2. Acquired Immune Deficiency Syndrome (AIDS) An acquired immunodeficiency caused by infection with human immunodeficiency viruses, HIV-1 or HIV-2, resulting in the loss of CD4+ T-lymphocytes. An acquired immunodeficiency caused by infection with human immunodeficiency viruses, HIV-1 or HIV-2, resulting in the loss of CD4+ T-lymphocytes. The resulting deficiency in both humoral and cellular immune responses allows the development of opportunistic infections and malignancies. The resulting deficiency in both humoral and cellular immune responses allows the development of opportunistic infections and malignancies.

3. Origins of AIDS HIV-1 from chimpanzees HIV-2 from sooty mangabeys Features of SIV/HIV Evolution *Cross species transmission *Fast rate of evolution *Recombination Adapted from CROI 2010

4. How long has HIV been around? By comparing how similar Scientists can estimate: By comparing how similar or, Scientists can estimate: By 1960, there was already evidence of significant diversity of HIV-1 in Kinshasa By 1960, there was already evidence of significant diversity of HIV-1 in Kinshasa Thus HIV likely entered into human population in early 1900’s Thus HIV likely entered into human population in early 1900’s

5. The Global HIV/AIDS Epidemic AIDS  One of the world’s most serious health & development challenges

6. Current AIDS Epidemic More than 34 Million people now live with HIV/AIDS More than 34 Million people now live with HIV/AIDS 3.4 mil are under the age of 15 3.4 mil are under the age of 15 2.5 Mil new cases in 2011 330,000 were under the age of 15 Nearly 30 million people have died of AIDS-related causes since the beginning of the epidemic Nearly 30 million people have died of AIDS-related causes since the beginning of the epidemic

7. Current AIDS Epidemic Over 7,000 new HIV-1 / day ~50% are Women Slide adapted from JP Moore Source: UNAIDS Fact Sheet 2012; Kaiser Family Foundation

8. Current AIDS Epidemic In South Africa 1/4 woman will be infected by age 22 In South Africa 1/4 woman will be infected by age 22 Almost all those living with HIV (97%) reside in low & middle-income countries, particularly in sub-Saharan Africa Almost all those living with HIV (97%) reside in low & middle-income countries, particularly in sub-Saharan Africa

9. HIV/AIDS situation in Middle East and North Africa Approximately 460000 PLWH in MENA and an estimated 75000 people became newly infected in 2009 Approximately 460000 PLWH in MENA and an estimated 75000 people became newly infected in 2009 Almost zero access to drugs Increased risk due to denial and lack of EDUCATION Risk behaviors unchecked Limited VCT Stigma and discrimination Lack of policies Government-Civil Society dialogue NO Reliable data NO Reliable data Source: UNAIDS Fact Sheet 2012; Kaiser Family Foundation

10. HIV / AIDS Chronic Condition, Controllable with Medications

11. HIV Epidemic Stratified Individuals with access to care Metabolic disorders Metabolic disorders Cardiovascular disease Cardiovascular disease Renal Disease Renal Disease Malignancies (non-AIDS) Malignancies (non-AIDS) Individuals without access to care Opportunistic infections and malignancies Opportunistic infections and malignancies

12. Effective therapy requires three drugs used in Anti-retrovirals combination Therapy is lifelong Therapy is lifelong Successful therapy requires 100% adherence Successful therapy requires 100% adherence HIV Treatment

