly stable; rate of decline dependant on viral loaddecline dependant on viral load

• CD4 cell count : production almost = destruction CD4 cell count : production almost = destruction for sustained period of timefor sustained period of time

CD4 counts & Opportunistic Infections

0

100

200

300

400

500

600

700

800

900

1000CD4

Asymptomatic

Mildly symptomatic

AIDS-definingillness

Years : mean survival ~ 10 yrs.

CD

4

counts

Examples of AIDS- defining Illness (ADI)

Examples of AIDS- defining Illness (ADI)

• Candidiasis: oesophagus, Candidiasis: oesophagus, trachea, lungs trachea, lungs

• Cervical ca., invasiveCervical ca., invasive• Cryptococcosis, Cryptococcosis,

extrapulmonaryextrapulmonary• Cryptosporidiosis: Cryptosporidiosis:

diarrhoea > 1 monthdiarrhoea > 1 month• CMV: except liver, spleen CMV: except liver, spleen

& lymph nodes& lymph nodes• Herpes simplex: ulcer > 1 Herpes simplex: ulcer > 1

month, lung, oesophagusmonth, lung, oesophagus• HIV dementiaHIV 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

Implications of growing AIDS Implications of growing AIDS population population

• Increasing strain on health sector esp. Increasing strain on health sector esp. hospital based serviceshospital based services

- hospital beds- hospital beds

- human resource- human resource

- finances- finances

• Social & developmental implications:Social & developmental implications:

- impact on families, communities, - impact on families, communities, countries countries

- political uncertainty / national threat - political uncertainty / national threat

Prevalence of Opportunistic Infections among AIDS Prevalence of Opportunistic Infections among AIDS patients in Indiapatients in India

InfectionInfection PrevalenceRatePrevalenceRate

TuberculosisTuberculosis 40%-68%40%-68%

ToxoplasmosisToxoplasmosis 10%-66%10%-66%

Oropharyngeal candidiasisOropharyngeal candidiasis 58%-60%58%-60%

CryptosporidiosisCryptosporidiosis 4%-11%4%-11%

CryptococcosisCryptococcosis 5%-8%5%-8%

Systemic candidiasisSystemic candidiasis 4%-8%4%-8%

Pneumocystis cariniiPneumocystis carinii pneumonia pneumonia 0.4%0.4%

IsosporiasisIsosporiasis 0.3%0.3%

Kaposi's sarcomaKaposi's sarcoma 0.27%0.27%

S. Singh, AIDS Reader 7(3);101-106, 1997S. Singh, AIDS Reader 7(3);101-106, 1997

Health Sector Under StressHealth Sector Under StressA.A. Care & treatment for PLWHAs heavily Care & treatment for PLWHAs heavily

taxing public health services in taxing public health services in developing countries. developing countries.

o Rwanda, 1990s – treatment Rwanda, 1990s – treatment consumed 66% of public health consumed 66% of public health spending.spending.

o 1997 – Public health spending for 1997 – Public health spending for AIDS > 2% of GDP in 7/19 African AIDS > 2% of GDP in 7/19 African countries (total health spending - countries (total health spending - 3-5% GDP)3-5% GDP)

o AIDS take up 50% beds in AIDS take up 50% beds in Provincial Hospital, Chiang Mai; Provincial Hospital, Chiang Mai; 39% - Hospital Kenyatta, Nairobi, 39% - Hospital Kenyatta, Nairobi, & 70% in Prince Regent Hospital, & 70% in Prince Regent Hospital, Bujumbura, BurundiBujumbura, BurundiUNAIDS Photo Library

B.B. Other patients do not get beds in hospitals & Other patients do not get beds in hospitals & die due to late treatment.die due to late treatment.

C.C. TB – rapidly increasing, kills 1/3 PLWHAs, TB – rapidly increasing, kills 1/3 PLWHAs, increases TB risk in community at largeincreases TB risk in community at large

o World Bank – 25% of HIV-negative people World Bank – 25% of HIV-negative people who die of TB in the future would not have who die of TB in the future would not have been infected with the bacillus in the been infected with the bacillus in the absence of AIDS.absence of AIDS.

o New AIDS therapies – increases health New AIDS therapies – increases health sector expenditure in infrastructure, drugs, sector expenditure in infrastructure, drugs, training and personnel.training and personnel.

