the global aids pandemic where do we go from here? paul de lay, m.d. chief, hiv/aids division usaid

The Global AIDS The Global AIDS PandemicPandemic

Where Do We Go Where Do We Go From Here?From Here?

Paul De Lay, M.D.Paul De Lay, M.D.

Chief, HIV/AIDS DivisionChief, HIV/AIDS Division

USAIDUSAID

June 5, 1981June 5, 1981MMWR publishes report on MMWR publishes report on five cases of Pneumocystis five cases of Pneumocystis

carinii pneumonia in carinii pneumonia in previously healthy young previously healthy young

menmen

Spread of HIV over timein sub-Saharan Africa, 1984 to 1999

Estimated percentage of adults

(15–49) infected with HIV 20.0% – 36.0%10.0% – 20.0% 5.0% – 10.0% 1.0% – 5.0% 0.0% – 1.0%trend data unavailable

outside region

HIV-Seroprevalence for Pregnant Women HIV-Seroprevalence for Pregnant Women in Selected Urban Areas of Africa: 1985-in Selected Urban Areas of Africa: 1985-

20002000

1985 1987 1989 1991 1993 1995 1997 1999 2001

0

5

10

15

20

25

30

35

40

45

50HIV Seroprevalence (%)

Kampala

Nairobi

Abidjan

Harare

Kwazulu/Natal

Lagos

Yaounde

Francistown

Blantyre

Lusaka

Dakar

Source: US Census Bureau

Leading causes of death Leading causes of death globally, 1999globally, 1999

1 1 Ischaemic heart diseaseIschaemic heart disease 2 2 Cerebrovascular diseaseCerebrovascular disease 3 3 Acute lower respiratory infectionsAcute lower respiratory infections 4 4 HIV/AIDSHIV/AIDS 5 5 Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease 6 6 Perinatal conditionsPerinatal conditions 7 7 Diarrhoeal diseasesDiarrhoeal diseases 8 8 TuberculosisTuberculosis

11 11 MalariaMalaria

12.7

9.9

7.1

4.8

4.8

4.2

4.0

3.0

1.9

Source: The World Health Report 2000, WHO

Rank % of total

The latest numbersThe latest numbers 16 countries in SSA now have general population 16 countries in SSA now have general population

rates >10%; of these 7 have rates greater than 20%rates >10%; of these 7 have rates greater than 20%

Mortality for women peaks at 30-34, for men at 40-Mortality for women peaks at 30-34, for men at 40-4444

By 2003, it is estimated 3 countries will be By 2003, it is estimated 3 countries will be experiencing negative population growth. 5 will be experiencing negative population growth. 5 will be experiencing a growth rate of 0experiencing a growth rate of 0

This will produce population pyramids unlike any This will produce population pyramids unlike any that we have seen beforethat we have seen before

By 2010, 44 infants out of every 1,000 live births will die in Zimbabwe due to AIDS.

Source: U.S. Bureau of the Census, International Data Base and unpublished tables.

Botswana

South Africa

Zimbabwe

Cote d'Ivoire

Nigeria

Kenya

Uganda

0 20 40 60 80 100 120

Infant deaths per 1,000 live births

Without AIDS

With AIDS

80 percent of deaths among children under-5 in Zimbabwe in 2010 will be due to AIDS.


