25 Years of HIV

Africa and beyond

Carol Ciesielski, MD
Centers for Disease Control and Prevention
Chicago Dept of Health

Origins of HIV-1
Simian Immunodeficiency Virus (SIVcpz )

HIV-1
1930s
Leap to
Humans

Origins of HIV-1
HIV remained unnoticed in
isolated populations.

1930s leap to human

from chimpanzees ~
1st human case from
Kinshasa 1959

In 1960s-70s; changing
social structures, migrations
to cities from rural areas,
building roads, commercial
trucking, wars, jobs far from
home.
Transmission amplified by
urbanization: reuse of
needles in health care
settings, sex workers along
truck routes, job migrations

Already 30% gay men in San Francisco HIV+

Leading causes of death globally,

2001
Rank

% of
total

Ischaemic heart disease

12.7

Cerebrovascular disease

9.9

Acute lower respiratory infections

7.1

HIV/AIDS

4.8

Chronic obstructive pulmonary disease

4.8

Perinatal conditions

4.2

Diarrhoeal diseases

Tuberculosis

11 Malaria

4.0
3.0

1.9
Source: The World Health Report 2000, WHO

HIV Transmission
Sexual:
Heterosexual >>
Male to male

Blood: blood or blood/tissue products

Injection drug use
Medical injections

Perinatal (Vertical): mother to child

Highest Risk Populations

Men who have Sex with Men (MSM)
Injecting Drug Users
Sex workers and their clients

Concentrated vs generalized epidemics

Concentrated (low level) HIV concentrated
in high risk groups
Generalized - >1% of population HIV+;
HIV penetrated into general population
(mostly heterosexual spread)

Sexual Transmission
Accounts for ~ 75% of infections
worldwide
Probability of infection through
sexual contact lower than through
other routes
Infectiousness and duration of
infectiousness important in
epidemic spread

Factors Facilitating HIV Pandemic

Long Period between Infection and
Symptoms (average 10-12 years)
Individual: long period of silent infection &
infectivity
Community: Prevalence >> incidence
resulting in an insidious epidemic
HIV persists for life time of human host

Global Spread
~65 million persons have been
infected
~25 million deaths

Global HIV Epidemic, 2005

HIV Prevalence -# of persons

HIV infected (38.6 million)
HIV Incidence
(Number of new
infections each year)
4.1 million

HIV related
deaths
2.8 million

A Global View of HIV Infection

38.6 million people living with HIV
4.1 million new infections 2005

HIV Epidemic in Sub-Saharan Africa,

1985-2005
2.7 million new infections, 2 million deaths

19821st AIDS
case

38.6 million

4.1 million

2.8 million

Leading causes of death in Africa,

2001
Rank

% of total

HIV/AIDS

Acute lower respiratory infections

Malaria

9.1

Diarrhoeal diseases

7.3

Perinatal conditions

5.9

Measles

4.9

Tuberculosis

3.4

Cerebrovascular disease

3.2

Ischaemic heart disease

3.0

20.6
10.3

2.4
10 Maternal conditions
Source: The World Health Report 2000, WHO

HIV Prevalence (%) in Adults in Africa, 2005

Adult Prevalence Rate

HIV prevalence among 1524 year-old

men and women, selected countries in
sub-Saharan Africa, 20012005
% HIV prevalence

20
15

Women

Men

10
5
0

Sources: Demographic and Health Surveys. ORC Macro (Ghana, Burkina Faso, Mali, United Republic of Tanzania, Cameroon, Lesotho, Kenya, Zambia); Department
of Health, Uganda HIV/AIDS sero-behavioural survey 2004/2005 (Uganda); Ministry of Health and Child Welfare, Zimbabwe National Family Planning Council, National
AIDS Council , and CDC, The Zimbabwe Young Adult Survey 2001-2002 (Zimbabwe); Pettifor AE, et al. HIV and sexual behaviour among young South African: a
national survey of 15-24 year olds (South Africa).

AIDS epidemic update, December 2005. Fig 3

Southern Africa
Global epicenter
All 7 countries in Southern Africa have
adult prevalence rates near or above 20%
(Swaziland >33%).
33% of HIV infected persons
43% of all HIV + children <15 live here
52% of all HIV + women (>14 years of age)
1/3 of all AIDS deaths

HIV Prevalence (%) among pregnant women attending antenatal

clinics in Southern Sub-Saharan Africa, 1997-2004

Africa -Economic Impact of HIV in

Hardest Hit Countries
Annual per capita growth in half of the countries
is falling by 0.5-1.2%.
By 2010 GDP may drop by 8%.
By 2020 GDP could drop more than 20%.
In several countries, 53% of all illnesses among
workers are AIDS-related.
7 million farm workers have died from AIDS.
85% of teacher deaths are from AIDS.

