Spectrum 2007Overview and New Changes

UNAIDS Reference Group on Estimates, Model and Projections

2007

Purpose

• Determine the consequences of the prevalence estimates made with EPP or Workbook– New infections, HIV+ population, AIDS deaths– Need for treatment and effects of treatment– Orphans and vulnerable children

New Features

1. New treatment options• Adults: 1st and 2nd line ART• Children: ART and cotrimoxazole

2. Updated progression periods• New infection to need for treatment• Need for treatment to AIDS death w/wo treatment

3. Expanded PMTCT options4. Calibrate to multiple national surveys5. Uncertainty analysis

Inputs required

Country data• Demographic data• Adult prevalence-------------------------• MTCT program

description• PMTCT coverage• Adult ART coverage• Child treatment

coverage

Epidemic patterns• Effect of HIV on fertility• Progression from infection to

need for treatment and to AIDS death

• Sex ratio of prevalence• Age distribution of infection• Mother-to-child transmission

rates by regimen and feeding options

• Effect of child treatment

Creating a new projection

Population Projection

Population Projection

Population Projection

The first year of the projection must be before the start of the AIDS epidemic, usually 1980

Population Projection

The last year of the projection can be anything up to 50 years, but it is best to match the prevalence estimate (2012 for EPP, 2007 for the Workbook)

Population Projection

Population Projection

Population Projection

Creates a projection using the UN Population Division’s World Population Prospects

Entering data

Selecting inputs to edit

Adult HIV Prevalence

Adult HIV Prevalence

Documenting sources

Effect of HIV on fertility

Effect of HIV on fertility

15-19: 50% increase

20-49: 30% decrease

TFR of HIV- adjusted to leave population TFR unchanged

Age and Sex Ratio of HIV Prevalence

Ratio of prevalence at each to prevalence at 25-29 : Females

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1980 1985 1990 1995 2000 2005 2010

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 +

Ratio of prevalence at each to prevalence at 25-29 : Males

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1980 1985 1990 1995 2000 2005 2010

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59

Age and Sex Ratio of HIV Prevalence

Sex ratio of HIV prevalence

Sex ratio of HIV prevalence

Ratio of Female to Male HIV Prevalence

0.0

0.5

1.0

1.5

2.0

2.5

0 5 10 15 20 25

Years Since the Start of the Epidemic

Cameroon DHS

Zambia DHS

Kenya DHSGhana DHS

Burkina Faso DHS

Kapiri Mposhi 98

Masaka 89-97Rwanda 86

Uganda 88

Mali DHS

DR DHS

Uganda 2004-05

Rwanda DHS

Senegal DHS

Guinea DHS

Tanzania DHS

Lesotho DHS

South Africa HSRC

Cote d'Ivoire DHS

Malawi 2004

Ethiopia DHS

Zim

Progression from HIV Infection to AIDS Death (Adults)

New HIV Infection

Need for Treatment

First Line ART

AIDS Death

Second Line ART

Need for 2nd Line

Net survival adjusted to age 25-29

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 1 2 3 4 5 6 7 8 9 1 1

Kisesa

Masaka

Rakai

SA miners

Thai military

0 1

Source: Zaba and Todd, Alpha network

Time from AIDS or CD4<200 to death in the absence of HAART

Time measured from

Published studies from resource-poor settings (median, range)

Estimates from the Swiss HIV cohort study (median, 95% CI)

AIDS

CD4 count <200 (median 100)

150< CD4< 250 (median 200)

11 (7 – 19)

11 (7 – 38)

35 (estimated)

17.6 (15.9 – 19)

24.0 (22.0 – 29.0)

77.0 (52.0 – 92.0)

Source: Zwahlen and Egger

Time from CD4 < 350 to death, and from CD4 < 350 combined with WHO stage III or IV to death in resource limited settings

Time measured from

Natural history of untreated patients

Bayesian synthesis analysis

200 < CD4 < 350

WHO stage III or IV and CD4 < 350

4 – 5 years 5.4 (1.9 – 15.7 years)

2.7 (0.76 – 9.6 years)

Source: Zwahlen and Egger

Incidence (%) of Death After Starting ART

3 months 6 months 12 months 24 monthsBrainstein 2006 5.1 [3.3 – 7.7] 5.1 [3.3 – 7.9] 2.7 [1.9 – 4.0]Etard 2006 12.5 [9.4 – 16.7] 6.6 [4.3 – 10.0]Jerene 2006 37.3 [N M]Lawn 2006 19.1 [14.4-25.2] 2.9 [1.8-4.8] 1.3 [0.4-3.9]Lawn 2005 19.4 [13.0-28.9] 6.2 [2.8-13.9] 2.9 [1.1-7.8]

Source: Dabis et al, ISPED

Progression from HIV Infection to AIDS Death (Adults)

New HIV Infection

Need for Treatment

First Line ART

AIDS Death

Second Line ART

Normal M 7.5yrs/F 8.5yrs, fast 6.1/6.9

3 years

15%/5%

Need for 2nd Line

15% FY / 5% SY3 years

Progression from HIV Infection to AIDS Death (Children)

New HIV Infection

Need for Treatment

First Line ARTAIDS Death

Age-dependent

>5 = 3 years<1, 0.80

>1, 0.9 first year, else 0.95

Marston and Newell, median = 2 years

Adult Male Progression without Treatment

0

20

40

60

80

100

0 2 4 6 8 10 12 14 16 18 20

Years Since Infection

Need TreatmentDead

Adult Male Progression with Treatment

0

10

20

30

40

50

60

0 2 4 6 8 10 12 14 16 18 20

Years Since Infection

On FLOn SLDead

The Need for ART will change from 2005 estimate!

0

50,000

100,000

150,000

200,000

250,000

300,000

1980 1985 1990 1995 2000

2007

2005

Projections of Adult ART Coverage

0102030405060708090

100

2000 2002 2004 2006 2008 2010 2012

Linear Trend Unmet Need % Target Unmet Need Trend

Orphans

% women 15-19 never married: 38%-94% (71%)

% married women in monogamous union: 45%-96% (71%)

Spectrum outputs

Various displays are available

Comparing effects

• Display up to four projections at one time

• Open same projection twice and rename to create comparison scenarios

Estimates of Need

Adult ART •Adults progressed to need for treatment•Simulates WHO guidelines

Child ART Children progressed to moderate-to-severe disease

Cotrimoxazole •Early detection–All HIV+ children

•No early detection–Children born to HIV+ mothers until 18 months–All HIV+ children over 18 months

PMTCT All births to HIV+ women

Plausibility Bounds

Plausibility Bounds

• Uncertainty around prevalence curve– EPP: read sampled curve from EPP .spu file– Workbook: generate 1000 logistic curve fits

by varying annual estimates according to data quality

Summary Table – Plausibility Bounds

Exercise

• Create a new demographic projection using EasyProj

• Read prevalence estimate from EPP or Projections Workbook

• Select appropriate patterns for Progression and Age/Sex Ratios

• Add data on coverage of PMTCT, ART and child treatment programs

• Review key indicators• Do uncertainty analysis