Botswana

South Africa

Zimbabwe

Cote d'Ivoire

Nigeria

Kenya

Uganda

0 50 100 150 200 250

Deaths under age 5 per 1,000 live births

Without AIDS

With AIDS

Growth Rates With and Without AIDSSelected Countries: 2010


Botswana

South Africa

Zimbabwe

Cote d'Ivoire

Nigeria

Kenya

Uganda

0 1 2 3 4 5-1-2

Percent

With AIDS

Without AIDS

Population of Zimbabwe, With and Without AIDS: 2010

US Census Bureau, World Population Profile 2000

80757065605550454035302520151050

02004006008001000

Thousands

0 200 400 600 800 1000

Thousands

Males Females

Without AIDS

With AIDS

3.6 million3.6 million









19901990

AIDS OrphansAIDS OrphansOrphans of Orphans of Other CausesOther Causes

20102010

20002000

TotalTotalOrphansOrphans

Total Orphans, 34 Study CountriesTotal Orphans, 34 Study Countries

Socio-Economic ImpactSocio-Economic Impact

Macro-economyMacro-economy Specific Labor Specific Labor

SectorsSectors AgricultureAgriculture TransportTransport ExtractionExtraction Skilled workersSkilled workers

CommunityCommunity Families/HouseholdsFamilies/Households

PoliticalPolitical Security/militarySecurity/military Social SectorsSocial Sectors

HealthHealth

0 10 20 30 40 50 60 70

Cambodia

Haiti

Mozambique

Rwanda

Côte d'Ivoire

Zambia

Kenya

South Africa

Zimbabwe

Botswana

Life expectancy at birth (years)

Predicted life expectancy Loss in life expectancy due to HIV/AIDS

Source: U.S. Census Bureau, 2000

Predicted loss in life expectancy Predicted loss in life expectancy due to HIV/AIDS in children born in 2000due to HIV/AIDS in children born in 2000

Impact of AIDS on Mortality Impact of AIDS on Mortality at Kenyatta National at Kenyatta National

Hospital, NairobiHospital, Nairobi

0

5

10

15

20

25

30

35

40

HIV + HIV -

1988/ 891992

ASIA & OCEANIA

CAMBODIA

THAILAND

BURMA

PAKISTAN

LAOS

INDIA

VIETNAM

LAC

HAITI

HONDURAS

GUYANA

BRAZIL

BELIZE

DOMINICAN REP.

ARGENTINA

BARBADOS

JAMAICA

TRIN. & TOB.

0 10 20 30 40 50

% Seropositive

AFRICA

BOTSWANA

SOUTH AFRICA

LESOTHO

MALAWI

SWAZILAND

ZIMBABWE

ZAMBIA

NAMIBIA

RWANDA

BURUNDI

ETHIOPIA

KENYA

UGANDA

TANZANIA

COTE D'IVOIRE

CAR

LIBERIA

MOZAMBIQUE

BURKINA FASO

TOGO

NIGERIA

CHAD

CONGO

CAMEROON

GABON

BENIN

CONGO, (ZAIRE)

0 10 20 30 40 50

% Seropositive

HIV-Seroprevalence among Pregnant HIV-Seroprevalence among Pregnant women from Capital or Major Urban women from Capital or Major Urban

Centers in Selected CountriesCenters in Selected Countries

Factors that influence the Factors that influence the spread of HIVspread of HIV

The VirusThe Virus The HostThe Host The Role of BehaviorThe Role of Behavior

The VirusThe Virus

Time of introduction into a Time of introduction into a populationpopulation

HIV subtypesHIV subtypes Levels of viremiaLevels of viremia

0

200

400

600

800

1000

1200

CD

4 co

unt/

mm

3

0.001

0.01

0.1

1

titr

e

CD4 Viral Titre

Natural History of HIV Natural History of HIV InfectionInfection

Weeks Years

Source: Fauci AS, et al. Ann Intern Med, 1996;124:654).

