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Global overview of the state of the epidemic and new strategies of Response
Peter Godfrey-Faussett, Senior Science Adviser, UNAIDSKarl Dehne, Chief, Prevention, UNAIDS
National Consultation on Combination Prevention, Lima , Peru
12-14 November 2014
Adults and children estimated to be living with HIV2013
Eastern Europe & Central Asia1.1 million
[980 000– 1.3 million]
North America and Western and Central Europe2.3 million
[2.0 million – 3.0 million]
Middle East & North Africa230 000
[160 000 – 330 000]
Caribbean
[230 000 – 280 000]
250 000 Asia and the Pacific4.8 million
[4.1 million – 5.5 million]
Sub-Saharan Africa24.7 million
[23.5 million – 26.1 million]
Latin America1.6 million
[1.4 million – 2.1 million]
Total: 35.0 million [33.2 million
Source: UNAIDS
– 37.2 million]
Chapter OneA disease sin nombre
1981
Slim’s disease Pneumocystis pneumonia
1983
1984
PrologueMan and the Environment
Chapter Two“Before the life boat”
www.youtube.com/watch?v=7kYrMw14cDQ
People living with HIV
First cases of unusual immune deficiency are identified among gay men in the USA June 1981
HIV identified as cause of AIDS May 1983
First regimen to reduce MTCT of HIV
Brazil becomes the first developing
country to provide ART
The first HIV antibody test becomes available
A heterosexual AIDS epidemic is revealed in Africa
HAART launched
The WHO launches the Global Programme on
AIDS
Acquired Immune Deficiency Syndrome (AIDS) defined
The first therapy for AIDS - zidovudine/
AZT - is approved for use in the USA
Global Network of People living with HIV/AIDS (GNP+)
Global Fund to fight AIDS, TB and Malaria
UNAIDS created
Millions
50
45
40
35
30
25
20
15
10
5
0
1980 ‘81 ‘05‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04
The chronology above summarises the ‘BIG Picture’ of AIDS – from the UNAIDS website
WHO and UNAIDS launch the
"3 x 5" initiative
President Bush announces
PEPFAR
2010 International AIDS Conference in Durban
The UN General Assembly Special Session on
HIV/AIDS
Source: UNAIDS 2008
• Epidemic of fear and stigma
• Social mobilisation• Activism• Peer-support• Social justice• Solidarity• Beyond Health• UNAIDS, NACs
Chapter ThreeBeyond the triumph of biomedicine
People living with HIV
First cases of unusual immune deficiency are identified among gay men in the USA June 1981
HIV identified as cause of AIDS May 1983
First regimen to reduce MTCT of HIV
Brazil becomes the first developing
country to provide ART
The first HIV antibody test becomes available
A heterosexual AIDS epidemic is revealed in Africa
HAART launched
The WHO launches the Global Programme on
AIDS
Acquired Immune Deficiency Syndrome (AIDS) defined
The first therapy for AIDS - zidovudine/
AZT - is approved for use in the USA
Global Network of People living with HIV/AIDS (GNP+)
Global Fund to fight AIDS, TB and Malaria
UNAIDS created
Millions
50
45
40
35
30
25
20
15
10
5
0
1980 ‘81 ‘05‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04
The chronology above summarises the ‘BIG Picture’ of AIDS – from the UNAIDS website
WHO and UNAIDS launch the
"3 x 5" initiative
President Bush announces
PEPFAR
2010 International AIDS Conference in Durban
The UN General Assembly Special Session on
HIV/AIDS
Source: UNAIDS 2008
Chapter FourTreatment and Global Solidarity
1990 1995 2000 2005 2010 20150
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
40,000,000
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
Es
tim
ate
d n
um
be
r o
f p
eo
ple
liv
ing
wit
h
HIV
(M
illi
on
s)
Es
tim
ate
d A
IDS
de
ath
s (
mil
lio
ns
)
Global number of people living with HIV & HIV-related deaths: Changes post-2005
Source: UNAIDS Global Report 2014
Chapter FiveA Prevention Revolution?
1990 1995 2000 2005 2010 20150.0
500,000.0
1,000,000.0
1,500,000.0
2,000,000.0
2,500,000.0
3,000,000.0
3,500,000.0
4,000,000.0
4,500,000.0
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
Nu
mb
er
of
ne
w H
IV i
nfe
cti
on
s
(Mil
lio
ns
)
Es
tim
ate
d n
um
be
r n
ew
HIV
in
fec
tio
ns
in
c
hil
dre
n (
tho
us
an
ds
)
Community driven approaches & movements
Biomedical tools & Interventions
Structural changes & political
HIV/STI Testing & Linkage to
Care
Individual & Small Group behavioral strategies
Combination
prevention
Adapted from Coates Lancet; 2008
COMBINATION Prevention for Maximum Effect
●Barrier protection●Circumcision●PreP - Oral - Topical (Gel, Film, Ring) - Injectable
Barrier protectionBlood screeningHarm reduction for PWIDART
Maternal-to-child transmissionDecrease partner’s viral loadTreatment of acute HIV infection
HIV Prevention: Increasing Choices
●Condom promotion●Individual-level interventions●Couples interventions●Community-based interventions●Structural interventions
Decrease Sourceof HIV Infection
Decrease Host Susceptibilityto HIV Infection
Alter Behavior:Exposure, Adherence
.
Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included – this is on sexual transmission
Behavioural Intervention
- Abstinence- Be Faithful
HIV Counselling and Testing
Coates T, Lancet 2000Sweat M, Lancet 2011
Male Condoms
Female Condoms
Treatment of STIs
Grosskurth H, Lancet 2000
Male circumcision
Auvert B, PloS Med 2005 Gray R, Lancet 2007Bailey R, Lancet 2007
Treatment for prevention
Cohen M, NEJM, 2011Donnell D, Lancet 2010Tanser, Science 2013
Microbicidesfor women
Abdool Karim Q, Science 2010
Grant R, NEJM 2010 (MSM)Baeten J , NEJM 2012 (Couples)Paxton L, NEJM 2012 (Heterosexuals)Choopanya K, Lancet 2013 (IDU)
Oral pre-exposure prophylaxis
Post Exposure prophylaxis (PEP)
Scheckter M, 2002
ARVprophylaxis
HIVPREVENTION
Consider….
• Consider a future time in which there are multiple prevention options available
• And those who use prevention tend to use consistently, but not everyone is perfect
consistent users
inconsistent users
long gaps in use
pills
condoms
injectable
none
other
Contraceptive choices, S
waziland 2013
Source: UNFPA
Consistency of contraceptive use, U
SA
Source: Guttm
acher Institu
te
Chapter SixHIV in 2014
Despite impressive progress, the spread of HIV has yet to be controlled!
In 2013, there were:
Source: UNAIDS Global Report 2014
1.5 million HIV deaths
35 million living with HIV
2.1 million new infections
3 Key Challenges1. Dysfunctional health systems
– Failing to convert efficacious treatment & prevention interventions fully for maximum effectiveness
2. Most new HIV infections now occur in Key Populations – the highest prevention priority
– Young women in Africa– Sex Workers– MSM & Transgender individuals– IDU
3. Stigma, discrimination & legislative hurdles– Major obstacle to prevention & care
34 years on: AIDS is still far from over
Despite Scientific Progress,Insufficient Decline in New Infections Globally
Sexual health promotion
Combination prevention
Advocacy for prevention revolution
Accelerated action, focus and innovation
Targets
Two global sub-targets are being proposed: 1. By 2020, new infections in key populations will be reduced by
75%2. By 2020, new infections in young women and girls will be
reduced by 75%
75% Reduction in New Infections: Can Peru make it?
Programmatic Targets that need to be reached to achieve 75% reduction (UNAIDS modelling results)
• Key populations reached with comprehensive service packages, including condoms– Assumed to translate in 80-90% consistent condom
use
• MSM and sex workers access PrEP
• Viral suppression of all PWHIV – 90:90:90 cascade
85%
10% 70%
Possible factors sustaining high HIV incidence in gay men and other MSM
• Insufficient programme coverage of traditional outreach programmes
• Expansion of social and sexual networks – those newly connected hardly reached
• Systemic conditions (like persistent stigma)
• Possible changes in perception of HIV among MSM
Too few MSM reached by HIV prevention services
Latin America Caribbean Eastern Europe
Asia, Pacific, Middle East
Africa 0%
20%
40%
60%
80%
43%
25%
70%
40%
12%
Source: the World Bank
29
(Almost) all persons attend an NHS clinic
• Annual follow up data (cd4, VL, ART) (SOPHID)
• Linked by soundex to previous years to form national cohort
Data used to inform• Diagnosed Prev trends
• Clinical outcomes
• Testing policies
• Undiagnosed infection
• TAsP
National cohort of Persons seen for HIV care = Prevalence of diagnosed HIV infection
30
HIV care provided through the National Health Service, UK
Among 81,500 persons living with diagnosed HIV
• 97% are linked to care after diagnosis within 3 months
• 95% are retained in care annually
• 92% of persons in need of treatment are on treatment (87% of all diagnosed)
• 95% of persons on treatment achieve VL<200 copies/ml
HIV in the UK: 2013
Presentation title - edit in Header and Footer
HIV diagnoses, AIDS & deaths
• 6,000 new HIV diagnoses reported • 42% diagnosed late• 319 reports of AIDS• 577 deaths – 75% are late diagnosed
• Incidence in MSM remains high with no sign of a decline (Birell, Phillips)
People living with HIV by diagnostic and treatment status, and number with detectable viral load, UK, 2006-2012
2008 2009 2010 2011 20120
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
Diagnosed and treatedDiagnosed and untreatedUndiagnosedNumber with VL>50 copies
27% 26% 24% 23% 22%
Whole system approach to prevention and care
Evidence that particularly sexual risk taking behaviour can only be addressed by tackling syndemic factors including depression, substance use, violence, sexual stigma, homophobia and poverty
Syndemic conditions associated with increased HIV risk in a global sample of MSM
Substance use
Socio-political context
• Legal (human rights, anti-discrimination, drug laws, access to healthcare)
• High level of stigma and discrimination despite human rights laws
• Access to ARV – cost, procurement process, stock-outs, limited regiments
• Affordable diagnostics and resistance testing
• Structural barriers – greater need for integrated health care aimed at most at risk communities, provision of sex education in schools
• Cultural barriers – providing friendly, non judging services in partnership with NGOs
35
Community engagement
• Stigma and discrimination remains major barrier to testing, link and retention in care and prevention efforts
• Need greater engagement of PLHIV and affected communities at every level
• Tailored messages for individuals recognising diverse nature of community
• Supporting peer-led initiatives and outreach programs
• Sustained funding for NGOs
• Provision of integrated and welcoming, non judging services in partnership with NGOs
36
Changes in perception of HIV?
