HIV 101

History of the Epidemic

Catherine Hankins MD MSc CCFP FRCPC Chief Scientific Adviser to UNAIDS Office of the Deputy Executive Director, Programme AIDS Vaccine 2011 Conference

Journalist Scholarship Program

Bangkok, Thailand, September 11, 2011

Zero new HIV infections Zero discrimination Zero AIDS-related deaths

HIV 101: History of the Epidemic

Milestones, new concepts, scientific breakthroughs Prevalence Incidence

Tracking structural determinants of HIV transmission and measuring behaviour change

Antiretroviral treatment coverage and impact

Commitments

2011 A year of milestones

30 years of AIDS since 1981
WHO Global Program on AIDS 1984-1995 Creation of Joint UN Programme on AIDS 1995

15 years of triple combination antiretroviral therapy (ART) 10 years implementing the Declaration of Commitment on HIV UNGASS 2001

10 years of Millennium Development Goals (MDGs) and 5 more years to achieve them 5 years of Universal Access (UA) 2006 Political Declaration on HIV High Level Meeting (HLM), New York, June 2011 and 2nd Security Council Resolution (first was in 2000)

2001
Epidemic Minimal response

2011
Endemic Increasing services

Increasing funding
Emergency response

Flat-lined funding
Sustained response

A,B,Cs
Treatment vs prevention Criminals AIDS exceptionalism

Combination prevention
HPTN 052 (treatment for prevention); Treatment and Prevention Citizens AIDS leads the way

Number of people living with HIV and scientific breakthroughs, 19812011

iPrEX trial in men who have sex with men in Peru, Ecuador, Brazil, Thailand, USA and South Africa reports 44% reduced HIV acquisition in men taking a single daily tablet of FTC/TDF
First combination pill uniting three drugs (AZT/3TC/ abacavir) approved First cases of unusual immune deficiency identified among gay men Short-course AZT and Combination single-dose treatment nevirapine with at least reduce three vertical HIV antiretroviral drugs transmission

CAPRISA 004 trial in South Africa shows that vaginal tenofovir gel reduces womens risk of HIV acquisition by 39% over 30 months
Clinical trials in Kisumu, Kenya, and in Rakai, Uganda, confirm efficacy of male circumcision for HIV prevention

First HIV antibody tests developed

Mio 40

Revised surveillance case definition for AIDS

RV144 vaccine trial in Thailand shows 31% protection

30

20

10

1981

1985
Zidovudine (AZT) approved for treatment

1990
ACTG protocol 076 shows that AZT prophylaxis reduces vertical transmission

1995
Effectivenes s of needle exchange programmes established

2000
Rapid HIV test approved

2005

2010 2011

Human immunodeficiency virus (HIV) identified as the cause of AIDS

Clinical trial of male circumcision in Orange Farm, South Africa, shows reduced HIV transmission

IMAGE intervention of combined microfinance and training results in reduced risk behaviour among young women

Kesho Bora study in Burkina Faso, Kenya, & South Africa reveals triple ART halves the risk of HIV transmission through breastfeeding; Partners PrEP and TDF-2 trials show 63-73% reduction in HIV acquisition; HPTN 052 trial finds ART reduces HIV transmission 96% in serodiscordant couples

Singapore, 1994 All the smartest bodies in town are wearing rubber. Design: Action for AIDS, Singapore. Museum fr Gestaltung Zrich

Adults and children estimated to be living with HIV 2009

Eastern Europe Western & Central Europe & Central Asia North America [1.2 million 2.0 million] Middle East & North Africa Caribbean [220 000 270 000] Central & South America [1.2 million 1.6 million] [400 000 530 000] Sub-Saharan Africa [20.9 million 24.2 million]

1.5 million

[720 000 910 000] [1.3 million 1.6 million] East Asia [560 000 1.0 million]

820 000

1.4 million

770 000

240 000

460 000

South & South-East Asia

[3.7 million 4.6 million] Oceania [50 000 64 000]

4.1 million

22.5 million

1.4 million

57 000

Total: 33.3 million [31.4 35.3 million]

HIV Prevalence: 33.3 million [31.4 35.3] in 2009, compared to 26.2 million [24.627.8] in 1999 (27% increase)
HIV Prevalence Proportion: constant at 0.8% of the global population since 2001

Source: UNAIDS.