The Host (Us)The Host (Us)

The presence of a sexually The presence of a sexually transmitted diseasetransmitted disease

Male circumcisionMale circumcision The age of the personThe age of the person

HIV prevalence rate among teenagers HIV prevalence rate among teenagers in Kisumu, Kenya, by agein Kisumu, Kenya, by age

0 0

3.62.2

8.68.3

17.9

29.4

22

33.3

0

5

10

15

20

25

30

35

15 16 17 18 19Age in years

HIV

pre

vale

nc

e (%

)

boys

girls

Source: National AIDS Programme, Kenya, and Population Council, 1999

The Role of BehaviorThe Role of Behavior

““Quantitative BehaviorQuantitative Behavior”” Number of partnersNumber of partners Number of persons engaging in risk Number of persons engaging in risk

behaviorbehavior Rate of partner exchangeRate of partner exchange Size of and rate of contact between Size of and rate of contact between

core groups and general core groups and general population-”population-”bridging”bridging”

Comparison of average number of Comparison of average number of clients per sex worker versus % of clients per sex worker versus % of young men to utilized sex workersyoung men to utilized sex workers

0

0.5

1

1.5

2

2.5

3

3.5

4

0 10 20 30 40 50 60

% males using sex workers

Avera

ge #

of

CS

cli

en

ts/d

ay

Indonesia

Philippines

Cambodia

Thailand

Infectious Disease ControlInfectious Disease ControlBasic PrinciplesBasic Principles

Modes of transmissionModes of transmission Stages of the epidemicStages of the epidemic Epicenters/ “hot zones” Concept of Epicenters/ “hot zones” Concept of

“core transmitters” “core transmitters” Those most likely to Those most likely to

transmit/Those most likely to transmit/Those most likely to contract (“TMLTC”)contract (“TMLTC”)

HIV TransmissionHIV TransmissionGlobal SummaryGlobal Summary

Type ofExposure

Efficiency persingle exposure

Percent ofglobal total

Blood transfusion >90% 5%

MTCT 20-40% 10%

Sexual intercourse:- vaginal- anal

0.1% - 1.0% 80% -75%

-5%

Injecting drug use 0.5% -1.0% 5%

Health Care <1.0% .01%

Stages of the EpidemicStages of the Epidemic

NascentNascent ConcentratedConcentrated GeneralizedGeneralized MatureMature

Essential Technical Elements Essential Technical Elements of an HIV/AIDS Programof an HIV/AIDS Program

PreventionPrevention Blood safetyBlood safety Universal precautionsUniversal precautions Sexual risk reductionSexual risk reduction Harm reductionHarm reduction Condom social Condom social

marketingmarketing STI managementSTI management Voluntary Counseling Voluntary Counseling

and Testing (1996)and Testing (1996) Stigma reductionStigma reduction Preventing MTCT (1998)Preventing MTCT (1998) Surveillance and M&ESurveillance and M&E

Care and MitigationCare and Mitigation Palliative carePalliative care Psychosocial supportPsychosocial support Treatment of Treatment of

Opportunistic Infections Opportunistic Infections (1995)(1995)

Orphans and Vulnerable Orphans and Vulnerable Children (1998)Children (1998)

Use of Highly Active Anti-Use of Highly Active Anti-Retroviral Therapy (1997)Retroviral Therapy (1997)

Other mitigation Other mitigation activitiesactivities

Major goalsMajor goals for Preventionfor Prevention

Reduce the number of risk Reduce the number of risk actsacts

Decrease the efficiency of Decrease the efficiency of transmissiontransmission

Global Response:Global Response:SuccessesSuccesses

At project level, we have evidence of sustained At project level, we have evidence of sustained behavior change to reduce the risk of HIV behavior change to reduce the risk of HIV transmission, resulting in decreased HIV and transmission, resulting in decreased HIV and STD prevalenceSTD prevalence

At national level, we have two categories of At national level, we have two categories of success:success: Preventing a major epidemicPreventing a major epidemic

(Senegal, Philippines, Indonesia)(Senegal, Philippines, Indonesia) Reducing an existing severe epidemicReducing an existing severe epidemic

(Uganda, Thailand, Zambia, Dominican (Uganda, Thailand, Zambia, Dominican Republic, Cambodia)Republic, Cambodia)

Source: National STD/AIDS Control Programmes, Senegal and Uganda Armed Forces Research Institute of Medical Sciences, Thailand