Gay health summit looks at life beyond HIV (14 Nov 2013)
A speaker stressed the importance of intergenerational dialogue, and recalled an exchange:
“The older men were chastising the younger men who admitted they chose not to use condoms regularly since they perceived that condoms were a barrier to the intimacy they sought in sex,” he said. “One of the older men said in response to this that ‘every time you do that you are asking to die.’ “So one of the younger men countered, ‘we can’t keep being afraid of sex because you were. We can’t carry the burden of everyone who died before us.’
Andrew Shopland says many of the young men who he works with at Mpowerment long for community. Really what we’re looking for is connection and acceptance, he told the summit. http://dailyxtra.com/vancouver/news/gay-health-summit-looks-at-life-beyond-hiv?market=210
Connectedness with gay subculture in repeated web surveys: behavioural surveillance among MSM in Germany
What % of MSM is using dating apps/web-based dating in Peru?
New media technology
•Where people meet partners•Where people get information•Apps may enhance self-assessment of risk•Monitoring PrEP adherence
Optimized service delivery: All-in-One Chain modelExample of the city-approach in Chengdu
city, China
• Out reach• Peer
education• Venue &
Internet based intervention
• Community VCT
• Venue based rapid testing
• Psychological support
• Community follow up
• Partner test promotion
• CD4 test
• Compliance education
• Guide for medicine & nutrition
• Positive prevention
Prevention Testing Follow up Treatment & Care
Integrating community systems • Mapping of available services• Provider Sensitization• Capacity building of community-based organizations• Formalize referral system• Linkages with interactive internet - based platforms• Collaborate with gay community on monitoring of
quality of services• Collaborate on advocacy and programming within local
government
Missing links and typical gaps • Reach of young gay men, hidden/unknown
networks, those only connected virtually, not gay self-identified MSM, outside main cities
• Retention in programs of those testing negative
• Condoms and lubricants! • Link to anal health and other clinical services • PreP, as part of comprehensive combination
strategy
Possible results framework
Service coverage through Community-led outreach
Coverage with
facility-based services
Outreach coverage with service
packages including condoms and lubs
Reach with interactive new
media and referrals
Community-based testing and retention
Facility-based HTC
PrEP ART
Community empowerment and mobilization, other enablers and synergies
Conclusion• Ambitious prevention targets achievable in principle!• Concept of combination prevention remains valid!• Wide programme gaps – need to expand reach and keep
those reached engaged• Condoms and lubs remain cornerstone of combination
prevention, but additional options, PreP (and early initiation of treatment) needed!
• Social and digital media• Strengthen linkages between community and facility
based services and virtual space• Community empowerment critical • Domestic funding, including city approach!
Chapter SevenHIV beyond 2015
Choosing a future… The End of AIDS
• “The End of AIDS” is an aspirational vision
• Epidemiological concepts of elimination and eradication not readily applicable to AIDS as millions are living with HIV and no cure available
• Key step to “The End of AIDS” is epidemic control– Epidemic control - Reduction of disease incidence, prevalence, morbidity
or mortality to a locally acceptable level as a result of deliberate intervention measures
– Point where HIV no longer represents a public health threat and no longer among the leading causes of country’s disease burden
– Mathematically defined as the point at which the reproductive rate of infection (R0) is below 1
What will it take to reach the ambitious target of epidemic control?
• Act on knowledge of detailed local epidemiology
• Build on successes ….learn from failures ….implement
to scale
• As the HIV epidemic changes – so too should our programs & interventions. Adapt with the changes!
• Target hotspots, pockets and key populations that continue to sustain high HIV incidence – will need combinations of appropriate prevention strategies
• Deal with underlying drivers such as legal barriers, stigma & social norms simultaneously
• Continued funding & greater program efficiency
• Biomedical, socio-behavioural and implementation science, incl. innovations
EpilogueA world without HIV?
Acknowledgements
Salim Abdool Karim, Chair, UNAIDS Science PanelValerie Delpech, Epidemiologist Public Health EnglandJared Baeten, Partners PrEP, University of Washington
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