AIDS at 25: A Global AIDS at 25: A Global PerspectivePerspective

AIDS at 25: A Global AIDS at 25: A Global PerspectivePerspective

The early years—a historical perspectiveThe early years—a historical perspective

AIDS in the developing worldAIDS in the developing world

NYC and AIDSNYC and AIDS Epidemiologic Characterization Epidemiologic Characterization

First reports of First reports of

– AIDSAIDS

– Infants of mothers with AIDSInfants of mothers with AIDS

– Heterosexual transmissionHeterosexual transmission

– IDUIDU

Most convincing reports of Most convincing reports of

– Lack of transmission by close contact Lack of transmission by close contact

– Low risk for occupational infectionLow risk for occupational infection

GH Friedland, MDGH Friedland, MD

Denial, Despair, DiscriminationDenial, Despair, Discrimination

Why AIDS Is DifferentWhy AIDS Is Different

Nature of the disease itselfNature of the disease itself

Young men and womenYoung men and women

Epidemic of death and dyingEpidemic of death and dying

Fear of transmissionFear of transmission

Rooted in intimate behaviorsRooted in intimate behaviors

– Stigma, stereotypes, and secrecyStigma, stereotypes, and secrecy

MortalityMortality

Denial and Despair, to Therapeutic Denial and Despair, to Therapeutic Optimism, to Therapeutic BalanceOptimism, to Therapeutic Balance

New York City, 1981-2003New York City, 1981-2003

NYC Incidence, Prevalence, and MortalityNYC Incidence, Prevalence, and Mortality

0

2,000

4,000

6,000

8,000

10,000

12,000

14,00019

81

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Calendar Year

Nu

mb

er o

f R

epo

rted

AID

S C

ases

an

d D

eath

s

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

Nu

mb

er of R

epo

rted P

LW

HA

*

First cases of PCP, KS

reported from NYC, LA

AIDS enters the

nomenclature

AIDS case definition

expanded (CD4 <200, 26 OIs)

NYS expands AIDS reporting to include HIV

1998 NYS HIV reporting law takes effect

HIV identified as

causative agent

First commercial EIA,

screening of US blood

supply begins

AIDS case

reporting mandated

by NYS*PLWHA=Persons living with HIV/AIDS

CDC AIDS case

definition (23 OIs)

Reported Persons Living with HIV (non-AIDS)

Reported Persons Living with AIDS

DeathsReported AIDS Cases

1987: AZT

1988: PCP prophylaxis

1992: Combination therapy

1994: ACTG 076: AZT reduces perinatal transmission

1995: Protease inhibitors

1996: HAART

Clinical Milestones in the History of the HIV/AIDS Epidemic

AIDS: The First Quarter AIDS: The First Quarter Century Century

New York CityNew York City >150,000 have been diagnosed with AIDS>150,000 have been diagnosed with AIDS

– 90,000 (60%) have died90,000 (60%) have died

~100,000 diagnosed and living with HIV/AIDS ~100,000 diagnosed and living with HIV/AIDS

– ~35,000 with HIV, ~65,000 with AIDS~35,000 with HIV, ~65,000 with AIDS

Remains epicenter of HIV/AIDS epidemic in USRemains epicenter of HIV/AIDS epidemic in US

– Highest AIDS case rate in US, more than Los Highest AIDS case rate in US, more than Los Angeles + San Francisco + Miami + Washington, DC Angeles + San Francisco + Miami + Washington, DC

>25,000 living with HIV not tested or known >25,000 living with HIV not tested or known to be infectedto be infected

Slide courtesy of Dr. Torian, BHIV Epi Prgm.Slide courtesy of Dr. Torian, BHIV Epi Prgm.

AIDS and the United StatesAIDS and the United States

> 1 million living with HIV/AIDS> 1 million living with HIV/AIDS

500,000-600,000 (50%-60%) have died500,000-600,000 (50%-60%) have died

At peak, leading cause of death in youngAt peak, leading cause of death in youngmen and women in 15 US cities men and women in 15 US cities

Demographic changesDemographic changes

Largest population MSM, but increasinglyLargest population MSM, but increasinglyan epidemic of poverty, people of color,an epidemic of poverty, people of color,women, and heterosexual transmissionwomen, and heterosexual transmission

40,000 new infections per year40,000 new infections per year

Trends in Annual Rates of Death From Leading Causes of Death Among Persons 25-44 Years

Old, USA, 1982-1998

*Preliminary 1998 data*Preliminary 1998 data

National Center for Health Statistics, National Center for Health Statistics, National Vital Statistics SystemNational Vital Statistics System