00

55

1010

1515

2020

2525

3030

89 90 91 92 93 94 95 96 97 98 99

HIV

pre

vale

nc

e (%

)H

IV p

reva

len

ce

(%)

Kampala, <20 year old ANC

Thailand, 21 year old military conscripts

Dakar, all ages ANC

Trends in HIV prevalence in selected populations Trends in HIV prevalence in selected populations in Kampala, Uganda; Dakar, Senegal; and Thailand;in Kampala, Uganda; Dakar, Senegal; and Thailand;

1989 to 19991989 to 1999

HIV prevalence rate among HIV prevalence rate among 13 to 19-year-olds, Masaka, Uganda, 1989 to 13 to 19-year-olds, Masaka, Uganda, 1989 to

19971997

0

1

2

3

4

5

1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97

girls

boys

Source: Kamali et al. AIDS 2000, 14: 427-434

HIV

pre

vale

nc

e (%

)

Percentage of sexually experienced by current Percentage of sexually experienced by current age (15-24 years old) in 1989 and 1995age (15-24 years old) in 1989 and 1995

0%

20%

40%

60%

80%

100%

120%

15 16 17 18 19 20 21 22 23 24Age

Perc

ent Sexually

Experi

ence

d

women1989men 1989

women1995men 1995

Key Elements of the Uganda Key Elements of the Uganda Response to HIV/AIDS Response to HIV/AIDS

Strong political commitmentStrong political commitment starting in starting in 1986 which encouraged all political 1986 which encouraged all political leaders to speak out on AIDS at all leaders to speak out on AIDS at all opportunitiesopportunities

Free pressFree press encouraged to print candid, encouraged to print candid, powerful articles on AIDS-intense ongoing powerful articles on AIDS-intense ongoing use of mass media (radio, TV, soap use of mass media (radio, TV, soap operas, etc)operas, etc)

Reliable ongoing Reliable ongoing national seroprevalence national seroprevalence datadata which was routinely disseminated which was routinely disseminated

Derived from E. Marum-USAID/CDC


Public figuresPublic figures openly discussed HIV status (Philly openly discussed HIV status (Philly Bongole Lutaya, Major Ruranga)Bongole Lutaya, Major Ruranga)

TASOTASO established in 1987-has served 50,000 established in 1987-has served 50,000 clientsclients

AIDS Information CentersAIDS Information Centers established in 1990- established in 1990-have served 500,000 clients (same day results have served 500,000 clients (same day results and “post test clubs”) and “post test clubs”)

Strong Strong religious networksreligious networks established for both established for both care and prevention (Islamic Medical Association, care and prevention (Islamic Medical Association, Protestants, Catholics)Protestants, Catholics)



Condom social marketingCondom social marketing program program was initially resisted by government, was initially resisted by government, now openly endorsednow openly endorsed

Multiple “Multiple “AIDS in the workplaceAIDS in the workplace” ” programs (implemented by programs (implemented by Federation of Ugandan Workers-Federation of Ugandan Workers-banks, breweries, military, police, banks, breweries, military, police, etc.)etc.)



Consistent Consistent outreach to young peopleoutreach to young people (use of radio, (use of radio, Straight TalkStraight Talk clubs, etc.) clubs, etc.)

Orphans programOrphans program with strong with strong commitment to keep children in commitment to keep children in communities and not support communities and not support institutions, includes microenterprise institutions, includes microenterprise efforts.efforts.

Staffing for AIDS programsStaffing for AIDS programs was strongly was strongly supported, attracting the best and the supported, attracting the best and the brightestbrightest


Key Elements of the Uganda Key Elements of the Uganda Response to HIV/AIDSResponse to HIV/AIDS

Active, well supported Active, well supported research research programsprograms with international with international collaborations (AIDS vaccines, mother collaborations (AIDS vaccines, mother to child transmission, TB, to child transmission, TB, pneumococcal vaccine, Vitamin A, pneumococcal vaccine, Vitamin A, mass STD Rx, etc)mass STD Rx, etc)

Ongoing, consistent, reliable Ongoing, consistent, reliable donor donor supportsupport, averaging $18 million/year, averaging $18 million/year


20012001Why hasn’t there been Why hasn’t there been

more impact on the more impact on the epidemic?epidemic?