13. Before After Impact of Treatment Courtesy of Paul Farmer

14. Impact of Treatment Courtesy of Paul Farmer After

15. When we look at past 30 years: AIDS is going down globally. It give us hope that we could overcome this bad dream

16. The Cascade of HIV Care and Treatment MMWR / December 2, 2011 / Vol. 60 / No. 47

17. ART 2012 Nucleos(t)ide Reverse Nucleos(t)ide Reverse Transcriptase Inhibitors (NRTIs) Transcriptase Inhibitors (NRTIs)  zidovudine (ZDV, AZT)  didanosine (ddI)  stavudine (d4T)  lamivudine (3TC)  abacavir (ABC)  emtricitabine (FTC)  tenofovir (TDF) Non-Nucleoside Reverse Transcriptase Inhibitors (NRTIs Non-Nucleoside Reverse Transcriptase Inhibitors (NRTIs)  nevirapine (NVP)  delavirdine (DLV)  efavirenz (EFV)  etravirine (ETR)  rilpivirine (RPV) Protease Inhibitors (PIs Protease Inhibitors (PIs)  saquinavir (SQV)  ritonavir (RTV)  indinavir (IDV)  nelfinavir (NFV)  lopinavir/r (LPV/r)  atazanavir (ATV)  fosamprenavir (FPV)  tipranavir (TPV)  darunavir (DRV) Entry Inhibitors (EIs) Entry Inhibitors (EIs)  enfuvirtide (T-20, fusion inhibitor)  maraviroc (MVC, CCR5 antagonist  maraviroc (MVC, CCR5 antagonist) Integrase Inhibitors (IIs)  raltegravir (RAL)

18. Overview of HIV Epidemiology in Iran The first cases were reported in 1981 and today:

19. Overview of HIV epidemiology in Iran Total 24290 PLWH had been identified in Iran until April 2012. 91% Male 9% Female. 91% Male and 9% Female. 3455 persons entered in advanced 3455 persons entered in advanced and AIDS Stage. 46.4% of HIV infected cases are in the 25-34 age

20. Overview of HIV epidemiology in Iran Transmission Root since present: Injection equipment IDUs (69.8%) Injection equipment IDUs (69.8%) Sexual intercourse (10.1%) Sexual intercourse (10.1%) Blood transfusion (1.0%) Blood transfusion (1.0%) Mother-to-child (0.9%) Mother-to-child (0.9%) Unknown case (18.2%). Unknown case (18.2%). No new cases of transmission through blood transfusion were reported during 2009-2010 No new cases of transmission through blood transfusion were reported during 2009-2010

21. Prevalence of HIV in Various Population based on 2010 The prevalence of HIV among IDUs is about 15%. The prevalence of HIV among IDUs is about 15%. In sex partners of IDUs the prevalence of HIV was found to be 3.7% In sex partners of IDUs the prevalence of HIV was found to be 3.7% In Female Sex workers HIV prevalence in 4.5% In Female Sex workers HIV prevalence in 4.5%

22. Prevalence of HIV in Various Population based on 2010 In prisons HIV prevalence is 2% In prisons HIV prevalence is 2% Among MSM was found to be 3.7% Among MSM was found to be 3.7% HIV prevalence in the street children was 4%-5% HIV prevalence in the street children was 4%-5% HIV prevalence in the general population is quite low. HIV prevalence in the general population is quite low.

23. How we began with: First national AIDS committee was held in 1988( 1366 ) First strategic plan First strategic plan 1381-1386 (2002- Scond strategic plan 1386-1388 (2007 Scond strategic plan 1386-1388 (2007 Third strategic plan 1389- 1393(2010 Third strategic plan 1389- 1393(2010

24. The third strategic plan ( 2010- 2014 ) 1. Education and Information 2. Safe blood provision 3. Voluntary, HIV Counseling and testing: 4. Harm Reduction 5. Prevention of sexual transmission of HIV 6. Care and Treatment of STDs 7. Counseling, Care and Treatment for PLWH and Their Families 8. Support and empowerment

25. Services provided for PLWHIV in Iran Services on Prevention - HIV Information and Education. Target populations. Youth education ( family education courses at universities) classes for marriage. classes for marriage. FSWs and IDUs FSWs and IDUs ( based on peer education, DICs, NGOs and Triangular clinics). ( based on peer education, DICs, NGOs and Triangular clinics).

26. Services provided for PLWHIV in Iran Services on Prevention - Voluntary Counseling and Testing. Behavioral disease counseling centers are the main centers for VCTs Behavioral disease counseling centers are the main centers for VCTs. 447 centers are providing VCTs in Iran. Target population : PLWHA, their families, drug users, FSWs and people who have risky behaviors. : From 2010 Up to Sep 2011, 25% of IDUs and 30% of FSWs had done HIV testing HIV Testing Strategy in Iran : From 2010 Up to Sep 2011, 25% of IDUs and 30% of FSWs had done HIV testing

27. Services provided for PLWHIV in Iran Services on Prevention Services provided for PLWHIV in Iran Services on Prevention Mother-to-Child Prevention. Any pregnant woman with any of the risk factors or with a spouse that has any of the risk factors  should refer to VCT clinic for HIV test.

