HIV: Beginning of the end?

- Opportunities, challenges
and lessons learnt in Asia
Pacific

Dr Shailendra Sawleshwarkar
Senior Lecturer and Clinical Academic
Western Sydney Sexual Health Centre
Program Director
Postgraduate Program in Sexual and Reproductive Health
Sydney Medical School, University of Sydney

The University of Sydney Page 1

 A complex epidemic

Huge complexity of:

– Countries,
– Transmission,
– Disease progression,
– Treatments
– Prevention interventions,
– Attitudes,
– Economic and social impacts.

The University of Sydney Page 2

 HIV/AIDS: History and Global Summary

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The University of Sydney Page 3

 History of HIV

1981 MMWR June 5 1981

–On June 5, the U.S. Centers for Disease Control and
Prevention (CDC) published a Morbidity and Mortality
Weekly Report (MMWR), describing cases of a rare lung
infection, Pneumocystis carinii pneumonia (PCP), in five
young, previously healthy, gay men in Los Angeles, USA.

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 History of HIV

– 1984 Retrovirus is discovered as cause of AIDS and later named

human immunodeficiency virus or HIV.
– 1987 The US FDA approves AZT as the first antiretroviral to be
used as a treatment for Aids.
– 1994 ACTG 076 study shows mother to child transmission is
preventable by using AZT
– 1996  Vancouver conference: HIV/AIDS researcher Dr David Ho
advocated "hit early, hit hard" in which patients were placed on
new more aggressive treatment regimes earlier.
– 2002 First rapid HIV diagnostic test kit introduced, providing results
within 20-40 minutes.
– 2007 Claims that Timothy Brown, 46, known as "the Berlin
Patient", is "cured" of HIV after receiving blood stem cell
transplant, during treatment for leukaemia, from donor with a
genetic mutation called delta 32 that made him immune to HIV.
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Global summary of the AIDS epidemic  2018

Number of people Total 37.9 million [32.7 million–44.0 million]

living with HIV Adults 36.2 million [31.3 million–42.0 million]
Women (15+ years) 18.8 million [16.4 million–21.7 million]
Children (<15 years) 1.7 million [1.3 million–2.2 million]

People newly infected Total 1.7 million [1.4 million–2.3 million]

with HIV in 2018 Adults 1.6 million [1.2 million–2.1 million]
Children (<15 years) 160 000 [110 000–260 000]

AIDS-related deaths Total 770 000 [570 000–1.1 million]

in 2018 Adults 670 000 [500 000–920 000]
Children (<15 years) 100 000 [64 000–160 000]
Adults and children estimated to be living with HIV  2018

Eastern
Eastern Europe
Europe
and
and central
central Asia
Asia
North
North America
America and
and western
western and
and central
central Europe
Europe 1.7
1.7 million
million
2.2
2.2 million
million [1.5
[1.5 million–1.9
million–1.9 million]
million]
[1.9
[1.9 million–2.4
million–2.4 million]
million]

Caribbean Middle
Middle East
East and
and North
North Africa
Africa
Caribbean
340
340 000
000 240
240 000
000
[290 [160
[160 000–390
000–390 000]
000]
[290 000–390
000–390 000]
000]
Western
Western and
and central
central Africa
Africa
5.0
5.0 million
million Asia
[4.0
[4.0 million–6.3
million–6.3 million]
million] Asia and
and the
the Pacific
Pacific
5.9
5.9 million
million
Latin
Latin America
America [5.1
[5.1 million–7.1
million–7.1 million]
million]
1.9 Eastern
Eastern and
and southern
southern Africa
Africa
1.9 million
million
[1.6
[1.6 million–2.4
million–2.4 million]
million] 20.6
20.6 million
million
[18.2
[18.2 million–23.2
million–23.2 million]
million]

Total: 37.9 million [32.7 million–44.0 million]

Estimated number of adults and children newly infected with HIV  2018

Eastern
Eastern Europe
Europe
and
and central
central Asia
Asia
North
North America
America and
and western
western and
and central
central Europe
Europe 150
150 000
000
68
68 000
000 [140
[140 000–160
000–160 000]
000]
[58
[58 000–77
000–77 000]
000]