South Africa
2nd highest number of persons
living with HIV/AIDS in the world ~
5.5 million/population 45 million;
~19% 15-49 HIV+
60%-70% military HIV+

57% are women

in 15-24 year olds, females are 3 x more likely to
be infected than males

HIV prevalence among pregnant women

in South Africa, 1990 to 2001

HIV prevalence (%)

30
25
20

15
10
5
0
1990 91 92 93 94 95 96 97 98 99 2000 01

Source: Department of Health, Republic of South Africa

Thousands

Number of people who died from HIV/AIDS

in sub-Saharan Africa, 1980-2001
2,500
2,000
1,500
1,000
500
0
1980

1983

Source: UNAIDS, 2002

1986

1989

1992

1995

1998

2001

Age in years

Projected population structure with and

without the AIDS epidemic, Botswana, 2020
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0

Projected population
structure in 2020

Males

140 120 100 80

Females

60

40

20

20

40

60

80 100 120 140

Population (thousands)

Source: US Census Bureau, World Population Profile

2000

Deficits due to AIDS

Sub-Saharan Africa
Poverty health care infrastructure and accessibility
Migration for jobs miners, long distance truck
drivers
Young girls having relationships with older men
(more likely to be HIV+)
Armed conflicts/displacements
Political leadership
Successes in several countries including Uganda,
Botswana, Nigeria
Severe economic consequences loss of skilled and
nonskilled workers, farmers, decreased food supply,
lack of educational opportunities

Has Epidemic Peaked in Sub

Saharan Africa?
Adult prevalence stable in many countries
Stable or declining prevalence ? Leveling
off vs increase in deaths
HIV Prevalence -# of persons
HIV infected (38.6 million)
HIV Incidence
(Number of new
infections each year)
4.1 million

HIV related
deaths
2.8 million

Worlds fastest growing epidemic- started in late

1990s 1.6 million living with HIV,
270,000 newly infected in 2005
75% infections in persons <30 years of age

Eastern Europe

Eastern Europe

Most affected countries

are Russia and Ukraine
0.8% population infected

Fueled by large numbers

of IDUsestimated 1% 2% population injects
drugs (up to 3,400,000)
5%-8% men <30 have
injected drugs
Inject in groups,
promoting multiple reuse
of injecting equipment
and transmission of HIV

Russia: 860,000 infected

Predictions of 5-8 million
infected by 2010

QuickTime and a
TIFF (LZW) deco mpressor
are neede d to se e this picture.

St. Petersburg, Russia, Rate of HIV

per 100,000 Population
250
200
Rate per 150
100,000
population 100
50
0
1996

1997

1998

1999

Year

2000

2001

Drug Use in Saratov Oblast

Drug use was a major problem in May 2000.
The drug market is expanding rapidly as
dealers enlist younger people into use and
distribution.
Over the past four years the average age of
drug initiation reportedly has dropped from
15-16 to 12-13.

Prevalence of syphilis among pregnant women

attending antenatal clinics in the Moscow region,
1993 to 1997
Prevalence per 100,000

800
700
600
500
400
300
200
100
0
1993

1994

1995

1996

1997

Source: Borisenko KK et al. Int J STD & AIDS, 1999, 10:665-668

Sex Workers in St. Petersburg Russia Observations

Motivations: quick money for survival needs, including
food, lodging and medicine;
obtain money for luxuries;
support a drug habit;
to travel abroad and meet potential marital partners.
Initiation into sex work usually through friends and
occasionally through applications to Internet
agencies.
Sex work in Russia in high demand, widespread and
reaches deep into society. The social backgrounds
of sex workers are highly varied; some from very
poor backgrounds; others from high socioeconomic
status families.

Ukraine
Estimated HIV prevalence 1.4% of population,
Fueled by IDUs, sex workers
High proportion of sex workers HIV+
42% newly diagnosed HIV in 2004 were
females

Epidemic in Eastern Europe is

Maturing
Increasing sexual transmission
(6% infections in 2001 -25% in 2004)
HIV + in pregnant women increased from
<0.01% in 1998 to 0.11% 2003.
Recent surveys ->80% male IDUs didnt
use condoms regularly in last month
Continued growth sex industry, rising
number women migrating for work

How HIV Spreads out of High Risk

Populations
IDUs are sexually active
Many sex workers also inject drugs
Most male clients of sex workers have other
sexual partners, including wives & steady
girlfriends
HIV infection filters gradually from injecting
drug users & commercial sex workers to their
regular sex partners who may have no other
risk of exposure to the virus

High Proportion of Men who Inject Drugs are also

Clients of Sex Workers. Most do not Use Condoms

HIV/AIDS in Asia
60% of worlds
population
8.3 million infected

There is no Asian HIV epidemic; much diversity in the nature,

pace, and severity of the HIV epidemic across Asia, between and
within countries. Areas of rapid increases in HIV (China, Vietnam,
Indonesia); Areas of sustained epidemic levels (India, Myanmar);
areas of HIV declines (Thailand, Cambodia), and low prevalence
countries (Laos, Pakistan, Sri Lanka, Phillippines).

