XVI International AIDS Conference

Toronto HIV Epidemiology Update

based on Plenary PresentationChris Beyrer MD, MPH

Johns Hopkins Bloomberg School of Public Health

Global HIV epidemic, 1990‒2005

Number of people living with HIV

% HIV prevalence, adult (15-49)

% HIV prevalence, adult (15‒49)

Number of peopleliving with HIV (millions)

0

10

20

30

40

50

1990 1995 2000 2005

0.0

1.0

2.0

3.0

4.0

5.0

Source: UNAIDS 2006

Bar indicates the range around the estimate

• 38.6 million living with HIV [33 to 46 million]

• 24.5 million in SS Africa

[21.6 to 27.4 million]

IMPORTANCE OF PREVENTION (estimates 2005)

40.3 millionpeople living

with HIV/AIDS

In 06/2006 1.65million on ART

3.1 millionAIDS related

Deaths

4.9 millionnew HIV infections

Prevalence main determinant of incidence

40 millionPeople living

with HIV/AIDS

3.1 millionAIDS related

deaths

4.9 millionNew HIV infections

A global view of HIV infection, 2005

Source: UNAIDS 2006 Report on the Global AIDS Pandemic

1.5 million200,000 in ‘05IDU

7.6 million830,000 in ‘05HeterosexualMSMIDU

12.1 million1.3 million in ‘05

Heterosexual

States with at least one site with HIV prevalence > 20% in IDU in 2006

• Belarus• Estonia • Kazakhstan• Russia • Ukraine• Serbia & Montenegro

• Iran

• Nepal• Indonesia

• Libya• Mauritius

• Kenya, Tanzania, Ghana, Nigeria**

• Burma• China• India

• Malaysia• Thailand• Vietnam

• Italy• Netherlands• Portugal• Spain

• Argentina• Brazil• Uruguay

• Canada• Puerto Rico• USA

**African States with at least one published report of IDU risks

Emergent Epidemics

Adapted from : Aceijas, et al, AIDS 2004 18:2295-2302

Established Epidemics

Individual Level Determinants for Parenteral HIV Infection

Needle sharing

Higher frequency of injection

Cocaine injection

Lack of opioid analogue therapy

MSM-IDU history

Injection use while incarcerated

Reported HIV cases in the Russian Federation and Ukraine, 1987–2005

1987 1989 1991 1993 1995 1997 1999 2001 2003 2005

0

50 000

100 000

150 000

200 000

250 000

300 000

350 000

400 000

30 000

45 000

60 000

75 000

90 000

105 000

120 000

15 000

0

Reported HIV cases

in the Russian FederationReported HIV cases

in Ukraine

Russian Federation

Newly reported cases

Cumulative (previous years)

Ukraine

Newly reported cases

Cumulative

Adapted from : Russian Federal AIDS Centre; Ukranian AIDS Centre and Ministry of Health of Ukraine, UNAIDS 2006 Report on the Global AIDS Pandemic

What are the Structural Drivers of Spread Across Eurasia?

Driver # 1Geographic proximity to overland drug trafficking routes

Driver # 2Limited use of HIV prevention measures with demonstrated efficacy for IDU transmission

Driver # 3Punitive and legalistic approaches to IDUs

Opiate seizures in Asia in 2004

Source : UNODC World Drug Report 2006

Sources: IDU Estimates: UNODC HIV/AIDS unit, September 2005; WHO/UNAIDS October 2005. Published in Harm Reduction Developments 2005. International Harm Reduction Development Program (IHRD) of the Open Society Institute

UNAIDS recommends 60% coverage for effective HIV prevention among IDUs

IDUs Reached by NSEP, Select FSU Countries, 2005

Structural limits on prevention & care for IDU

• US continues ban on federal funding for Needle Syringe Exchange Programs (NSEP) in US and globally

• Methadone Maintenance Therapy (MMT) remains illegal in many countries Ex: Russian Federation

• Across 50 developing countries, 34,000 IDU on ARV: 30,000 were in Brazil

Source: Aceijas, et al, Addiction, 2006

Photo: Hans Jürgen Burkard

MSM Trends in High and Low Income Country Settings

Estimated Number of HIV/AIDS Diagnoses, by Transmission Category — 33 States, 2001–2004.

