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