Transmission of HIV in Asia

Most infections
occur through
unsafe commercial
sex
injecting drugs with
contaminated
equipment

What do Asian epidemics look

like?
FSW

Clients
Low or no risk
males

Multiple interlinked
& interrelated
epidemics in higher
risk populations
and their immediate
sex partners

MSM

IDUs

Low or no risk
females

~10% Asian men go to sex

workers

HIV prevalence in Asia, 2003

2.0% 5.0%
1.0% 2.0%
0.5% 1.0%
0.1% 0.5%
0.0% 0.1%
trend data unavailable
outside region

Spread through
IDUs, sex workers

Southeast Asia adult HIV prevalence, 2003

Myanmar 1.2%
(330,000)

Vietnam 0.4%
(220,000)
Laos 0.1%
(1,700)

Thailand 1.5%
(570,000)

Cambodia 2.6%
(170,000)

Malaysia 0.4%
(52,000)

Singapore 0.2% (4,100)

Adult HIV prevalence (Numbers of HIV+ cases)

Source: WHO

Expanding HIV/AIDS
Epidemic in China
1985

1989

Source: UNAIDS

1995

1998

650,000 HIV+ in 2004; 80% IDU & commercial sex

Percent of Men Buying Sex in Previous 12 Months

among Men in High Risk Occupations and the General
Population
Estimated that ~10% of Asian Men Buy Sex

High risk occupations =truck drivers, police, sailors, migrant

workers

HIV in Asia vs. Africa

Prevalence in Asia lower but populations
larger
1 percent in India or China = 10 million people

Effective intervention easier in Asia

Focus on IDUs, MSM, sex workers and clients

Lower prevalence and growing economies

make early identification (testing) and
effective treatment (HAART) possible

HIV/AIDS Treatment
Antiretroviral Therapy (ART), available 1996
by 1997, death, hospitalizations, OIs
declined by 60-80%

Antiretroviral therapy coverage for adults,

Developing World, end 2005
1.3 million people on treatment:
60
50
40
%

30
20
10
0
Africa

Source: UNAIDS/WHO, 2004

2004 Report on the Global AIDS Epidemic (Fig 33)

Asia

Latin
America and
the Caribbean

Eastern
Europe and
Central Asia

North
Africa and
Middle East

Challenges
HIV testing -only 10% of 39 million
persons HIV + are aware of their infection
Affordable HIV treatment
HIV prevention
Education and awareness
Overcome stigma and discrimination

Impact of HAART-Behaviors
HIV is now a manageable chronic
illness, no longer a death sentence
HIV+ persons less concerned about
transmitting HIV to HIV - partners
mistaken belief that nondetectable viral
load means that they are not infectious
to others

in unprotected sex, in STIs and in

HIV transmission

Percentage of young people aged 1524 years

who correctly identified major ways
of preventing the sexual transmission of HIV*, 2003
60
50

Female

Male

40
%

30
20
10
0
Burkina Faso Cameroon

Ghana

Kenya

Madagascar Mozambique

Nigeria

UR Tanzania

*Using condoms and limiting sex to one faithful, uninfected partner,

who reject the two most common local misconceptions about HIV transmission,
and who know that a healthy looking person can transmit HIV.

Source: Demographic and Health Surveys. ORC Macro (Burkina Faso, Cameroon, Ghana, Kenya, Madagascar, Mozambique and Nigeria); Tanzania HIV/AIDS
Indicator Survey 2003-04, TACAIDS, NBS, and ORC Macro (UR Tanzania).

AIDS epidemic update, December 2005. Fig 4

Factors Facilitating Pandemic of HIV

Long Period between Infection and Symptoms
Individual: long period of silent infection & infectivity
Community: Prevalence >> incidence resulting in an
insidious epidemic
HIV persists for life time of human host

Stigma/Discrimination

Modes of transmission (sex and drugs)

High case fatality rate
Fear of contagion
Linked to poverty -competing priorities