28. Services provided for PLWHIV in Iran Services on Prevention Harm Reduction - Needle exchange programs. Free needles and syringes to IDUs. - Substance Maintenance Treatment. MMT to IDUs 42.6% of our IDUs received MMT. 42.6% of our IDUs received MMT.

29. Services provided for PLWHIV in Iran Services on Prevention - Prevention of Sexual Transmission of HIV. Condoms are provided free of charge in DIC, Primary health care centers, VCTs and Condoms are provided free of charge in DIC, Primary health care centers, VCTs and …

30. Services provided for PLWHIV in Iran Services on Treatment & Care - ARV treatment by behavioral disease counseling centers ( triangular clinics ) under supervision of Medical Universities. - 46 local medical sciences universities in 32 provinces with 103 Active clinics. - 134 centers are delivering care & treatment to patients inside prisons.

31. Services provided for PLWHIV in Iran Services on Treatment & Care - Procurement & Distribution of ARV drugs began by national health and treatment system in 1997

32. Services provided for PLWHIV in Iran Services on Treatment & Care - There are currently 14 types of ARV drugs available in Iran

33. Services provided for PLWHIV in Iran Services on Treatment & Care. - ARV therapy is free of charge. - 96% of ARV therapy delivery centers are equipped with CD4 counting machines. - Initial evaluation

34. Services provided for PLWHIV in Iran Services on Treatment & Care - TB and HIV:. TB screening programs include regular check-ups, annual PPDs, sputum examination and chest X-rays.

35. Services provided for PLWHIV in Iran Services on Treatment & Care - Prevention and Treatment of Opportunistic Infections and Vaccination: - Cotrimoxazole prophylaxis,( 77.3% have received treatment. 2010 and 2011) - Hepatitis B and influenza vaccination was 68% and 43%, - The Pneumococcal vaccination, (not routinely ) 12 %.

36. Services provided for PLWHIV in Iran Support - Treatment Services Insurance to PLWH - Occupational status of PLWH in Iran is still worse than …

37. Best Practices up to September 2011 - Establishment and supports of Iranian National Center for Addiction Studies, a Regional Training Hub for Harm Reduction among IDUs. - Establishment and supports of Iranian Regional Knowledge Hub for HIV/AIDS Surveillance. - Iranian Research Center for HIV/AIDS. - Counseling Hotlines. - Positive Clubs.

38. IRCHA History: History: Iranian Research Center for HIV/AIDS (IRCHA),, Its activities began in 2005 and it received official approval for its operations from MOHME by 2007. Iranian Research Center for HIV/AIDS (IRCHA),, Its activities began in 2005 and it received official approval for its operations from MOHME by 2007. Because of its valuable contributions in HIV/AIDS care and treatment, the WHO has recognized it as a center for HIV/AIDS care and treatment education in the MENA region. Because of its valuable contributions in HIV/AIDS care and treatment, the WHO has recognized it as a center for HIV/AIDS care and treatment education in the MENA region.

39. IRCHA IRCHA had 4 research departments Treatment and care Prevention and epidemiology Mental health and substance misused Laboratory and basic sciences

40. Iranian research Center for HIV/AIDS (IRCHA) 140 project 140 project 250 article 250 article PHD by Research course. PHD by Research course. HIV/AIDS fellowship training HIV/AIDS fellowship training.

41. HOT- PEP line Pep line for post exposure, what to do, how to do, where to go. Hot line 24 hours availability of consultant to answer the questions by phone

42. The HIV/AIDS Bio-Behavioral study of street children In Tehran

43. A clinical trial on the efficacy of IMOD in AIDS patients

44. Adherence rate The average rate of adherence to ART is 60 - 70%. The average rate of adherence to ART is 60 - 70%. The adherence rate of more than 95% is essential for prevention of treatment failure. The adherence rate of more than 95% is essential for prevention of treatment failure..

