1. Spectrum 2007 Overview and New Changes UNAIDS Reference Group on Estimates, Model and Projections 2007

2. Purpose Determine the consequences of the prevalence estimates made with EPP or Workbook –New infections, HIV+ population, AIDS deaths –Need for treatment and effects of treatment –Orphans and vulnerable children

3. New Features 1.New treatment options Adults: 1 st and 2 nd line ART Children: ART and cotrimoxazole 2.Updated progression periods New infection to need for treatment Need for treatment to AIDS death w/wo treatment 3.Expanded PMTCT options 4.Calibrate to multiple national surveys 5.Uncertainty analysis

4. Inputs required Country data Demographic data Adult prevalence ------------------------- MTCT program description PMTCT coverage Adult ART coverage Child treatment coverage Epidemic patterns Effect of HIV on fertility Progression from infection to need for treatment and to AIDS death Sex ratio of prevalence Age distribution of infection Mother-to-child transmission rates by regimen and feeding options Effect of child treatment

5. Creating a new projection

6. Population Projection

8. The first year of the projection must be before the start of the AIDS epidemic, usually 1980

9. Population Projection The last year of the projection can be anything up to 50 years, but it is best to match the prevalence estimate (2012 for EPP, 2007 for the Workbook)

10. Population Projection

12. Creates a projection using the UN Population Division’s World Population Prospects

13. Entering data

14. Selecting inputs to edit

15. Adult HIV Prevalence

17. Documenting sources

18. Effect of HIV on fertility

19. 15-19: 50% increase 20-49: 30% decrease TFR of HIV- adjusted to leave population TFR unchanged

20. Age and Sex Ratio of HIV Prevalence

21. Ratio of prevalence at each to prevalence at 25-29 : Females

22. Ratio of prevalence at each to prevalence at 25-29 : Males

23. Age and Sex Ratio of HIV Prevalence

24. Sex ratio of HIV prevalence

27. Progression from HIV Infection to AIDS Death (Adults) New HIV Infection Need for Treatment First Line ART AIDS Death Second Line ART Need for 2 nd Line

28. Net survival adjusted to age 25-29 0 1 Source: Zaba and Todd, Alpha network

29. Time from AIDS or CD4<200 to death in the absence of HAART Time measured from Published studies from resource-poor settings (median, range) Estimates from the Swiss HIV cohort study (median, 95% CI) AIDS CD4 count <200 (median 100) 150< CD4< 250 (median 200) 11 (7 – 19) 11 (7 – 38) 35 (estimated) 17.6 (15.9 – 19) 24.0 (22.0 – 29.0) 77.0 (52.0 – 92.0) Source: Zwahlen and Egger

30. Time from CD4 < 350 to death, and from CD4 < 350 combined with WHO stage III or IV to death in resource limited settings Time measured from Natural history of untreated patients Bayesian synthesis analysis 200 < CD4 < 350 WHO stage III or IV and CD4 < 350 4 – 5 years5.4 (1.9 – 15.7 years) 2.7 (0.76 – 9.6 years) Source: Zwahlen and Egger

31. Incidence (%) of Death After Starting ART Source: Dabis et al, ISPED

32. Progression from HIV Infection to AIDS Death (Adults) New HIV Infection Need for Treatment First Line ART AIDS Death Second Line ART Normal M 7.5yrs/F 8.5yrs, fast 6.1/6.9 3 years 15%/5% Need for 2 nd Line 15% FY / 5% SY 3 years

33. Progression from HIV Infection to AIDS Death (Children) New HIV Infection Need for Treatment First Line ARTAIDS Death Age-dependent >5 = 3 years <1, 0.80 >1, 0.9 first year, else 0.95 Marston and Newell, median = 2 years

36. Adult Male Progression without Treatment

37. Adult Male Progression with Treatment

38. The Need for ART will change from 2005 estimate!

42. Projections of Adult ART Coverage

46. Orphans % women 15-19 never married: 38%-94% (71%) % married women in monogamous union: 45%-96% (71%)

47. Spectrum outputs

48. Various displays are available

49. Comparing effects Display up to four projections at one time Open same projection twice and rename to create comparison scenarios

50. Estimates of Need Adult ARTAdults progressed to need for treatment Simulates WHO guidelines Child ARTChildren progressed to moderate-to- severe disease CotrimoxazoleEarly detection –All HIV+ children No early detection –Children born to HIV+ mothers until 18 months –All HIV+ children over 18 months PMTCTAll births to HIV+ women

51. Plausibility Bounds

52. Uncertainty around prevalence curve –EPP: read sampled curve from EPP.spu file –Workbook: generate 1000 logistic curve fits by varying annual estimates according to data quality

58. Summary Table – Plausibility Bounds

59. If you use the Workbook you need to generate prevalence curves

68. Logistic Curve Fits to Annual Estimates with 95% Plausibility Bounds

69. After generating prevalence curves from Workbook estimates, process the uncertainty analysis

70. Exercise Create a new demographic projection using EasyProj Read prevalence estimate from EPP or Projections Workbook Select appropriate patterns for Progression and Age/Sex Ratios Add data on coverage of PMTCT, ART and child treatment programs Review key indicators Do uncertainty analysis