Global summary of the AIDS epidemic 2009

Number of people living with HIV
Total 33.3 million [31.4 35.3 million] Adults 30.8 million [29.2 32.6 million] Women 15.9 million [14.8 17.2 million] Children (<15 years) 2.5 million [1.6 3.4 million]

People newly infected with HIV in 2009 AIDS deaths in 2009

Total 2.6 million [2.32.8 million] Adults 2.2 million [2.0 2.4 million] Children (<15 years) 370 000 [230 000510 000]

Total 1.8 million [1.6 million2.1 million] Adults 1.6 million [1.4 million1.8 million] Children (<15 years) 260 000 [150 000360 000]

Figure 2.6

Trends in women living with HIV

Proportion of people 15 years and older living with HIV who are women, 19902009.

70

Sub-Saharan Africa
60 50 40

Caribbean

GLOBAL
Eastern Europe and Central Asia Central and South America Asia Western and Central Europe and North America
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09

30
20 10 %

Source: UNAIDS.

Estimated number of adults and children newly infected with HIV 2009
Eastern Europe Western & Central Europe & Central Asia North America [44 000 130 000] Middle East & North Africa Caribbean [13 000 21 000] Central & South America [70 000 120 000] [61 000 92 000] Sub-Saharan Africa [1.6 million 2.0 million]

70 000

[23 000 40 000]

31 000

[110 000 160 000] East Asia 82 000 [48 000 140 000] South & South-East Asia [240 000 320 000] Oceania [3400 6000]

130 000

17 000

75 000

270 000

1.8 million

92 000

4500

Total: 2.6 million [2.3 2.8 million]

Annual number of people newly infected with HIV decreased by 19% from 3.1 million [2.93.4] in 1999 to 2.6 million [2.32.8] in 2009
4.0 3.5 3.0 MILLIONS 2.5 2.0 1.5 1.0 0.5 0.0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

HIV Incidence

Dotted lines represent ranges, solid lines represent the best estimate.

Young people are leading the prevention revolution by taking definitive action to protect themselves from HIV
HIV prevalence in young people aged 15-24 has declined in 22 high burden countries in sub-Saharan Africa (by 25% in 15 of these countries): delaying onset of sex fewer partners correct and consistent condom use

Figure 2.5

Global HIV trends, 1990 to 2009

Number of people living with HIV Number of children living with HIV

Adult and child deaths due to AIDS

Number of orphans due to AIDS

Dotted lines represent ranges, solid lines represent the best estimate.
Source: UNAIDS.

Regional distribution of HIV-1 subtypes and recombinants (2004-2007)

A B C D F G H

J K CRF01_AE CRF02_AG CRF03_AB Other CRFs URFs

Intertwined epidemiology
People are injecting drugs in 148 countries: 16 million [11-21] people worldwide (largest populations of
people who inject drugs are in USA, Russia, Brazil)

5 million in 13 PEPFAR focus countries: Cambodia, China,

Indonesia, Vietnam, Georgia, Kazakhstan, Kyrgyzstan, Russia, Tajikistan, Ukraine, Kenya, Tanzania, and South Africa

Among people who inject drugs, HIV has been documented in 120 countries:
3 million [0.8-6.6 million] people

10% of people living with HIV

30% of people living with HIV outside sub-Saharan Africa

Source: Mathers, Degenhardt, Phillips et al for the 2007 UN Reference Group on HIV and Injecting Drug Use. Lancet Sept 24, 2008

Table 3.1

Countries in which HIV infections among people who inject drugs represent 20% or more of the total number of people living with HIV

Azerbaijan

Malaysia

Canada China Estonia Georgia Indonesia Islamic Republic of Iran Italy Kazakhstan Kyrgyzstan

New Zealand Pakistan Russian Federation Spain Tajikistan Ukraine United States of America Uzbekistan

Source: Mathers et al. (12).

Countries setting universal access targets, by region 20042010

% of countries setting targets 100

80

60

40

20

Caribbean (4)

Central and Eastern EuropeMiddle East and Sub-Saharan Western and South Americaand Central Asia North Africa Africa Central Europe (10) (12) (7) (39) (9)

South and South East Asia (13)

ART Coverage Prevention prioritising key populations

Insufficient data available from North America,Oceania, East Asia.

Countries criminalizing same-sex sexual activities between consenting adults, 2009

Violence against women in 2009*

* Ever-married women who experienced physical or sexual violence from their most recent spouse or coresident partner.