45. Iranian HIV/AIDS Guidelines  Adult ART & patients evaluation  HIV/AIDs in children  Mother to child transmission  TB & HIV/AIDS  Post-exposure prophylaxis(pep&nopep)  Disease & compliant specific syndrome  Nutrition in HIV/AIDS patients

46. Adherence rate in Iran Hadadi et al study: Hadadi et al study: Eighty-nine exposed people were followed monthly for 4 months. 27 subjects (30.3%) were physicians, 35 (39.3%) nurses and 27 (30.3%) had occupations outside the healthcare system. Eighty-nine exposed people were followed monthly for 4 months. 27 subjects (30.3%) were physicians, 35 (39.3%) nurses and 27 (30.3%) had occupations outside the healthcare system. Self-report: 59.6% Self-report: 59.6%

47. ART Coverage in Iran In January 2010, as a whole, only 9% of the total people who needed ART received it. (UNGASS* report 2010)Female 2 times more than male In January 2010, as a whole, only 9% of the total people who needed ART received it. (UNGASS* report 2010)Female 2 times more than male *United Nations General Assembly Special Session

48. Main issues for more implementation on HIV services - There is a wide gap between the number of identifies and number of estimated cases due to limitations of diagnostic services. - Treatment interruptions are frequent (can be due to patient non-compliance, simultaneous drug addiction or intermittent incarcerations.)

49. Main issues for more implementation on HIV services Social stigma. Social stigma. Insufficient co-management of HIV & hepatitis C Insufficient co-management of HIV & hepatitis C Insufficient dental services for PLWHIV. Insufficient dental services for PLWHIV. Quality of existing services needs improvement. Quality of existing services needs improvement. Shortage of financial and human resources. Shortage of financial and human resources.

50. Main issues for more implementation on HIV services - Rural population - HIV prevention services. Dug use related programs. Dug use related programs. - Private sectors - Disjunction of Harm reduction programs and VCT programs. Media Media

51. Main issues for more implementation on HIV services - Inadequacy of treatment services for psychoactive and meth amphetamine drugs across country. - Improvement of the socio-economic support such as universal insurance coverage, employment and psycho-social support committees for PLWH.

52. Main issues for more implementation on HIV services Existing of the laws which can affect and limits working with high risk groups such as Female sex workers and MSM. Existing of the laws which can affect and limits working with high risk groups such as Female sex workers and MSM. Working on HIV & street children Working on HIV & street children Supporting NGOs and expansion of these organizations. Supporting NGOs and expansion of these organizations.

53. Global Strategies against HIV Global Strategies against HIV ` zero new HIV infections zero new HIV infections zero AIDS related deaths zero AIDS related deaths zero discrimination zero discrimination

54. Thank You

55. The main achievements from 2009 to 2011 1- Reduction of HIV epidemic amongst IDUs and prisoners. 2- Establishment of Monitoring and Evaluation Committees. 3- Reduction of Stigma on high risk behaviors. 4- Improvement of ART provision and distribution system. 5- Continuation of appropriate service coverage such as insurance.

56. Services provided for PLWHA in Iran Services on Prevention  Needle exchange programs  Substance Maintenance Treatment  Prevention of Sexual Transmission of HIV  Male condoms are provided free of charge in DIC, Primary health care centers, VCTs.

57. Services provided for PLWHA in Iran Services on Prevention  HIV Information and Education  Activities for youth education include family education courses at universities or marriage.  Educational Activities for FSWs and IDUs are based on peer education, DICs, NGOs and Triangular clinics.  Voluntary Counseling and Testing  Mother-to-Child Prevention

58. Services provided for PLWHA in Iran Services on Treatment & Care  Included ARV treatment by VCT centers  46 local medical sciences universities in 32 provinces with 103 Active clinics.  134 centers are delivering care & treatment to patients inside prisons.  Procurement & Distribution of ARV drugs began within the framework of the national health and treatment system in 1997.