Caribbean Middle
Middle East
East and
and North
North Africa
Africa
Caribbean
16
16 000
000 20
20 000
000
[11 [8500–40
[8500–40 000]
000]
[11 000–24
000–24 000]
000]
Western
Western and
and central
central Africa
Africa
280
280 000
000 Asia
[180
[180 000–420
000–420 000]
000] Asia and
and the
the Pacific
Pacific
310
310 000
000
Latin
Latin America
America [270
[270 000–380
000–380 000]
000]
100 Eastern
Eastern and
and southern
southern Africa
Africa
100 000
000
[79
[79 000–130
000–130 000]
000] 800
800 000
000
[620
[620 000–1.0
000–1.0 million]
million]

Total: 1.7 million [1.4 million–2.3 million]

 UNAIDS Goals 2014

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The University of
Sydney Page 10
 UNAIDS 2030 targets

In 2018
– 37.9 million people globally were living with HIV.
New infections are
– 23.3 million people were accessing antiretroviral therapy.
going down but not
– 1.7 million people became newly infected with HIV.
fast enough
– 770 000 people died from AIDS-related illness

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 Progress on UNAIDS 2030 targets:

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 2013 A global tipping point?

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Source: One: At the tipping point, Tracking global commitments on AIDS Volume 3. 1
HIV/AIDS in Asia
Pacific

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 HIV in Asia
Pacific

More than 75% of

new HIV infections
are among key
populations and
their partners

The University of Page 16

Sydney
 HIV and AIDS Data Hub for Asia-Pacific
Fast-Track Treatment to Reach 90–90–90 by 2020
P e o p le re c e iv in g A R T

People receiving ART in Asia and the Pacific

Fast-Track Target
2020:
4.2 million
5,100,000 people on ART
At current pace:

2017 estimate:
3.4 million
people on ART
2.7 million
by 2020

14% annual
increase
between 2013 and 2017

0
0

People receiving ART

Trend to Fast-Track target People receiving ART by 2020 (at current pace)
Source: Prepared by www.aidsdatahub.org based on UNAIDS 2018 HIV Estimates; Global AIDS Monitoring (GAM) 2018
 HIV and AIDS Data Hub for Asia-Pacific
Regional overview: 90-90-90 target and gaps
HIV testing and treatment cascade, Asia and the Pacific, 2017
Gap Progress (%) Target
100
%
90
80 0.8 million 81
73
74 % 1.5 million
60 1.4 million
53%
40 45%

20
3.8 2.7 2.3
million million million
0
PLHIV who know their PLHIV on PLHIV who are
status treatment virally suppressed

ACHIEVED ACHIEVED ACHIEVED

Singapore; Thailand Cambodia Cambodia

NOT ON-TRACK (<50%) NOT ON-TRACK (<30%) NOT ON-TRACK (<30%)

Prepared by
www.aidsdatahub.org
based on UNAIDS special
analysis 2018; UNAIDS
2018 estimates and
Global AIDS Monitoring
2018
Bangladesh; Indonesia;
Mongolia; Pakistan
DATA NOT AVAILABLE
Afghanistan; Australia; China;
Japan; Myanmar; New Zealand;
PNG; Viet Nam
Bangladesh; Indonesia;
Mongolia; Pakistan
DATA NOT AVAILABLE
Afghanistan; China; Japan; New
Zealand; PNG
Pakistan
DATA NOT AVAILABLE
Afghanistan; Australia; Bangladesh;
China; Indonesia; Japan; Mongolia;
Myanmar; New Zealand; PNG; Philippines
 HIV in Asia

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Asia and Towards 90-90-90 Fast-Track
the Pacific treatment targets
Treatment cascade, 2017

N u m b er o f p eo p le
5.2 M
74%

71%

5.2 M
3.8 M 85%
2.7 M
0
PLHIV Tested
0.41 M 0.39 M
Estimated People on Suppressed
know their for viral
PLHIV ART viral load
status load*