0

5

10

15

20

25

30

35

40

82 84 86 88 90 92 94 96 98*

Year

Dea

ths

per

100

,000

Po

pu

lati

on

Unintentionalinjury

Cancer

Chronic liverdisease

Stroke

Diabetes

Heart disease

Suicide

HIV infection

Homicide

Social Change and HIV Social Change and HIV TransmissionTransmission

The Seed and the WindThe Seed and the Wind IV drug route, “shooting galleries,” IV drug route, “shooting galleries,”

cocaine “fourth world”cocaine “fourth world”

Sexual behavior/practiceSexual behavior/practice

– Gender inequalityGender inequality

Migration, urbanization, and detribalizationMigration, urbanization, and detribalization

International travelInternational travel

Widespread manufacture and distribution Widespread manufacture and distribution of blood componentsof blood components

Lessons in HIV/AIDS PreventionLessons in HIV/AIDS Prevention

Denial is not a river in Egypt Denial is not a river in Egypt Prevention works but can’t start too early Prevention works but can’t start too early The goal is not elimination of risk but its The goal is not elimination of risk but its

reductionreduction Both communitywide and targeted interventionsBoth communitywide and targeted interventions Integrate prevention and care, biology and Integrate prevention and care, biology and

behaviorbehavior– Focus on HIV+s and HIV-sFocus on HIV+s and HIV-s

– Understand belief, meaning, and practiceUnderstand belief, meaning, and practice

– Don’t beat around the BushDon’t beat around the Bush

Lessons in HIV/AIDS CareLessons in HIV/AIDS Care

Comprehensiveness

Continuity

Competence

Compassion

Colleagueship

Cost-effectiveness

AIDS at 25: A Global AIDS at 25: A Global PerspectivePerspective

The early years—a historical perspectiveThe early years—a historical perspective

AIDS in the developing worldAIDS in the developing world

Adults and Children Estimated Adults and Children Estimated to Be Living With HIV at the to Be Living With HIV at the

End of 2005End of 2005

Total: 40.3 (36.7–45.3) millionTotal: 40.3 (36.7–45.3) million

Western & Central Europe

720,000720,000(570,000–890,000)(570,000–890,000)

North Africa & Middle East510,000510,000

(230,000–1.4 million)(230,000–1.4 million)

Sub-Saharan Africa25.8 million25.8 million(23.8–28.9 million)(23.8–28.9 million)

Eastern Europe & Central Asia1.6 million 1.6 million

(990,000–2.3 million)(990,000–2.3 million)

South & Southeast Asia7.4 million7.4 million

(4.5–11.0 million)(4.5–11.0 million)

Oceania74,00074,000

(45,000–120,000)(45,000–120,000)

North America1.2 million1.2 million

(650,000–1.8 million)(650,000–1.8 million)

Caribbean300,000300,000

(200,000–510,000)(200,000–510,000)

Latin America1.8 million1.8 million(1.4–2.4 million)(1.4–2.4 million)

East Asia870,000870,000

(440,000–1.4 million)(440,000–1.4 million)

Estimated Number of Adults and Estimated Number of Adults and Children* Living With HIV by Region, Children* Living With HIV by Region,

1986–20051986–2005

AIDS Epidemic Update, December 2005.AIDS Epidemic Update, December 2005.

0

5

10

15

20

25

30

35

40

45

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Oceania

North Africa & Middle East

Eastern Europe & Central Asia

Western and Central Europe and North America

Latin America and Caribbean

Asia

Sub-Saharan Africa

Millions

Nu

mb

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f p

eop

le li

vin

g w

ith

HIV

Nu

mb

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f p

eop

le li

vin

g w

ith

HIV

* Under 15 years old* Under 15 years old

Challenges Facing the Challenges Facing the New African NationsNew African Nations

Very fragile and volatile links bound myriad ethnic Very fragile and volatile links bound myriad ethnic groups within nations groups within nations

Africa was the poorest, least developed regionAfrica was the poorest, least developed regionon the planeton the planet

Climate harsh and variableClimate harsh and variable

At least 80% of the population engaged in subsistence At least 80% of the population engaged in subsistence agriculture without education or health servicesagriculture without education or health services

Economies had been built to serve colonial interestsEconomies had been built to serve colonial interests

Rapidly enlarging populations and urban migration Rapidly enlarging populations and urban migration

Challenges Facing the Challenges Facing the New African NationsNew African Nations