59. Preferred Regimens: Zidovudine + Lamivudine + Efavirenz Zidovudine + Lamivudine + Efavirenz OR OR Zidovudine + Lamivudine + Nevirapine Zidovudine + Lamivudine + NevirapineAlternative: Efavirenz + lamivudine +( didanosine or abacavir) Efavirenz + lamivudine +( didanosine or abacavir) Or Or Nevirapine+ lamivudine +( didanosine or abacavir) Nevirapine+ lamivudine +( didanosine or abacavir)

60. Services provided for PLWHA in Iran Services on Treatment & Care  Treatment had started by Indinavir, Nelfinavir and NNRTIs respectively.  Currently 14 types of ARV drugs are available in Iran, focusing on three-drug combination regimens.  ARV drug prescriptions are free across the country.  96% of ARV therapy delivery centers are equipped with CD4 counting machines.

61. Services provided for PLWHIV in Iran Services on Treatment & Care  22% of the centers CD4 counting can be performed at the same city which the clinic is located.  The number of persons covered by therapy has increased up to 93%.  Level of coverage should be improved significantly by improvement of VCT services.  Recipients of ARV therapy are 8.5% female and 91.5% male.

62. Services provided for PLWHIV in Iran Services on Treatment & Care  TB and HIV: TB and HIV has been heeded since the first set of guidelines for HIV care and treatment.  TB screening programs include regular check-ups, annual PPDs, sputum examination and CXR.  27.9% of the total HIV & TB co infection were treated (Sep 2010 - Sep 2011).  We estimates too much under reporting in HIV TB co infection, it seems that TB programs for PLWHA are in serious need of improvement.

63. Services provided for PLWHA in Iran Services on Treatment & Care  During September 2010 and 2011, of the 1421 patients indicated for TMP-SXM prophylaxis, 77.3% have received treatment.  In evaluation of services at triangular clinics, coverage of hepatitis B and influenza vaccination was 68% and 43%, respectively.  The Pneumococcal vaccination, which is not routinely provided by the national health system, was only 12 %.

64. Services provided for PLWHA in Iran Support  Insurance to PLWHA has been required of relevant authorities.  Positive clubs have been established to provide support for PLWHA.  PLWHA can receive all the services of welfare organization without any deny from support service centers  PLWHA can receive all the services of welfare organization without any deny from support service centers.

65. از كجا آغاز كرديم : اولين كميته كشوري ايدز در سال 1366 بدنبال گزارش اولين مورد تشكيل شد. بسياري از اعضا اين كميته كماكان به فعاليت خود ادامه ميدهند.

66. اقدامات در فاصله سالهاي 1381- 1366 برقراري اولين نظام ثبت و مراقبت اين بيماري، راه اندازي شبكه تهيه و ارائه خون سالم در سراسر كشور، راه اندازي نظام آزمايشگاهي تشخيص عفونت در سراسر كشور، ايجاد برنامه هاي آموزش و اطلاع رساني و تلاش براي گسترش آن، تامين امكانات درمان براي مبتلايان، مطالعات مختلف براي شناخت وضعيت همه گيري، شروع برنامه هاي كاهش آسيب

67. برخی از دستاوردهای برنامه های کشوری کنترل ایدز ایجاد ساختار مراکز مشاوره بيماريهاي رفتاري يا كلينيك هاي مثلثي ( كه در جهان به همين نام مشهور است ) جهت ارائه بسته کاملی از خدمات پیشگیری و درمان به افراد در معرض خطر زیاد و نیازمند؛ تجربه موفق در زمینه کاهش آسیب؛ راه اندازي و گسترش مراكز ارائه دهنده خدمات كاهش آسيب ( درمان با متادون، ارائه سرنگ و سوزن و...) در بخش هاي دولتي و غير دولتي،

68. ارائه رایگان خدمات درمانی برای اولین بار در منطقه و بر طبق آخرين منابع علمي توصيه شده در سطح جهان، و تشكيل شبكه مراقبت و درمان در سطح كشور معرفي برنامه پیشگیری از HIV/AIDS در زندانها بعنوان يك مدل موفق در سطح جهان، برنامه حمایت از مبتلایان و خانواده آنها بشکل پوشش بیمه؛ راه اندازی برنامه های پیشگیری مثبت برای متاثرین از HIV/AIDS در 9 استان با اهداف توانمند سازی و حمایت اجتماعی