The major challenges for an The major challenges for an expanded, comprehensive expanded, comprehensive

responseresponse Resource levels Resource levels What are we trying to achieve?What are we trying to achieve? Political willPolitical will Strategic planningStrategic planning Scaling up new activitiesScaling up new activities Urgent need for new technologiesUrgent need for new technologies

USG Resources for USG Resources for HIV/AIDSHIV/AIDS

FEDERAL AGENCY

1999 2000 2001 2002 ESTIMATED

USAID $142 $190 $310 $415

Food for Peace (USAID)

$10 $10 $10

CDC $35 $104 $116.5

Dept. of Defense 0 $5 $5

Dept. of Labor 0 $10 $10

Total $142 $235 $439 $556

• Reduce HIV prevalence rates among those Reduce HIV prevalence rates among those 15-24 years of age by 50% in high prevalence 15-24 years of age by 50% in high prevalence countriescountries

• Maintain prevalence below 1% among 15-49 Maintain prevalence below 1% among 15-49 year olds in low prevalence countriesyear olds in low prevalence countries

• Ensure that at least 25% of HIV/AIDS infected Ensure that at least 25% of HIV/AIDS infected mothers in high prevalence countries have mothers in high prevalence countries have access to interventions to reduce HIV access to interventions to reduce HIV transmission to their infantstransmission to their infants

“Shared” Targets for the Year 2007

“Shared” Targets for the Year 2007

Help local institutions provide basic care Help local institutions provide basic care and support services to at least 25% of and support services to at least 25% of HIV infected personsHIV infected persons

Provide community support services to at Provide community support services to at least 25% of children affected by AIDS in least 25% of children affected by AIDS in high prevalence countrieshigh prevalence countries

Political WillPolitical Will

Resource allocationResource allocation Use of State controlled mediaUse of State controlled media Removing taxes and duties on the Removing taxes and duties on the

import of public health commoditiesimport of public health commodities Willingness to work with NGOsWillingness to work with NGOs Use of the Education sectorUse of the Education sector Prevention activities in the Military Prevention activities in the Military Surveillance activitiesSurveillance activities

National Strategic PlansNational Strategic Plans

Inadequate fundingInadequate funding Inadequate biologic and risk behavior Inadequate biologic and risk behavior

surveillance surveillance Not very strategicNot very strategic

Resource Allocation in Resource Allocation in Strategic PlansStrategic Plans

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ResearchPreventionMitigationCareAdvocacyAdmin

Country Strategic PlanningCountry Strategic Planning

BrazilSouth AfricaThailand

Cote d’IvoireKenyaMalawiMozambiqueUgandaZaire

High prevalence

MexicoDominican RepublicGhanaHondurasSenegal

Low prevalence

Non-donor-drivenDonor-driven

Targeting CountriesTargeting Countries

Three Country Designations:Three Country Designations: Rapid Scale Up (4 countries)Rapid Scale Up (4 countries) Intensive Focus (16 countries)Intensive Focus (16 countries) Basic Programs (25 countries)Basic Programs (25 countries)

Intensive Focus Countries

Rapid Scale Up Countries

HIV/AIDS Basic Programs Countries

Criteria for Rapid Scale-Up &Criteria for Rapid Scale-Up &Intensive Focus CountriesIntensive Focus Countries

The relative The relative severityseverity of the epidemic of the epidemic

The The magnitudemagnitude of epidemic of epidemic

The The impactimpact on economic and social sectors on economic and social sectors

Enabling Enabling environmentenvironment

The The riskrisk of a rapid increase in prevalence of a rapid increase in prevalence