Drastic shortage of skilled workforceDrastic shortage of skilled workforce

Adult literacy at 16%Adult literacy at 16%

Of 200 million people, only 8000 secondary school Of 200 million people, only 8000 secondary school graduates, half from Ghana and Nigeriagraduates, half from Ghana and Nigeria

Most states had fewer than 200 students in university Most states had fewer than 200 students in university training, none in former French coloniestraining, none in former French colonies

At independence, 75% of higher level personnel in At independence, 75% of higher level personnel in government and business were foreigners government and business were foreigners

Kinship and ethnicity became the route to powerKinship and ethnicity became the route to power

In 50 African Countries in 1989In 50 African Countries in 1989

Opposition parties were illegal in 32 statesOpposition parties were illegal in 32 states

Almost all were one-party states or military Almost all were one-party states or military dictatorshipsdictatorships

In 29 countries, 150 elections held between 1960 and In 29 countries, 150 elections held between 1960 and 1989 never allowed a single seat to go to the opposition 1989 never allowed a single seat to go to the opposition parties parties

Only Senegal, Botswana, and Gambia maintained Only Senegal, Botswana, and Gambia maintained multiparty politics with regular elections …multiparty politics with regular elections …

A survey of 20 African countries in 1995 revealed that A survey of 20 African countries in 1995 revealed that half had 25 or fewer fully qualified accountants in the half had 25 or fewer fully qualified accountants in the entire public sectorentire public sector

Developing World: Emerging Developing World: Emerging Results of ART TrialsResults of ART Trials

A summary of 28 articles and abstracts up to A summary of 28 articles and abstracts up to February 2005 of ART in Africa shows:February 2005 of ART in Africa shows: Median sample size of 139 monitored for about Median sample size of 139 monitored for about

6 months6 months 74.5% received 2 NRTIs and an NNRTI74.5% received 2 NRTIs and an NNRTI Mean CD4 increase was 165.9 cells/Mean CD4 increase was 165.9 cells/µµl over a mean l over a mean

of 10.4 monthsof 10.4 months Among 21 studies assessing VL, a median of 73%Among 21 studies assessing VL, a median of 73%

of patients achieved undetectable VLof patients achieved undetectable VL Participants achieving >95% adherence ranged between Participants achieving >95% adherence ranged between

68% and 99%68% and 99% In 5 studies assessing resistance, at least 1 mutation In 5 studies assessing resistance, at least 1 mutation

was detected in 10.1% was detected in 10.1% Akileswaran C, et al. Akileswaran C, et al. CID.CID. 2005;41:376-85. 2005;41:376-85.

Developing World: Emerging Developing World: Emerging Results of ART TrialsResults of ART Trials

Experience in 8 clinics in western Kenya Experience in 8 clinics in western Kenya enrolling 2059 adults between November 2001 enrolling 2059 adults between November 2001 and February 2005and February 2005

With median f/u of 40 weeks, 5.4% died and With median f/u of 40 weeks, 5.4% died and 24.5% lost to f/u24.5% lost to f/u

CD4 increase was 160, 225, and 297 cells/CD4 increase was 160, 225, and 297 cells/µµl l at 12, 24, and 36 monthsat 12, 24, and 36 months

Adherence in 1766 patients was perfectAdherence in 1766 patients was perfectin 78% in 78%

Wools-Kaloustian K, et al. Wools-Kaloustian K, et al. AIDS.AIDS. 2006;20:41-8. 2006;20:41-8.

Developing World: Emerging Developing World: Emerging Results of ART TrialsResults of ART Trials

Efficacy of ART in the first 1004 consecutive ART-Efficacy of ART in the first 1004 consecutive ART-naive patients in Haiti enrolled over naive patients in Haiti enrolled over 14 months starting March 200314 months starting March 2003 Initial median CD4 was 131 cells/Initial median CD4 was 131 cells/µµll 87% alive 1 year after initiating therapy87% alive 1 year after initiating therapy At 12 months median CD4 increase was At 12 months median CD4 increase was

163 cells/163 cells/µµll 11% experienced treatment-limiting toxicity11% experienced treatment-limiting toxicity Of subgroup of 100 patients followed 48-56 Of subgroup of 100 patients followed 48-56

weeks, 76% had VL <400 copies/mL weeks, 76% had VL <400 copies/mL Severe P, et al. Severe P, et al. NEJM.NEJM. 2005;353:2325-34. 2005;353:2325-34.