69. راه اندازي مراکز تحقيقاتي در زمينه hiv/aids ، تا کنون سه مرکز از دانشگاههای علوم پزشکی ایران بعنوان همکار سازمان جهانی بهداشت برای آموزش کشورهای منطقه مدیترانه شرقی و شمال افریقا برگزیده شده اند : مرکز ملی مطالعات اعتیاد دانشگاه تهران؛ مرکز آموزش نظام مراقبت نسل دوم HIV/AIDS دانشگاه کرمان؛ مرکز تحقیقات ایدز ایران؛ ( در مرحله تائید )

70. برخی از مشخصات برنامه سوم تلاش در جهت به صفر رساندن موارد جدید انتقال از طریق مصرف مواد و مادر به کودک توجه بیشتر به انتقال از طریق جنسی و بیماریهای آمیزشی گسترش خدمات موجود شامل برنامه های کاهش آسیب، مراقبت و درمان، مشاوره و آزمایش توجه ویژه به زنان در معرض خطر

71. انتظارات :

72. همه با هم برای فردایی بدون مورد جدید HIV/AIDS

73. وضعیت ایران کشور در مرحله همه گیری متمرکز قرار دارد. شیوع HIV در بین مصرف کنندگان تزریقی 15% محاسبه شده است. گسترش برنامه های کاهش آسیب روند رشد در این گروه را کنترل کرده است. در بین زنان در معرض بیشترین خطر این میزان 4.5% محاسبه شده است. شیوع در بین زنان باردار نزدیک به صفر بوده، شواهدی از همه گیری منتشر وجود ندارد.

74. استراتژی های سومین برنامه کنترل ایدز کشور  آموزش و اطلاع رسانی  تامین سلامت خون  مشاوره و آزمایش داوطلبانه  کاهش آسیب  پيشگيري از انتقال جنسي  مراقبت و درمان بیماریهای آمیزشی  مشاوره، مراقبت و درمان مبتلایان به HIV و خانواده آنها  حمایت و توانمندسازي  بر قراری نظام مراقبت اپیدمیولوژیک و مدیریت داده ها  تقویت زیر ساخت های لازم

75. مفاد اعلانیه تعهد سیاسی 2011 کاهش انتقال جنسی کاهش انتقال در بین مصرف کنندگان مواد حذف موارد ابتلا از طریق مادر به نوزاد ایجاد دسترسی به درمان برای 15 میلیون نفر جلوگیری از مرگ ناشی از سل در بین مبتلایان به HIV پایان دادن به کمبود منابع اطمینان از دسترسی برابر هر دو جنس به خدمات حذف انگ اجتماعی و تبعیض نسبت به بیماران حذف ایجاد محدودیت سفر برای مبتلایان تقویت برنامه ها از طریق ادغام خدمات

76. تعداد افرادیکه که با ویروس HIV زندگی میکنند به بیشترین میزان خود رسیده. برآورد می شود در پایان سال 2010 ، 34 میلیون نفر در سراسر جهان با این ویروس زندگی میکنند. این رقم 17% نسبت به سال 2001 افزایش دارد. این افزایش به دو علت ایجاد شده : تعداد زیاد موارد جدید مبتلا افزیش طول عمر مبتلایان در اثر دسترسی بهتر به خدمات درمانی

77. موارد جدید ابتلا در کل جهان بین سالهای 1997 تا 2010 ، 21% کاهش داشته. این میزان برای همه کشورها یکسان نیست ؛ در اروپای شرقی و آسیای مرکزی تعداد افرادیکه با HIV زندگی میکنند نسبت به سال 2001 ، 250% افزایش داشته. برخی از این کشورها همسایگان شمالی ایران هستند. در 22 کشور افریقای جنوب صحرا ، بروز موارد جدید در فاصله سالهای 2001 تا 2009 ، 25% کاهش داشته. عمده این موفقیت مربوط به سرمایه گذاریهای جهانی است و در صورت قطع این کمکها این موفقیت از بین خواهد رفت. موارد مرگ ناشی از HIV از 2.2 میلیون در اواسط سال 2000 به 1.8 در سال 2010 کاهش پیدا کرده است.