Update on the Status of the AIDS Epidemic The 3rd Global TB HIV Working Group Meeting Montreux, Switzerland, 4-6 June 2003 Ties Boerma HIV Department Surveillance, Research and Monitoring & Evaluation

OUTLINE Update on the spread of HIV in the world Key features of the spread of HIV that affect TB epidemiology - gender, age, HIV and TB - geographic differences: urban - rural Potential to reduce HIV incidence

Adults and children estimated to be living with HIV/AIDS as of end 2002 Eastern Europe & Central Asia 1.2 million Western Europe 570 000 North America 980 000 East Asia & Pacific 1.2 million North Africa & Middle East 550 000 Caribbean 440 000 South & South-East Asia 6 million Sub-Saharan Africa 29.4 million Latin America 1.5 million Australia & New Zealand 15 000 42 million people living with HIV 5 million new infections 3.1 million deaths 70% of the world’s infections are in Africa

Growth of the African epidemic Trends in Number of People Living with HIV infection 1980 - 2002 by WHO Region Growth of the African epidemic slowed down since 1997 Changes in the African epidemic will greatly affect global numbers

Trends in Number of People Living with HIV infection 1980 - 2002 by WHO Region (2) Caribbean 2.5% <1% <1% There is epidemic growth in all regions

HIV prevalence in adults in sub-Saharan Africa, 1986-2001 1991 20 – 39% 10 – 20% 5 – 10% 1 – 5% 0 – 1% trend data unavailable 1996 2001 outside region Source: UNAIDS/WHO July 2002 Large differences in severity within Africa: Southern >> Eastern and Central > Western

Huge differences within Africa not likely to be just temporal Trends in HIV prevalence among antenatal women (same clinics), selected countries, 1990-2002 Huge differences within Africa not likely to be just temporal

The epidemic is leveling off at extremely high levels of prevalence Trends in median HIV prevalence in the same antenatal sites by country and period, Southern Africa, 1997-2002 The epidemic is leveling off at extremely high levels of prevalence

Overall trend in sub-Saharan Africa Surveillance systems are improving, especially in terms of coverage of rural populations where prevalence is lower than some model-based estimates have assumed - will affect estimates of the size of the epidemic in 2003 Some countries may still show increases in HIV prevalence but the overall prevalence levels appear to be stabilizing or decline somewhat Constant prevalence may conceal high incidence

OUTLINE Update on the spread of HIV in the world Key features of the spread of HIV that affect TB epidemiology - gender, age, HIV and TB - geographic differences: urban - rural Potential to reduce HIV incidence

More women are infected than men HIV prevalence by gender 15-49 years in countries with a recent national population-based survey More women are infected than men

HIV prevalence by age and sex, Zambia DHS 2001-02 Women get infected earlier than men, often under 25 years

Female to Male Ratios in HIV prevalence and in smear positive TB notification rates More women More men TB data from Kenya, 1989, Malawi, 1990, Tanzania, 1987, (Borgdorff et al., 2000) TB case in HIV- person is more commonly a man, HIV effect on TB possibly greatest in young women

HIV prevalence among 15-54 years by sex and residence, Burundi, 2002 There are very large geographic differences which may affect TB

OUTLINE Update on the spread of HIV in the world Key features of the spread of HIV that affect TB epidemiology - gender, age, HIV and TB - geographic differences: urban - rural Potential to reduce HIV incidence

HIV prevalence in adults in Latin America, 1986-2001 1991 2 – 8% 1 – 2% 0.5 – 1% 0.1 – 0.5% 0 – 0.1% trend data unavailable 1996 2001 outside region Source: UNAIDS/WHO July 2002 Most affected country Haiti, not much epidemic growth in recent years

Rapid growth in several countries May slow down a bit in 2003, surveillance improving

HIV prevalence in adults in Asia, 1986-2001 1991 2 – 5% 1 – 2% 0.5 – 1% 0.1 – 0.5% 0 – 0.1% trend data unavailable 1996 2001 outside region Source: UNAIDS/WHO July 2002 Steady growth during the past decade in most parts of Asia

