Global HIV Pandemic 2015 Professor Pamina M. Gorbach Department of Epidemiology, Fielding School of Public Health Division of Infectious Diseases, David Geffen School of Medicine University of California, Los Angeles

15 by 15: A Global Target Achieved For the first time in global health history, in March 2015 the world has reached a global numerical treatment target prior to the agreed deadline: providing antiretroviral therapy to 15 million people by 2015.

Tremendous progress has been made in the process of reaching this goal

But we still have an epidemic

Adults and children estimated to be living with HIV  2014 Eastern Europe & Central Asia 1.5 million [1.3 million – 1.8 million] North America and Western and Central Europe 2.4 million [1.5 million – 3.5 million] Middle East & North Africa 240 000 [150 000 – 320 000] Caribbean 280 000 [210 000 – 340 000] Asia and the Pacific 5.0 million [4.5 million – 5.6 million] Sub-Saharan Africa 25.8 million [24.0 million – 28.7 million] Latin America 1.7 million [1.4 million – 2.0 million] The epidemic is not spread evenly around the globe Total: 36.9 million [34.3 million – 41.4 million]

Global estimates for adults and children  2014 People living with HIV 36.9 million [34.3 million – 41.4 million] New HIV infections in 2014 2.0 million [1.9 million – 2.2 million] Deaths due to AIDS in 2014 1.2 million [980 000 – 1.6 million]

About 5,600 new HIV infections a day in 2014 About 66% are in Sub Saharan Africa About 600 are in children under 15 years of age About 5,000 are in adults aged 15 years and older, of whom: ─ almost 48% are among women ─ about 30% are among young people (15-24)

Challenges Although HIV testing capacity has increased over time, enabling more people to learn their HIV status, nearly half of all people with HIV are still unaware they are infected.3 HIV has led to a resurgence of tuberculosis (TB), particularly in Africa, and TB is a leading cause of death for people with HIV worldwide.4, 5 In 2013, approximately 13% of new TB cases occurred in people living with HIV.6 However, between 2004 and 2014 TB deaths in people living with HIV declined by 33%, largely due to the scale up of joint HIV/TB services.

More Challenges Women represent approximately half (51%) of all adults living with HIV worldwide. HIV is the leading cause of death among women of reproductive age. Gender inequalities, differential access to service, and sexual violence increase women’s vulnerability to HIV, and women, especially younger women, are biologically more susceptible to HIV. Young people, ages 15-24, account for approximately 30% of new HIV infections (among those 15 and over).2 In sub-Saharan Africa, young women account for 63% of young people living with HIV. Globally, there were 2.6 million children living with HIV in 2014, 220,000 new infections among children, and 150,000 AIDS deaths.

Sub-Saharan Africa Sub-Saharan Africa, the hardest hit region: home to 70% of people living with HIV but only about 13% of the world’s population.1, 7 Most children with HIV live in this region (88%).2 Almost all of the region’s nations have generalized HIV epidemics— that is, their national HIV prevalence rate is greater than 1%. In 9 countries, 10% or more of adults are estimated to be HIV-positive. South Africa has the highest number of people living with HIV in the world (6.8 million). Swaziland has the highest prevalence rate in the world (27.7%). Recent data offer promising signs, with national HIV prevalence and/or incidence stabilizing or even declining in many countries in the region.1

What we do: President’s Emergency Plan for AIDS Relief (PEPFAR Created in 2003 brought significant new attention and funding to address the global epidemic, as well as TB and malaria.11 PEPFAR authorized up to $15 billion over 5 years, primarily for bilateral programs and multilateral contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) as well as UNAIDS. Reauthorized in 2008 and, in 2013 In FY 2015, Congress appropriated a total of $5.2 billion for bilateral HIV and $1.35 billion for the Global Fund, totaling $6.6 billion. The President’s FY 2016 budget request for bilateral HIV programs is $5.2 billion. The Global Fund request is for $1.1 billion, which would represent a decrease of $244 million below FY 2015 levels.13

US Role Today, there are multiple federal departments, agencies, and programs that address the global epidemic, and the U.S. government is the single largest donor to international HIV efforts in the world, including the largest donor to the Global Fund.13, 14

Global effort International efforts to combat HIV began in the first decade of the epidemic with the creation of the WHO’s Global Programme on AIDS in 1987. UNAIDS was formed in 1996 to serve as the UN system’s coordinating body and to help galvanize worldwide attention to AIDS. In 2000, all nations agreed to global HIV targets to halt and begin to reverse the spread of HIV by 2015, as part of the UN Millennium Development Goals (MDGs), and the World Bank launched its Multi- Country AIDS Program (MAP). As of 2015, the AIDS-related targets of MDGs were met.1

Next steps The international community will soon agree upon new Sustainable Development Goals (SDGs), which include a target to end the AIDS epidemic by 2030.15 On World AIDS Day 2014, UNAIDS set targets for 2020 aimed at ending the epidemic by 2030. The targets include achieving “90% of people living with HIV knowing their HIV status; 90% of people who know their HIV-positive status on treatment; and 90% of people on treatment with suppressed viral loads.”17

To contribute to ending the AIDS epidemic as a public health threat by 2030, the world must ensure that by 2020: (a) 90% of all people living with HIV know their HIV status; (b) 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy; and (c) 90% of all people receiving antiretroviral therapy achieve sustained viral suppression.