Countries with CD4 threshold policy for treatment initiation

2016 2018
15 30 treat all regardless of CD4
* China and India do not
CD4 ≤ 500 but treat all key report viral load testing
6 0 populations regardless of CD4 data in 2018 GAM
reporting. Estimated 55%
9 2 CD4 ≤ 500 of PLHIV who are on
treatment in 13 reported
CD4 ≤ 350 but treat all key
2 0 populations regardless of CD4
countries had tested for
viral load in the past 12
countries have national policy on routine viral load months.
25 monitoring for antiretroviral therapy

Prepared by www.aidsdatahub.org based on Global AIDS Monitoring 2018 Reporting and UNAIDS 2018 HIV Estimates
 HIV/STIs and ethnic minorities

– Studies from the Australia, UK, USA and Canada suggest

disparities in sexual health outcomes in ethnic minorities
which persist even when controlling for sexual
behaviour.
– Enhanced HIV testing, HIV pre-exposure prophylaxis
and treatment as prevention have been very effective in
interrupting HIV transmission but people from ethnic Melbourne Incident HIV infections in
minorities backgrounds especially men who have sex MSM: HIV infection fell significantly in
with men (MSM) continue to face difficulties in other MSM but not in newly-arrived
Asian-born MSM.
accessing these interventions.
– Understanding service delivery issues for these
populations is critical to the development and
implementation of effective public health policy and
health services. • Assortative sexual mixing patterns,
• Higher prevalence of unsuppressed HIV
• Limited access to biomedical
interventions

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 HIV/AIDS Treatment and
Prevention: What works?

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The University of Sydney
Source: www.avac.org Page 23
 Spectrum of STIs/HIV prevention (good and bad)

New or
Inspect partner
cleaned
Male injecting Strategic positioning
circumcision equipment Condom Serosorting

Biomedical Behavioural

Celibacy
Vaccination STI screen Notify Monogamy
partner(s) Masturbation
Avoid intoxication
Chemoprophylaxis: Chemoprophylaxis: Avoid temptation
Systemic Topical Exercise +++
PEP No penetration
PrEP Withdrawal

Donovan B. Sex Transm Infect 2000

Screen
The University blood
of Sydney and organs Page 24
 FIVE PREVENTION PILLARS

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Key populations

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 More than 75% of new HIV infections are
The University of Sydney
among key populations and their partnersPage 27
 Number of HIV infections averted
through condom use, global, 1990–2015

Source: John Stover, Avenir Health, 2016. The Contribution of Condoms to HIV Prevention. Data for Fast-Tracking Condom Programmes. Presented at of the Global Condom Steering Group
21-23 March 2016, Geneva.
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 Voluntary Medical Male Circumcision

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The University of Sydney Page 30
HIV Prevention using antiretrovirals:
towards an integrated approach

• Post-exposure prophylaxis (PEP)

• Pre-exposure prophylaxis (PrEP)
• Treatment as prevention (TasP)
• Prevention of mother-to-child transmission
(PMTCT) – (separate session on this topic)

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Post exposure prophylaxis (PEP/nPEP)

– A course of ART: 2-3 drugs

– Started within 72 hours

– Taken for 28 days.

– Extensive animal evidence of efficacy

– Used in occupational and non-occupational (sexual

exposure) settings

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Pre-exposure prophylaxis (PrEP)

– PrEP – pre-exposure prophylaxis (preventive treatment before

exposure to HIV)
– Two drug regimen for preventing sexual transmission –
tenofovir plus emtricitabine
– Effective, well tolerated, low rates of side effects
– Also the same drugs used in post-exposure prophylaxis (PEP or
NPEP)
– In clinical trials conducted in Africa, Asia, Europe and North
America over the past decade, PrEP has been shown to
significantly reduce the risk of HIV acquisition among
– Men who have sex with men (MSM)
– heterosexual men and women, and
– People who inject drugs (PWID)