Used a condom at last higher risk sex females Countries with prevalence more than 2%, 19952010

) identifies statistically significant decrease in high-risk sex 2) indicates statistically significant increase in high-risk sex.
1

Source: Demographic and Health Surveys, and other national surveys

Number of people receiving ART in low- and middle-income countries by region 20022009

2010 > 6 million people

AIDS-related deaths decreased from 2.1 million [1.92.3] in 2004 to 1.8 million [1.62.1] in 2009

Souce: WHO/UNAIDS Universal access Report 2010

Coverage of antiretroviral therapy at the end of 2009

(WHO 2010 Guidelines, CD4<350) 2140%
Algeria Angola Armenia Azerbaijan Bangladesh Belarus Belize Bulgaria Cameroon Chad China Congo Cte dIvoire Ecuador Eq Guinea Eritrea Fiji Ghana Guinea GuineaBissau Honduras Hungary India Indonesia Kazakhstan Lithuania Malaysia Mauritania Mauritius Morocco Mozambique Nicaragua Niger Nigeria Panama Paraguay Peru Philippines Benin Poland Brazil Serbia Burkina Faso Dominican South Africa Rep Togo El Salvador Uganda Ethiopia UR Tanzania Gabon

020%
Bolivia Bhutan Burundi CAR Colombia DR Congo Djibouti Egypt Gambia Iran Madagascar Maldives Mongolia Myanmar Nepal Pakistan Moldova Russian Fed Sierra Leone Somalia

4160%
Lesotho Malawi Mali Mexico PNG Senegal Suriname

6180%
Argentina Chile Namibia Slovakia

>80%
Botswana Cambodia Cuba Guyana Oman Romania Rwanda

Kyrgyzstan Latvia Lebanon Liberia

Sri Lanka Sudan Tajikistan Ukraine

Uzbekistan Viet Nam Zimbabwe

Guatemala Haiti Jamaica Kenya

Swaziland Tunisia Uruguay Venezuela

Costa Rica Thailand Croatia Turkey Georgia Zambia Lao PDR

Treatment benefits are clear.

Since 1996 the availability of effective treatment, has saved some 2.9 million lives
Estim ated n u m b er o f Life -years ad d ed d u e to an tiretr oviral th erap y, b y reg io n , 1 9 9 6 2 0 0 8
8
7 . 2 m illio n

7 6

( m illio n s)

5 4 3 2 1 0

2 . 3 m illio n 1 . 4 m illio n 590 000 73 000 40 000 49 000 7500

W estern Eu ro p e a n d No rth Am erica

Su b Sa h a ra n Af rica

La tin Am erica

Asia

Ea stern Ca rib b ea n Eu ro p e a n d Cen tra l Asia

Ocea n ia

M id d le Ea st a n d No rth Af rica

2009 AIDS epidemic update Figure VII

Estim ated n um b er o f AID S-related d eaths wi th and w itho ut antiretroviral therap y, g lob ally, 1 9 9 6 2 0 0 8
3 .0 2 .5
N um ber (m illio ns)

2 .0 1 .5 1 .0 0 .5 0

The number of AIDS-related deaths has declined by over 10% over the past five years

1 9 96 1 9 97 1 9 98 1 9 99 2 0 00 2 0 01 2 0 02 2 0 03 2 0 04 2 0 05 2 0 06 2 0 07 2 0 08 Yea r N o a ntiretrovira l thera py At current levels o f a ntiretro vira l therap y

2009 AIDS epidemic update

Figure V

The epidemic has changed

tremendous progress in stabilizing or reducing new infections in nearly 60 countries

rampant stigma and discrimination continues to contribute to rising HIV infections among key populations at higher risk and to the vulnerability of women and girls
many

countries still have laws, regulations or policies that present obstacles for populations at higher risk or other vulnerable populations to access prevention, treatment, care and support

Bold new targets for 2015

50% in sexual transmission of HIV 50% of HIV among people who inject drugs 50% TB deaths in people living with HIV Ensure no children are born with HIV and reduce AIDSrelated maternal deaths 15 million on antiretroviral treatment

Security Council Resolution number 1983

Reaffirms significance of epidemic to individual, national and global security Respects and promotes human rights in conflict/post-conflict

Recognizes link between HIV and violence against women

Recognizes contribution of UN peacekeeping operations to integrated response to HIV

UNAIDS Strategy: Getting to Zero

Vision and goals:
Zero new infections

Strategic directions:
Revolutionize prevention

Zero AIDS-related deaths Catalyze the next phase of treatment, care and support Zero discrimination Advance human rights and gender equality for the HIV response

Overview of the state of the HIV epidemic

Milestones, new concepts, scientific breakthroughs to 2011 Prevalence: increased 27% in 10 years

Incidence: decreased 19% in 10 years Tracking structural determinants of HIV transmission and measuring behaviour change: need to address stigma and discrimination, criminalisation, intimate partner violence, and gender inequality Antiretroviral treatment coverage and impact: increasing Commitments: 50% transmission reductions and 15 by 15.

VISION

Mellors 5.25.10

ZERO NEW HIV INFECTIONS.

ZERO DISCRIMINATION.

ZERO AIDS-RELATED DEATHS.