Correlation between HIV treatment and incidence 1.1% (0.8%-1.4%) reduction in HIV incidence, for each 1.0% increase in treatment coverage. 1.0 p=0.325 p=0.003 0.8 p=0.0001 p=0.013 Incidence rate ratio 0.6 0.4 0.2 ART & HIV incidence: Hlabisa, South Africa 0% 30% 60% ART coverage Source: Tanser et al. Science 2013;339:966-971

People living with HIV accessing antiretroviral therapy As of March 2015, 15 million people living with HIV were accessing antiretroviral therapy, up from 13.6 million in June 2014. 41% [38%-46%] of all adults living with HIV were accessing treatment in 2014, up from 23% [21%-24%] in 2010. 32% [30%-34%] of all children living with HIV were accessing treatment in 2014, up from 14% [13%-15%] in 2010. 73% [68%-79%] of pregnant women living with HIV had access to antiretroviral medicines to prevent transmission of HIV to their babies in 2014; new HIV infections among children were reduced by 58% from 2000 to 2014.

HIV incidence vs. ART coverage in 51 countries, weighted by epidemic size (2012 data) Copyright Colin Purrington (http://colinpurrington.com/tips/academic/posterdesign). Table: country number with HIV % on treatment % new infection % deaths. Highlight the Euuropean countries. MAP with countries color coded with % on ART with categories. % of expected death -> assuming that the percetnage of death is like in Botswana -> Preventable death? Preventable infection and preventable death Add the european country in the list to show where they are on the list of countries. Enphasize that linear AND non-linear regression have been done, and no curve could Add limitations. Diferent attiture, stigma, needle exchange, condoms, quality of care. Source: Hill, Pozniak, Raymond, Heath and Ford, AIDS 2014, 2014.

UNAIDS 90-90-90: HIV Treatment Targets for 2020 with Global Estimates (2014) 90% of HIV+ people diagnosed Target 2: 90% of diagnosed people on ART Target 3: 90% of people on ART with HIV RNA suppression In 2014 UNAIDS set 3 ambitious targets to increase global coverage of HIV care by the year 2020   These are: Target 1 - 90% of all people living with HIV to be diagnosed Target 2 - 90% of those diagnosed to receive antiretroviral treatment And Target 3 - 90% of all of those on treatment to achieve viral suppression This means that in the final category, 73% of all HIV positive people should be achieving viral suppression by 2020. The numbers here in white show how many people should be in each category, given that nearly 37 million people are estimated to be living with HIV globally. http://www.unaids.org/sites/default/files/media_asset/JC2702_GARPR2015guidelines_en.pdf Ref: The Joint United Nations Programme on HIV/AIDS. 90-90-90 An ambitious treatment target to help end the AIDS epidemic. 2014; JC2684 (Numbers as of March 2015) How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS RESPONSE July 2015.

Global Estimates (2014-15) vs the Gap to reach 90-90-90 Targets Breakpoint 1: 13.4 million Undiagnosed Breakpoint 2: 14.9 million not treated Breakpoint 3: 15.3 million Not Virally Supressed Using the most recent data from UNAIDS, and a systematic review on viral suppression rates by Mcmahon et al, this global cascade estimates where we are currently compared to the targets.   Just over half of all HIV + people know their status and 41% (about 15 million) are on treatment as of March 2015. The numbers in white show the most current estimates for the number of people in each category worldwide. Where the targets are not yet reached – red arrows illustrate the gaps in the cascade – This is where we are missing the targets and we will define these as breakpoints. Can these UNAIDS 90-90-90 target be reached? … (Pause) July 2014 – 13,950,296 http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2014/july/20140716prgapreport Ref: On ART = March 2015. How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS RESPONSE July 2015. * Average viral suppression% Intention to Treat LMIC rate from a Systematic Review by McMahon J. et al. Viral suppression after 12 months of antiretroviral therapy in low-and middle-income countries: a systematic review." Bulletin of the World Health Organization 91.5 (2013): 377-385.

Sustainable East Africa Research for Community Health SEARCH Study Design Sustainable East Africa Research for Community Health SEARCH Key Questions 32 communities of 10,000 each 3 geographic regions SEARCH Partners PEPFAR NIH WHO World Bank UNAIDS Gilead Sciences Uganda MOH Kenya MOH UGANDA KENYA Mbarara Tororo Nyanza • Can a population-based ART test and treat strategy“shut down” new HIV infections? * *As part of combination prevention • What are the additional gains? (maternal child health, TB, education, household earning power?) • What is the best way to do it? • What would it cost? • Can efficient HIV chronic care models be adapted to establish care for other chronic diseases (hypertension and diabetes)? SEARCH: Cluster randomized trial of universal vs. standard ART Intervention Communities: ART at all CD4+ Annual & targeted testing Enhanced linkage & retention Community Health Campaign Community Health • HIV incidence • HIV population viral metrics • AIDS • Maternal and child health • TB • NCD (HT, DM) Community Productivity/Costs • Workforce participation • Child labor prevalence • Agricultural output • Household income • Educational attainment • Healthcare utilization 16 communities n = 10,000 each HIV Screening/Diagnosis Malaria testing & care HTN and Diabetes testing Maternal/child health Outcomes Year 3 and 5 Standard of Care: Country-guided ART 16 communities n = 10,000 each

“Mobile” Hybrid HIV Testing Approach: Census, Community Health Campaigns, Home testing Goal HIV and NCD status of 90% of adults residents Approach Community Mobilization , input into health campaigns Household Census Community Health Campaigns- Multi-disease Home testing for non attendees Refer HIV+, hypertension to public clinic using “streamlined care” Outcome: 340,000 persons enrolled in study 90% HIV testing stable adult residents

How was 15 by 15 Achieved? strong and sustained leadership and commitment, community engagement, robust funding, increased knowledge of HIV status, a reliable supply of effective and affordable medicines, improved efficiency and quality of treatment services, innovation, progress in reducing HIV-related stigma and discrimination.

Without addressing the social, structural and behavioral determinants of health: including poverty, hunger, human rights, punitive laws, we will not «end» HIV/AIDS