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The University of Sydney Page 34
The University of Sydney Page 35
ART to prevent HIV transmission
: Treatment as prevention (TasP)
– HPTN 052: RCT to evaluate the effectiveness of ART versus
HIV primary care alone to prevent the sexual transmission of
HIV-1 in serodiscordant couples.
– Two study arms: (1) ART at enrollment, or (2) no ART until
CD4 < 200, or AIDS.
– Early vs delayed ART 2003-11
• 96% reduction in linked HIV-1 transmission
• 41% reduction in HIV-related disease
– 10 year follow-up
• 93% risk reduction in linked HIV transmissions
• 8 linked infections after infected partner started ART
– 4 before or soon after start, 4 after failure of ART
• No infections occurred while partner stable VL undetectable

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Cohen MS et al. NEJM 2011

 The impact of combination prevention on the
annual number of new HIV infections

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Cremin I et al. AIDS 2013; 27: 447
 HIV/AIDS Treatment and
Prevention: Challenges

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 Challenges

– Late diagnosis
– HIV drug resistance
– HIV-TB co-infection
– Stigma and discrimination
– Physical and sexual violence
– Economics of HIV/AIDS
– Politics of HIV/AIDS and Global health

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 HIV and AIDS Data Hub for Asia-Pacific

Late diagnosis: up to 50% of PLHIV have the initial CD4 count

of <200 cells/mm³ in 2017
Proportion of PLHIV who have had initial CD4 count in 2017 by CD4 level
Thailand 54% 19% 27%
Indonesia 50% 28% 22%
Philippines 50% 22% 28%
Papua New Guinea 49% 29% 22%
Viet Nam 46% 11% 43%
Mongolia 41% 27% 32%
Myanmar 40% 14% 46%
CD4<200
India 40% 25% 35%
Singapore 39% 22% 38%
Malaysia 36% 19% 45% CD4 200-350
Cambodia 33% 16% 51%
China 31% 31% 39%
CD4>350
Afghanistan 31% 24% 46%
Sri Lanka 23% 21% 55%
Lao PDR 23% 28% 50%
Nepal 22% 14% 64%
New Zealand 20% 14% 65%

0% 20% 40% 60% 80% 100%

40
Prepared by www.aidsdatahub.org based on Global AIDS Monitoring Reporting 2018
 HIV Drug resistance in the region

 Extensive drug resistance emerges in a high proportion of

patients after virological failure on a tenofovir-containing first-
line regimen across low-income and middle-income regions.

TenoRes Study Group. Global epidemiology of drug resistance after failure of WHO recommended first-line regimens for adult HIV-1 41
infection: a multicentre retrospective cohort study [published correction appears in Lancet Infect Dis. 2016 Jun;16(6):636]. Lancet Infect
Dis. 2016;16(5):565–575. doi:10.1016/S1473-3099(15)00536-8
 HIV and AIDS Data Hub for Asia-Pacific
TB snapshot 2017
Asia and the Pacific is the home for…
6.8 M
More than

2/3 of estimated new TB cases globally

199 K
More than

1/5 of estimated TB-HIV co-infections globally

830 K
More than

1/2 of estimated TB mortality globally

(both HIV-negative and HIV-positive)
42
Source: Prepared by www.aidsdatahub.org based on WHO. (2018). Global TB Report 2018
 HIV and AIDS Data Hub for Asia-Pacific

About 74% of people with TB-HIV co-infection did not have access
to antiretroviral therapy in Asia and the Pacific, 2017

Access to antiretroviral therapy among PLHIV vs. people with TB-HIV co-infection, 2017

100

75
% ART coverage

50 Treatment gap

25 53
26
0
All PLHIV HIV-positive TB patients

Denominator: Denominator:
Estimated total PLHIV Estimated new TB cases
who are HIV- positive
43
Source: Prepared by www.aidsdatahub.org based on WHO. (2018). Global TB Report 2018
 HIV and AIDS Data Hub for Asia-Pacific
8 countries account for 94% of all TB-related deaths among
PLHIV in Asia and the Pacific, 2017

44
Source: Prepared by www.aidsdatahub.org based on WHO. (2018). Global TB Report 2018
 Stigma has declined…

Percentage of people who would not buy vegetables from a shopkeeper living with HIV, 2000–2008 compared to 2009–2016

100

90

80

70

60
Per cent

50

40

30

20

10

0
Global Eastern and Western and Caribbean Asia and Eastern Europe and
southern Africa central Africa the Pacific central Asia*

2000–2008 2009–2016

* Data for females respondents only.