Developing World: Emerging Developing World: Emerging Results of ART TrialsResults of ART Trials

In an urban public clinic in GaboroneIn an urban public clinic in Gaborone– 153 ART-naive patients with median CD4 69 cells/153 ART-naive patients with median CD4 69 cells/µµl initiated l initiated

therapy: 2/3 with DDI, d4T, and either EFV or NVPtherapy: 2/3 with DDI, d4T, and either EFV or NVP

– Mean CD4 increase was 149 cells/Mean CD4 increase was 149 cells/µµl at 24 weeks, 204 cells/l at 24 weeks, 204 cells/µµl l at 48 weeksat 48 weeks

– HIV RNA was <400 copies/mL in 87% at 24 weeks and 79% HIV RNA was <400 copies/mL in 87% at 24 weeks and 79% at 48 weeksat 48 weeks11

In an urban public clinic in KampalaIn an urban public clinic in Kampala– 137 ART-naive patients on continuous ART for at least 137 ART-naive patients on continuous ART for at least

12 weeks 12 weeks

– 66% had VL <400 copies/mL after median of 38 weeks66% had VL <400 copies/mL after median of 38 weeks

– 22% of patients on NNRTIs developed resistance; treatment 22% of patients on NNRTIs developed resistance; treatment interruption due to finances and drug availability occurredinterruption due to finances and drug availability occurred22

1. Wester CW, et al. 1. Wester CW, et al. JAIDS.JAIDS. 2005;40:336-43. 2005;40:336-43.2. Spacek LA, et al. 2. Spacek LA, et al. CID.CID. 2006;42:252-9. 2006;42:252-9.

Developing World: Emerging Developing World: Emerging Results of ART TrialsResults of ART Trials

In Cape Town, South Africa, all in-program deaths among In Cape Town, South Africa, all in-program deaths among ART-naive patients in ART program were evaluated ART-naive patients in ART program were evaluated between September 2002 and March 2005between September 2002 and March 2005 A high pretreatment mortality rate of 35.6 deaths/100 person-years A high pretreatment mortality rate of 35.6 deaths/100 person-years

decreased to 2.5/100 person-years at 1 year among those who decreased to 2.5/100 person-years at 1 year among those who received ARTreceived ART

Risk of death independently associated with CD4 count and WHO Risk of death independently associated with CD4 count and WHO clinical stageclinical stage

Within the first 90 days from enrollment, 66% of the deaths Within the first 90 days from enrollment, 66% of the deaths occurred in patients not yet on ART; 80% had stage IV disease occurred in patients not yet on ART; 80% had stage IV disease or CD4 count <50 cells/or CD4 count <50 cells/µµll

Utilizing only on-treatment analysis underestimates early mortality Utilizing only on-treatment analysis underestimates early mortality Most deaths were attributed to wasting syndrome, tuberculosis, Most deaths were attributed to wasting syndrome, tuberculosis,

acute bacterial infections, malignancy, and immune reconstitution acute bacterial infections, malignancy, and immune reconstitution disease disease

Lawn SD, et al. Lawn SD, et al. AIDS.AIDS. 2005;19:2141-8. 2005;19:2141-8.

Developing World: Current Developing World: Current Quandaries Quandaries

Point of therapy initiationPoint of therapy initiation

Detection and treatment of OIs, especially in Detection and treatment of OIs, especially in advanced patients before initiation of therapy advanced patients before initiation of therapy

Dilemmas with current first regimensDilemmas with current first regimens

Monitoring for efficacy and toxicityMonitoring for efficacy and toxicity

Switching therapy for failure—how and to whatSwitching therapy for failure—how and to what

Developing World: Current Developing World: Current QuandariesQuandaries

Critical consequences of underdevelopmentCritical consequences of underdevelopment

Critical shortages of capable healthcare Critical shortages of capable healthcare professionalsprofessionals

Need for expedient and practical initial and Need for expedient and practical initial and ongoing trainingongoing training

Incentives to retain capable professionals Incentives to retain capable professionals within their countries and providing care to within their countries and providing care to patientspatients

Lack of infrastructure capacity to support care Lack of infrastructure capacity to support care deliverydelivery

International Tactical Plan to Maximize International Tactical Plan to Maximize Use of Limited Resources Within Use of Limited Resources Within

Individual NationsIndividual Nations

The “Three Ones” of UNAIDSThe “Three Ones” of UNAIDS

One comprehensive national AIDS framework One comprehensive national AIDS framework fully negotiated, endorsed, and costed by key fully negotiated, endorsed, and costed by key stakeholdersstakeholders

One national AIDS coordinating authority, One national AIDS coordinating authority, recognized in law and with multisectorial recognized in law and with multisectorial support and technical capacitysupport and technical capacity

One national monitoring and evaluation One national monitoring and evaluation system integrated into the national AIDS system integrated into the national AIDS frameworkframework