Health Sector Under StressHealth Sector Under Stress

Non-AIDS bedsNonNon--AIDS bedsAIDS beds

AIDS bedsAIDS bedsAIDS beds

199019901990 200020002000

Source :Source : UNAIDS, 2000UNAIDS, 2000

Bed occupancy required for AIDS patients, Zimbabwe

Bed occupancy required for AIDS patients, Bed occupancy required for AIDS patients, ZimbabweZimbabwe

From “Health Issue” to “Development Crisis”

• Destruction of social capitalDestruction of social capital– Knowledge base of societyKnowledge base of society– Production sectors: agriculture, industryProduction sectors: agriculture, industry

• Weakening of institutionsWeakening of institutions– Governance, civil service, judiciary, Governance, civil service, judiciary,

armed forces, education, health armed forces, education, health – Inhibition of private sector growthInhibition of private sector growth

• Wider, deeper povertyWider, deeper poverty

Economic Growth Impact of HIV (1990-97)

Growth Impact of HIV (1990-97) (80 developing countries)

-1.6

-1.4

-1.2

-1

-0.8

-0.6

-0.4

-0.2

0

0 5 10 15 20 25 30 35

HIV Prevalence Rate (%)

Re

du

cti

on

in

gro

wth

ra

te G

DP

p

er

ca

pit

a (

%,

pe

r y

ea

r)

Source: R. Bonnel (2000) Economic Analysis ofHIV/AIDS, ADF2000 Background paper, World Bank

HIV/AIDS changes the welfare of countriesHIV/AIDS changes the welfare of countriesHIV/AIDS changes the welfare of countries

In 1998 UNDP estimated that the Human Development

Index (HDI) of South Africa would be 15% lower due

to AIDS in 2010.

Source: HIV/AIDS & Human Development South Africa, UNAIDS & UNDP, 2000

In 1998 UNDP estimated that the Human Development In 1998 UNDP estimated that the Human Development

Index (HDI) of South Africa would be 15% lower due Index (HDI) of South Africa would be 15% lower due

to AIDS in 2010.to AIDS in 2010.

Source: HIV/AIDS & Human Development South Africa, UNAIDS & UNDPSource: HIV/AIDS & Human Development South Africa, UNAIDS & UNDP, 2000, 2000

AIDS - Developmental Crisis AIDS - Developmental Crisis

Botswana 2020 – Botswana 2020 – More adults aged More adults aged 60 – 70 yrs than 60 – 70 yrs than 40 – 50 yrs40 – 50 yrs

Small number of Small number of young adults young adults support large support large number of young number of young & old people& old people

Demographic Impact of AIDSDemographic Impact of AIDS

Projected population structure with & without the AIDS epidemic, Botswana 2020

Source: US Census Bureau, World Population Profile 2000

Household ImpactHousehold Impact

Survey: Impact of family member with AIDS – households suffer in income. Leads to fewer purchases & savingsThailand

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.

Impact of HIV/AIDS in urban households, Côte d’Ivoire

Impact of HIV/AIDS in urban households, Impact of HIV/AIDS in urban households, Côte d’IvoireCôte d’Ivoire

General populationGeneral population Families living with AIDSFamilies living with AIDS

Source: Source: SimulationSimulation--based on data from Bechu, Delcroix and Guillaume, 1997based on data from Bechu, Delcroix and Guillaume, 1997

Monthly income per capitaMonthly income per capita

Monthly consumptionper capitaMonthly consumptionper capita

00

5 0005 000

10 00010 000

15 00015 000

20 00020 000

25 00025 000

– 5 000– 5 000

30 000 Francs CFA30 000 Francs CFA

Savings/DisavingsSavings/Disavings

AIDS OrphansAIDS OrphansChildren who lose their mothers or both parents to AIDS < age of 15 yrs13.2 mil AIDS orphans; 95% in developing countriesBefore AIDS - 2% of children in developing countries were orphans. 1997, 7 – 11% of children were orphansAIDS 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.

