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

9. 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) 0 10 20 30 40 50 1990199520002005 0.0 1.0 2.0 3.0 4.0 5.0 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]

10. IMPORTANCE OF PREVENTION (estimates 2005) 40.3 million people living with HIV/AIDS In 06/2006 1.65million on ART 3.1 million AIDS related Deaths 4.9 million new HIV infections

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

12. 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

13. 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 2004 18:2295-2302 Established Epidemics

14. 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

15. Reported HIV cases in the Russian Federation and Ukraine, 1987–2005 1987198919911993199519971999200120032005 0 50 000 100 000 150 000 200 000 250 000 300 000 350 000 400 000 30 000 45 000 60 000 75 000 90 000 105 000 120 000 15 000 0 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

16. 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

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

18. Sources: IDU Estimates: UNODC HIV/AIDS unit, September 2005; WHO/UNAIDS October 2005. Published in Harm Reduction Developments 2005. 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

19. 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

20. Photo: Hans Jürgen Burkard

21. MSM Trends in High and Low Income Country Settings

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

23. 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

24. Sexual orientation of male syphilis cases registered in the sentinel network of clinicians, Belgium, Oct 2000 - Jan 2003 From: IPH, Belgium

25. 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

26. 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, 2006. 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

27. HIV prevalence among MSM, Bangkok, Thailand Age (years) 2003 2005 ≤22 23-28 ≥29 N = 194/1,121; 113/399 Overall Source: Van Griensven, et al, MMWR. 2006 12.9 22.3 17.5 30.5 20.8 29.7 17.3 28.3 0 5 10 15 20 25 30 35 40 HIV Prevalence (%) p-values all < 0.05

28. 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

29. HIV prevalence in adults in Africa Source : UNAIDS, 2006

30. 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)24.024.1Stable Lesotho23.5 (2004)23.723.2Stable South Africa16.2 (2005)18.618.8Increasing 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)(1.0-3.5)(0.9-3.5)Decline in urban areas Adult HIV prevalence in Sub-Saharan Africa, 2003 and 2005. Source: UNAIDS 2006 Report on the Global AIDS Epidemic

31. HIV prevalence by age and gender South Africa 2005 12.1 6.0 3.2 33.3 23.9 9.4 0 5 10 15 20 25 30 35 40 45 15 – 1920 – 2425 – 29 Age group (years) HIV Positive (%) Males Females Source: South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2005

32. 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