““Traps and Legacies: The Traps and Legacies: The Whirlpool”Whirlpool”

“…“…it will be difficult to make a difference it will be difficult to make a difference in the AIDS epidemic if HIV is viewed in in the AIDS epidemic if HIV is viewed in isolation from its root social, economic, isolation from its root social, economic, and political context; or if it is seen only and political context; or if it is seen only as a medical problem or as an issue of as a medical problem or as an issue of individual behavior change…”individual behavior change…”

Disunity, denial, stigma, and competing Disunity, denial, stigma, and competing sources of power and authority undermine sources of power and authority undermine capacity for response capacity for response

““Tough Choices—Tough Choices—Africa Takes a Stand”Africa Takes a Stand”

“…“…while there are enormous odds to overcome, while there are enormous odds to overcome, there is much that countries in Africa can do with there is much that countries in Africa can do with their own resources to grow their economies, to their own resources to grow their economies, to prioritize developmental objectives, to lay the prioritize developmental objectives, to lay the foundation for future growth and development, foundation for future growth and development, and to reduce the incidence and prevalence of and to reduce the incidence and prevalence of AIDS.”AIDS.”

African countries on their own efficiently build African countries on their own efficiently build capacity within overall health structures, capacity within overall health structures, recognizing AIDS as indication of overall crisis of recognizing AIDS as indication of overall crisis of underdevelopment, poverty, and poor governance. underdevelopment, poverty, and poor governance. Sustained increases in international aid falters. Sustained increases in international aid falters.

““Times of Transition: Times of Transition: Africa Overcomes”Africa Overcomes”

““Pan-African solidarity and high levels of regional Pan-African solidarity and high levels of regional co-operation…put public good before private co-operation…put public good before private office. AIDS acts as an international catalyst for office. AIDS acts as an international catalyst for the formation of a new global covenant, involving the formation of a new global covenant, involving security and human rights agendas brought security and human rights agendas brought together in a coherent international framework together in a coherent international framework that encompasses economics, trade, social that encompasses economics, trade, social justice, and political reform.”justice, and political reform.”

National autonomy is promoted, African National autonomy is promoted, African resources are consistently amplified in ways that resources are consistently amplified in ways that do not engender dependency, and marked strides do not engender dependency, and marked strides in healthcare development are possible. in healthcare development are possible.

Potential Outcomes for Potential Outcomes for ScenariosScenarios

Adults and Children, 2003-2025Adults and Children, 2003-2025

IndicatorIndicatorTough Choices

Tough Choices

Times of Transition

Times of Transition

Traps and Legacies

Traps and Legacies

Scenario:Scenario:

Cumulative program cost (US$ billion)Cumulative program cost (US$ billion)

Cumulative deaths from AIDS (1980-2025, million)Cumulative deaths from AIDS (1980-2025, million)

Cumulative new infections (million)Cumulative new infections (million)

Cumulative infections averted (million)Cumulative infections averted (million)

195195 9898 7070

6767 7575 8383

4646 8989

4343 2424 00

UNAIDS, AIDS in Africa Scenarios Project; historical data: UNAIDS, 2004 Report on the Global AIDS EpidemicUNAIDS, AIDS in Africa Scenarios Project; historical data: UNAIDS, 2004 Report on the Global AIDS Epidemic

6565

HIV/AIDS: The Next 25 Years—HIV/AIDS: The Next 25 Years—The Long HaulThe Long Haul

HIV/AIDS will be with us for the rest of human HIV/AIDS will be with us for the rest of human historyhistory

Transmission and disease burden will Transmission and disease burden will increase, with attendant personal and increase, with attendant personal and societal danger and disruption societal danger and disruption

More resources/sustaining current resourcesMore resources/sustaining current resources

More focus on human rightsMore focus on human rights

New and more effective prevention strategiesNew and more effective prevention strategies

– Vaccine, microbicides, structural, behavioralVaccine, microbicides, structural, behavioral

HIV/AIDS: The Next 25 Years—HIV/AIDS: The Next 25 Years—The Long HaulThe Long Haul

Growth of comprehensive systems of careGrowth of comprehensive systems of care

Integration of prevention with careIntegration of prevention with care

– HIV and TBHIV and TB

– Substance abuse and HIVSubstance abuse and HIV

New, more potent, and less expensive drugsNew, more potent, and less expensive drugs

Equity—provision of prevention, care,Equity—provision of prevention, care,and treatment worldwideand treatment worldwide

New generation of unsung heroes and New generation of unsung heroes and heroinesheroines