Data coverage of regional aggregates: global: 45 countries, 28% 2017 population coverage; Asia and the Pacific: 7 countries, 29% 2017 population coverage; Eastern and southern Africa: 12
countries, 71% 2017 population coverage; Western and central Africa: 16 countries, 91% 2017 population coverage; Caribbean: 6 countries, 88% 2017 population coverage; Eastern Europe and
central Asia: 9 countries, 32% 2017 population coverage. Aggregates for Latin America, the Middle East and North Africa and western and central Europe and North America are not shown as data
were only available from 2 countries in the region or less.
Source: Population-based surveys, 2000–2016.
 Intimate partner violence: a global issue

Percentage of ever-married or partnered women aged 15–49 years who experienced physical and/or sexual violence
by an intimate partner in the past 12 months, 2012–201

Western and
central Europe
6.5%

Caribbean
Western and Asia and
12.4% central Africa the Pacific
19.4% 21.2%

Eastern and
Global southern Africa
18.0% 21.0%

0–12% 13–24% 25–37% 38–50%

Note: Data for all countries in western and central Europe except Turkey are for women aged 18–49 years. Data coverage of regional aggregates: Global: 74 countries, 49% of 2017 population; Asia and the Pacific: 11 countries, 47% of 2017
population; Eastern and southern Africa: 14 countries, 89% of 2017 population; Western and central Africa: 8 countries, 68% of 2017 population; Caribbean: 4 countries, 90% of 2017 population; Western and central Europe: 29 countries,
60% of 2017 population. Aggregates for eastern Europe and central Asia, Latin America, North America and the Middle East and North Africa are not shown as data available reflected less than 40% of the regional population in 2017.

Source: Population-based surveys, 2012–2017. United Nations Statistics Division, SDG Indicators Global Database. Accessed 29 June 2018 (https://unstats.un.org/sdgs/indicators/database/).
HIV/AIDS : Financing

– In Asia and the Pacific, the US$ 3.5 billion available in 2018 fell
short of the estimated US$ 5 billion needed to reach the 2020
Fast-Track targets.
– Bridging that gap implies an increase of about 40% in HIV
resources by 2020.
– In the region, the domestic share of HIV funding grew from 53%
in 2010 to 81% in 2018, meanwhile international contributions
diminished by 48% over the same period.

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 HIV and AIDS Data Hub for Asia-Pacific

Newer, more effective, less toxic medicines often unaffordable for

the poor and developing countries

2000
$1859
US$ per person per year

1500
X17.4 X6.5
1000

500 X2.7
$106 $286
0
First-line regimen
First-line regimen Second-line
Second-line regimen
regimen Third-line
Third-line regimen
regimen
Lowest generic price Lowest generic price
(TDF/3TC/EFV) (AZT/3TC+ATV/r) (RAL+DRV+r+ETV)

Prepared by www.aidsdatahub.org based on Medecins Sans Frontieres (MSF) (2016). Untangling the Web of Antiretroviral Price Reductions -18th Edition
HIV/AIDS treatment and prevention
today

– HIV is now a chronic disease requiring treatment for

many decades, which has created a series of new
challenges
– Increased emphasis on country owned and sustainable
programs
– Dynamic nature of HIV prevention and management
– Global relevance with local adaptation

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 HIV/AIDS and Global Health

– AIDS Invented Global Health1 :

– development of linkages between researchers,
clinicians, public health officials and the affected
community
– No individual country can adequately address
diseases in the face of movement of people, trade
microbes and risks

– 1: Brandt AM. How AIDS invented global health. NEJM

– 368;23:2149 -2152

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 We have been to zero before!

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5
 ACON Ending HIV Campaign in NSW

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5