AvailabilityAvailability of other sources of funding of other sources of funding

ReturnReturn on investment on investment

SecuritySecurity and safety issues and safety issues

National InterestNational Interest

Adding New Components to Adding New Components to an Expanded an Expanded

Comprehensive ResponseComprehensive Response CareCare Preventing Mother to Child Preventing Mother to Child

TransmissionTransmission Children Affected by AIDSChildren Affected by AIDS

PYRAMID OF HIV/AIDS CARE AND SUPPORT PRIORITIES

•Prevention*, Human Rights*

•Prevent Opportunistic Infections

•Anti Retroviral Drugs

Cos

t an

d C

ompl

exity

People Served

•Strengthen Communities to support affected

persons*

•Improve health care systems*TB*

*These programs serve the community as well as PLHA’s

•Palliative Care, Psycho-Social Care*

USAID 1998

ARV Treatment: What Does ARV Treatment: What Does It Involve:It Involve:

Potentially complex regimensPotentially complex regimens Need for trained HCWs and Need for trained HCWs and

improving lab supportimproving lab support Life long intervention Life long intervention Concerns about multi-drug resistanceConcerns about multi-drug resistance Equity of access Equity of access Need for prevention remainsNeed for prevention remains

Drug Access/Drug PricesDrug Access/Drug Prices

AdvocatesAdvocates Compulsory Compulsory

licensinglicensing Parallel importing Parallel importing Expanded Expanded

definition of definition of generics (CIPLA)generics (CIPLA)

PharmaceuticalsPharmaceuticals Drug donationsDrug donations Individual Individual

negotiationsnegotiations Merck Merck

announcement announcement (Crixovan: $600/yr, (Crixovan: $600/yr, Stocrin $500/yr)Stocrin $500/yr)

Mother to Child HIV Transmission(MCT)

Risk ofHIV Transmission:

Conception Birth 1 Yr 2 Yrs

34% Overall

14%20%} }

Preventing Mother-To-Child HIV Preventing Mother-To-Child HIV TransmissionTransmission

Current Activities/IssuesCurrent Activities/Issues

2 programs: Kenya, Zambia- 2 programs: Kenya, Zambia- expanding to 6 in 2001expanding to 6 in 2001

Issues:Issues:

Extremely slow scale up due to:Extremely slow scale up due to: stigmastigma controversies over breast feedingcontroversies over breast feeding lack of synergylack of synergy

Children Affected by AIDS Children Affected by AIDS Current Activities/IssuesCurrent Activities/Issues

18 country programs, 40 individual 18 country programs, 40 individual projectsprojects

Issues:Issues: Integrating PL 480 Food ProgramsIntegrating PL 480 Food Programs Overwhelming demands compared to Overwhelming demands compared to

resourcesresources OrphanagesOrphanages

Urgent need for new Urgent need for new Technologies Technologies

MicrobicidesMicrobicides Preventive and Therapeutic VaccinesPreventive and Therapeutic Vaccines DiagnosticsDiagnostics Improved male and female condomsImproved male and female condoms Simpler, more affordable treatmentsSimpler, more affordable treatments ?Curative therapies?Curative therapies

The Next 20 YearsThe Next 20 Years

What will happen in Asia, E&EWhat will happen in Asia, E&E Long term demographic impactLong term demographic impact Societal changes (+&-)Societal changes (+&-) Chronic, treatable disease vs ongoing Chronic, treatable disease vs ongoing

drug resistancedrug resistance Further mutationsFurther mutations

Indonesia HIV infection Indonesia HIV infection ratesrates

= 0 % = 1 - 5 % = < 1% = > 5 %

SW 17.5%

IDUs 40%

SW 26.5%

IDUs 53%

SW 6.4%

8 %

SW

6%

IDUs 24.5% SW = sex worker

IDUs = injecting drug users

the global aids pandemic where do we go from here? paul de lay, m.d. chief, hiv/aids division usaid

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