Impact of AIDS in sugar estate, KenyaImpact of AIDS in sugar estate, Kenya

a)a) AbsenteeismAbsenteeism (8,000 days of labour lost due (8,000 days of labour lost due to sickness between ’95-97)to sickness between ’95-97)

b)b) Lower productivityLower productivity (50% (50% in the ratio of in the ratio of processed sugar from raw cane from ’93-97)processed sugar from raw cane from ’93-97)

c)c) Higher overtime costsHigher overtime costs when healthy when healthy workers fill in for sick colleaguesworkers fill in for sick colleagues

d)d) Spending on funerals Spending on funerals 5 times 5 times between ’89- between ’89-9797

e)e) Health costsHealth costs > 10 times > 10 times (3/4 HIV-related (3/4 HIV-related illness)illness)

HIV-related illness & death – main reason HIV-related illness & death – main reason people leaving companypeople leaving company

HIV is hurting businessHIV is hurting business

Current Status: the HKL cohortCurrent Status: the HKL cohort> 2800 patients registered since `92> 2800 patients registered since `92• New patients per year: New patients per year:

~ from 150 (1993) to about ~ from 150 (1993) to about 565 (2005) patients565 (2005) patients

• 82% Malays IV drug users82% Malays IV drug users• 78% Chinese infected through 78% Chinese infected through

sexsex• 70% education level : 70% education level :

<< Form 3 Form 3 • Employment: 79% blue-collared Employment: 79% blue-collared

workersworkers CLee,IDclinic,HKL

Is there any Good News ?

                                                                                              

HIV Prevalence among antenatal women, Cambodia 1997-2000 (%)

1997 1998 1999 2000

3.2

3.0

2.8

2.6

2.4

2.2

Source : MOH Cambodia

Trend in HIV prevalence in 21 year old military Trend in HIV prevalence in 21 year old military conscripts in Thailandconscripts in Thailand

Source: Armed Forces Research Institute of Medical Sciences, Thailand

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

HIV

pre

vale

nc

e (%

)H

IV p

reva

len

ce

(%)

00

55

Prevention StrategiesPrevention Strategies

Has to be individualised for Has to be individualised for countries, districts, communities, countries, districts, communities, etc.etc.

Targetted vs GeneralisedTargetted vs Generalised

Objective: Behavioural ChangeObjective: Behavioural Change

Community sensitiveCommunity sensitive

Gender sensitiveGender sensitive

Obstructive policies need to be Obstructive policies need to be addressedaddressed

Multisectoral involvement often Multisectoral involvement often requiredrequired

What has worked …?What has worked …?

HIV Education programs for HIV Education programs for schoolchildren – various modelsschoolchildren – various models

Harm Reduction programs:Harm Reduction programs: - methadone maintenance treatment- methadone maintenance treatment

- needle exchange programs- needle exchange programs

Targeted Condom promotionTargeted Condom promotion

Women specific & sensitive Women specific & sensitive programsprograms

Involvement of civil society – Involvement of civil society – religious, community leaders, religious, community leaders, corporate sector corporate sector

H.A.A.R.T.

HHighly ighly

AActivective

AAnti-nti-

RRetroviraletroviral

TTherapyherapy

Declining morbidity & mortality among patients with advanced HIV infection

0

5

10

15

20

25

30

35

40

Deaths

ARV

‘‘9494 ’’9595 ‘‘9696 ‘‘9797

100100

7575

5050

2525

00

Dea

ths

p er

1 00

p ers

on y

rsA

RV

therapy including protease inhibitors

Pallella FJ et al, HIV Outpatient Study Investigations, N Engl J Med 1998; 338:853-860

00001-E-42– 27 June 2000

Annual number of deaths due to AIDS, Annual number of deaths due to AIDS, Canada, 1990 to 1999Canada, 1990 to 1999

0

200

400

600

800

1000

1200

1400

1600

90 91 92 93 94 95 96 97 98 99

Num

ber

of A

IDS

dea

ths

Source: Health Canada, HIV and AIDS in Canada. Surveillance Report to December 31, 1999 00001-E-42– 27 June 2000

Annual number of deaths due to AIDS, Annual number of deaths due to AIDS, Canada, 1990 to 1999Canada, 1990 to 1999

0

200

400

600

800

1000

1200

1400

1600

90 91 92 93 94 95 96 97 98 99

Num

ber

of A

IDS

dea

ths

Source: Health Canada, HIV and AIDS in Canada. Surveillance Report to December 31, 1999

ARV drug Prices in Malaysia

0100200300400500600700800900

1000

1999 2000 2001 2002 2003*

IndinavirddINevirapineAZTEfavirenzd4T3TC

Rin

gg

it p

er m

on

th

* Expected new * Expected new pricesprices

Thank YouThank You

““Do What you CanDo What you Can

with what you Havewith what you Have

Where you Are !”Where you Are !”

Theodore RooseveltTheodore Roosevelt