From a presentation by Jim Chin The general HIV prevalence trend of the three highest HIV prevalence countries (> 1% of the total 15-49 year old population in Cambodia, Thailand and Myanmar) is clearly seen in the above figure – a decreasing trend during the last few years. Some of the marked prevalence increase in Cambodia from 1997 to 1999 can probably be attributed to an overestimate of HIV prevalence in 1999 and this also contributes to the marked decrease in estimated prevalence from 1999 to 2001. A detailed review of all of HSS data in Cambodia during this time period showed that HIV prevalence rates in most of the HSS sentinel populations have been stable or declining since 1996. The HIV prevalence in Thailand show a slow declining trend since the mid-1990s. Both Thailand and Cambodia have instituted the “100% condom program” and it is believed that this is the main factor for their decreasing HIV prevalence. In Myanmar, based on new estimates of the HIV prevalence differential in rural ANC females compared to urban ANC females the HIV prevalence estimate for Myanmar in 2001 was lowered to 177,000 (0.69 percent of the total 15-49 year old population). This new national HIV prevalence estimate is probably too low. The actual HIV prevalence in Myanmar in 2001 is probably more than 1 percent of the 15-49 year old population or about 250,000-350,000. All of the other countries in Asia and the Pacific region have estimated HIV prevalence of less than 1%. The only country where a consistent, but slowly increasing prevalence is seen is PNG.   From a presentation by Jim Chin Cambodia and Thailand have shown decline Myanmar data are limited for trend assessment

From a presentation by Jim Chin (2) From a presentation by Jim Chin Growth in some countries, decline or no change in others

India 2002 Source: NACO Great diversity in epidemic by state Jammu & Kashmir Himachal Pradesh Punjab Chandigarh Haryana Delhi Arunachal Pradesh > 1% Antenatal Women Sikkim Rajasthan Uttar Pradesh Assam Nagaland > 5% High Risk Group Meghalaya Bihar Manipur Tripura < 5% High Risk Group Madhya Pradesh West Bengal Mizoram Gujarat No Data Daman & Diu Orissa Dadra Nagar Haveli Maharashtra Andhra Pradesh Goa Karnataka Pondichery Tamil Nadu Lakshwadeep Source: NACO Kerala Great diversity in epidemic by state

Percentage of reported HIV infections by gender in China: 1985 – June 2001 Male 81.6% (21,274) Female 16.9% (4,391) Unknown 1.5% (393) Source: National Center for AIDS Prevention and Control Predominantly an epidemic among men, mainly IDU (70%)

What is the potential of Asian epidemics? 0.3-1% 5-20% FSW Clients MSM IDUs Low or no risk males 2-3% 0.1-5% Low or no risk females Given that HIV continues to spread in the region, what are the potential limits of growth in Asia? To understand this we need to understand a little about how epidemics play out in the region Asian epidemics consist of multiple interlinked and interrelated epidemics: Epidemics among injecting drug users – these have played a key role in China, Vietnam, Malaysia Epidemics among men who have sex with men – prevalences of 15% are not uncommon, as was recently measured in Phnom Penh Epidemics among sex workers and their clients – by far the largest component of the epidemic in Asia Epidemics among the “low risk” female partners of the IDUs, men who have sex with men and clients and their children It is worth noting that over 80% of women infected in Asia have NO risk behavior at all by conventional definitions – they contracted HIV in what was for them a “monogamous” relationship with their husbands The size of all of these populations combined is what determines the potential in Asia. By far the largest population is that of clients of sex workers and their female partners, so let’s look at the size of this population in various Asian societies. From a presentation by Tim Brown Growth of the size of the risk populations is key The type of epidemic is sensitive to concerted prevention efforts

Potential to reduce HIV incidence OUTLINE Update on the spread of HIV in the world Key features of the spread of HIV that affect TB epidemiology - gender, age, HIV and TB - geographic differences: urban - rural Potential to reduce HIV incidence

Anti-Retro Viral Treatment for HIV: The 3 By 5 goal Effect on TB incidence (e.g. Brazil)

The effect of treatment on HIV transmission Treatment no cure Treatment can affect HIV transmission: Positive: more HIV testing & counselling, stigma reduction, behavioural change, reduction in infectiousness of people on treatment Negative: behavioural disinhibition, more STIs, resources diverted from prevention Treatment should be part of a comprehensive response that includes a strong prevention component Treatment is an opportunity for better prevention that must not be missed

Reducing HIV incidence: Preventive interventions Promotion of safe sex: ABC (Abstinence, Be Faithful, Condom use) general population targeted - young people, risk populations STD control Prevention of Mother to Child Transmission HIV testing & counselling (voluntary, for diagnosis, for PMTCT) Safe injections and safe blood transfusions Vaccine development Microbicides development

Reducing HIV incidence: Does prevention work? National success stories: countries with a decline in HIV transmission: Uganda, Thailand, Cambodia perhaps also countries with little growth (Senegal, Ghana) HIV prevention research: randomized community trials: very few only handful used biological outcomes only one showed strong significant effect of the intervention, contradicted by other trials Some evidence of what works, but clearly more is needed

CONCLUSION HIV - spread across the globe but huge differences between and within countries exist Some levelling off of the increase taking place In Africa young women and urban populations are bearing the brunt of the AIDS epidemic and this will have implications for TB programs The combination of prevention and treatment of HIV/AIDS has greater potential to reduce HIV transmission, although evidence is still limited