1. 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

2. 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

3. Adults and children estimated to be living with HIV/AIDS as of end 2002
Eastern Europe & Central Asia
1.2 million
Western Europe
North America
East Asia & Pacific
1.2 million
North Africa
& Middle East
Caribbean
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

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

5. 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

6. 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

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

8. 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,
The epidemic is leveling off at
extremely high levels of prevalence

9. 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

10. 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

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

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

13. 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

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

15. 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

16. 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

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

18. 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

19. From a presentation by Jim Chin
The general HIV prevalence trend of the three highest HIV prevalence countries (> 1% of the total 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 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 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 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 year old population or about 250, ,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

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

21. 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

22. 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%)

23. 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

24. 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

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

26. 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

27. 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

28. 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

29. 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