* Statistically significant

Source: Espinoza, CDC, 2005

−9.1*

2.7

−3.9*

% Δ / year

−3.4* 0

5000

10000

15000

20000

2001 2002 2003 2004

Year of Diagnosis

HIV

/ A

IDS

MSM

IDU

MSM/IDU

HC

Trends HIV among MSMmid ’90- now

HAART introduced, resulting in dramatic improvement of survival of AIDS patients, as well as reduction in AIDS cases

HIV/AIDS becomes a “chronic disease” and “less visible”

Rise in “unsafe sex” and STI , including outbreaks of Syphylis and LGV

Sexual orientation of male syphilis cases registered in the sentinel

network of clinicians, Belgium, Oct 2000 - Jan 2003

0

5

10

15

20

25

Oct 2000-Jan 2001 Oct 2001-Jan 2002 Oct 2002-Jan 2003

Period of registration

Number of active syphilis cases

MSM

Het.men

From: IPH, Belgium

Possible explanations for increased risk behaviour

HAART changed the face of the epidemic: less AIDS and less deaths

Prevention fatigue: challenge of maintaining safe sex for an extended period

Changing environment : internet as new way of recruiting partners

Young MSM (<20y) sexually active earlier , and never exposed to AIDS as a killer disease

Source: Wade et al. 2005; Girault et al. 2004; van Grievsven et al. 2005; Action for AIDS Singapore, 2006, Go et al. 2004; Pando et al. 2006; UNAIDS, 2006; Caceres et al, 2005, Strathdee, et al, 2006. CENSIDA, CA State Office of AIDS; Patterson et al, IAS, 2006; Strathdee et al, pers. comm; Viani et al, 2006

HIV prevalence among MSM in low prevalence settings

HIV prevalence among MSM, Bangkok, Thailand

Age (years)

2003

2005

≤22 23-28 ≥29

N = 194/1,121; 113/399

Overall

Source: Van Griensven, et al, MMWR. 2006

12.9

22.3

17.5

30.5

20.8

29.7

17.3

28.3

0

5

10

15

20

25

30

35

40

HIV

Pre

vale

nce

(%)

p-values all < 0.05

MSM structural risk contexts

• Criminalization and stigma limit MSM access to HIV prevention, treatment and care

• MSM understudied in emerging contexts: MSM not included in national HIV surveillance in Thailand, Vietnam, Senegal

• Only one African study (Wade, et al) of MSM risk and HIV rates

• Fewer than 1 in 10 MSM worldwide have access to necessary prevention services

Sources: UNAIDS; USAID, 2004; Wade 2005; Go 2006 personal communication; HRW; UNAIDS 2006

HIV prevalence in adults in Africa

Source : UNAIDS, 2006

Region Country

Population-based survey

prevalence (%) (year)

Adjusted 2003 HIV

prevalence (%) in current

report

2005 HIV prevalence (%)

in current report

Trend in prevalence

SOUTH

Botswana 25.2 (2004) 24.0 24.1 Stable

Lesotho 23.5 (2004) 23.7 23.2 Stable

South Africa 16.2 (2005) 18.6 18.8 Increasing

EAST

Burundi 3.6 (2002) 3.3 3.3 Decline in capital city

Rwanda 3.0 (2005) 3.8 3.1 Decline in urban areas

Tanzania 7.0 (2004) 6.6 6.5 Stable

Uganda 7.1 (2004-5) 6.8 6.7 Stable

WEST

Burkina Faso 1.8 (2003) 2.1 2.0 Decline in urban areas

Cameroon 5.5 (2004) 5.5 5.4 Stable

Ghana 2.2 (2003) 2.3 2.3 Stable

Guinea 1.5 (2005) 1.6 1.5 Stable

Senegal 0.7 (2005) 0.9 0.9 Stable

Sierra Leone 1.5 (2005) 1.6 1.6 Stable

HORN Ethiopia 1.6 (2005) (1.0-3.5) (0.9-3.5) Decline in urban areas

Adult HIV prevalence in Sub-Saharan Africa, 2003 and 2005.

Source: UNAIDS 2006 Report on the Global AIDS Epidemic

HIV prevalence by age and gender South Africa 2005

12.1

6.03.2

33.3

23.9

9.4

0

5

10

15

20

25

30

35

40

45

15 – 19 20 – 24 25 – 29

Age group (years)

HIV

Po

sit

ive

(%

)

Males

Females

Source: South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2005

Ecological Model for HIV Risk in Southern Africa

Individual Risks for HIV Infection

Widening Risk Contexts for HIV Infection Beyrer & Baral, 2006

Condom Usage, Circumcision, HSV-2/GUD, Viral Load, Acute Infection, Age of Coital Debut, Marriage, ARV Status