XVI International AIDS Conference Toronto HIV Epidemiology Update based on Plenary Presentation C hris Beyrer MD, MPH Johns Hopkins Bloomberg School of Public Health

Global HIV epidemic, 1990 ‒ 2005 Number of people living with HIV % HIV prevalence, adult (15-49 ) % HIV prevalence, adult (15 ‒ 49) Number of people living with HIV (millions) Source: UNAIDS 2006 Bar indicates the range around the estimate 38.6 million living with HIV [33 to 46 million] 24.5 million in SS Africa [21.6 to 27.4 million]

IMPORTANCE OF PREVENTION (estimates 2005) 40.3 million people living with HIV/AIDS In 06/ million on ART 3.1 million AIDS related Deaths 4.9 million new HIV infections

Prevalence main determinant of incidence 40 million People living with HIV/AIDS 3.1 million AIDS related deaths 4.9 million New HIV infections

A global view of HIV infection, 2005 Source: UNAIDS 2006 Report on the Global AIDS Pandemic 1.5 million 200,000 in ‘05 IDU 7.6 million 830,000 in ‘05 Heterosexual MSM IDU 12.1 million 1.3 million in ‘05 Heterosexual

States with at least one site with HIV prevalence > 20% in IDU in 2006 Belarus Estonia Kazakhstan Russia Ukraine Serbia & Montenegro Iran Nepal Indonesia Libya Mauritius Kenya, Tanzania, Ghana, Nigeria** Burma China India Malaysia Thailand Vietnam Italy Netherlands Portugal Spain Argentina Brazil Uruguay Canada Puerto Rico USA **African States with at least one published report of IDU risks Emergent Epidemics Adapted from : Aceijas, et al, AIDS : Established Epidemics

Individual Level Determinants for Parenteral HIV Infection Needle sharing Higher frequency of injection Cocaine injection Lack of opioid analogue therapy MSM-IDU history Injection use while incarcerated

Reported HIV cases in the Russian Federation and Ukraine, 1987– Reported HIV cases in the Russian Federation Reported HIV cases in Ukraine Russian Federation Newly reported cases Cumulative (previous years) Ukraine Newly reported cases Cumulative Adapted from : Russian Federal AIDS Centre; Ukranian AIDS Centre and Ministry of Health of Ukraine, UNAIDS 2006 Report on the Global AIDS Pandemic

What are the Structural Drivers of Spread Across Eurasia? Driver # 1 Geographic proximity to overland drug trafficking routes Driver # 2 Limited use of HIV prevention measures with demonstrated efficacy for IDU transmission Driver # 3 Punitive and legalistic approaches to IDUs

Opiate seizures in Asia in 2004 Source : UNODC World Drug Report 2006

Sources: IDU Estimates: UNODC HIV/AIDS unit, September 2005; WHO/UNAIDS October Published in Harm Reduction Developments International Harm Reduction Development Program (IHRD) of the Open Society Institute UNAIDS recommends 60% coverage for effective HIV prevention among IDUs IDUs Reached by NSEP, Select FSU Countries, 2005

Structural limits on prevention & care for IDU US continues ban on federal funding for Needle Syringe Exchange Programs (NSEP) in US and globally Methadone Maintenance Therapy (MMT) remains illegal in many countries Ex: Russian Federation Across 50 developing countries, 34,000 IDU on ARV: 30,000 were in Brazil Source: Aceijas, et al, Addiction, 2006

Photo: Hans Jürgen Burkard

MSM Trends in High and Low Income Country Settings

Estimated Number of HIV/AIDS Diagnoses, by Transmission Category — 33 States, 2001–2004. * Statistically significant Source: Espinoza, CDC, 2005

Trends HIV among MSM mid ’90- now HAART introduced, resulting in dramatic improvement of survival of AIDS patients, as well as reduction in AIDS cases HIV/AIDS becomes a “chronic disease” and “less visible” Rise in “unsafe sex” and STI, including outbreaks of Syphylis and LGV

Sexual orientation of male syphilis cases registered in the sentinel network of clinicians, Belgium, Oct Jan 2003 From: IPH, Belgium

Possible explanations for increased risk behaviour HAART changed the face of the epidemic: less AIDS and less deaths Prevention fatigue: challenge of maintaining safe sex for an extended period Changing environment : internet as new way of recruiting partners Young MSM (<20y) sexually active earlier, and never exposed to AIDS as a killer disease

Source: Wade et al. 2005; Girault et al. 2004; van Grievsven et al. 2005; Action for AIDS Singapore, 2006, Go et al. 2004; Pando et al. 2006; UNAIDS, 2006; Caceres et al, 2005, Strathdee, et al, CENSIDA, CA State Office of AIDS; Patterson et al, IAS, 2006; Strathdee et al, pers. comm; Viani et al, 2006 HIV prevalence among MSM in low prevalence settings

HIV prevalence among MSM, Bangkok, Thailand Age (years) ≤ ≥29 N = 194/1,121; 113/399 Overall Source: Van Griensven, et al, MMWR HIV Prevalence (%) p-values all < 0.05

MSM structural risk contexts Criminalization and stigma limit MSM access to HIV prevention, treatment and care MSM understudied in emerging contexts: MSM not included in national HIV surveillance in Thailand, Vietnam, Senegal Only one African study (Wade, et al) of MSM risk and HIV rates Fewer than 1 in 10 MSM worldwide have access to necessary prevention services Sources: UNAIDS; USAID, 2004; Wade 2005; Go 2006 personal communication; HRW; UNAIDS 2006

HIV prevalence in adults in Africa Source : UNAIDS, 2006

RegionCountry Population- based survey prevalence (%) (year) Adjusted 2003 HIV prevalence (%) in current report 2005 HIV prevalence (%) in current report Trend in prevalence SOUTH Botswana25.2 (2004) Stable Lesotho23.5 (2004) Stable South Africa16.2 (2005) Increasing EAST Burundi 3.6 (2002)3.3 Decline in capital city Rwanda 3.0 (2005)3.83.1Decline in urban areas Tanzania 7.0 (2004)6.66.5Stable Uganda 7.1 (2004-5)6.86.7Stable WEST Burkina Faso 1.8 (2003)2.12.0Decline in urban areas Cameroon 5.5 (2004)5.55.4Stable Ghana 2.2 (2003)2.3 Stable Guinea 1.5 (2005)1.61.5Stable Senegal 0.7 (2005)0.9 Stable Sierra Leone 1.5 (2005)1.6 Stable HORN Ethiopia 1.6 (2005)( )( )Decline in urban areas Adult HIV prevalence in Sub-Saharan Africa, 2003 and Source: UNAIDS 2006 Report on the Global AIDS Epidemic

HIV prevalence by age and gender South Africa – 1920 – 2425 – 29 Age group (years) HIV Positive (%) Males Females Source: South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2005

Ecological Model for HIV Risk in Southern Africa Individual Risks for HIV Infection Widening Risk Contexts for HIV Infection Beyrer & Baral, 2006 Condom Usage, Circumcision, HSV-2/GUD, Viral Load, Acute Infection, Age of Coital Debut, Marriage, ARV Status