The World of HIV/AIDS

Photos (good ones) by Malcolm

 Overview*
 History and Epidemiology
 Existing prevention
strategies
 Existing treatment
strategies
 Future treatment and
prevention strategies

* Heavily spiced with politics,

economics, ethics, odd ideas
and opinions
End of 2005,
UNAIDS

Total: 38.6M
Sub-Saharan Africa: 24.5
M
Asia: 8.3M
LatAm and Carib: 1.9M

90% of infections in SSA, Asia, and LatAm and Carib

*First report
in MMWR on
June 5, 1981

* 11 MMWR
Reports by
September
1982
 The “Race” is On: April 23,
1984

PREDICTIONS
 Blood test, widely available 6 months YES
 “We hope to have such a vaccine ready for testing in approximately
two years,” HHS Secretary Margaret Heckler YES, BUT NO
 “What we have at the moment is not particularly of great benefit to
people who have the disease…but it hopefully will be in a short
while,” Asst. Sec. of Health, Edward Brandt NO
 The #1 Problem

9
subtypes

If HIV were TB, a cure would exist

If HIV were HBV or polio, a vaccine would exist today
 Get Inside the Enemy’s
HIV’s Profile
Head
Objectives: Copy and Spread

Body Type: Retrovirus, RNA

Attributes: No brains, morals or

political agenda

Desired residence: Anywhere

Turn Ons: Anal Sex, Vaginal Sex,

Injecting Drugs, Pregnancy

Turn Offs: Condoms, ARVs, Clean

needles, Immune System
 We Aren’t the World

 Countries, companies, research

institutions have different agendas and
needs
 Organizing scientists is like herding cats
 Politics continues to trump science
 The Big Logistical Problems
 Most HIV+ don’t know infected

 Only 1.3 million of 5.5 million in

need receive ARVs as of 12/05

 Scaling up treatment: monitoring,

training, FDCs

 Not much $ in vaccines,

microbicides, generics

 Prevention efforts woefully lacking

What Drives HIV’s Spread?
 Sub-Saharan Africa has 10
countries with adult prevalence
>10%

Namibia: 19.6%
Botswana: 24.1%
South Africa: 18.8%
CAR: 10.7%
Swaziland: 33.4%
Lesotho: 23.2%
Zambia: 17.0 %
Malawi: 14.1%
Zimbabwe: 20.1%
Mozambique: 16.1%
 Why the high Prevalence in
Sub-Saharan Africa?

 Concurrent sexual partnerships both male and

female
 Intergenerational sex: Sugar daddies
 Migration and poverty
 Concurrent untreated STDs (HSV-2)
 Lack of circumcision
 Sex work and clients
General Population Multi-Partner
Sex in Last Year

Males Females HIV %

Country (%) (%)
Kenya 45 20 16
Zambia 43 29 26
Zimbabwe 43 16 34
UNAIDS
 Epidemiology: Gender differences
10
Male
Female
8
JUN/JUL 92
Prevalence (%)

<9 10-14 15-19 20-24 25-29 30-39 40-49

Age and gender specific prevalence of HIV infection in rural South
Africa

Source : Abdool Karim Q et al, AIDS 1992

 HSV-2 and Circumcision
 2 high
prevalence
cities, 2
low
 ~1000
males and
~1000
females in
each
(Buve, AIDS, 2001)
Circumcising Adults?

 Orange Farm, South

Africa, August 2005
 Asia

 Huge populations in India and China: >1/3 of world

 Injecting drug use: heroin producing
 Sex work
 Thai Success
 India
 Different
epidemics
 5.7 million
HIV+
 Adult
prevalence:
0.9%
 China

 Blood plasma scandal

 IDUs
Southeast Asia

 Thailand: sex workers and IDUs

 Myanmar/Burma: big heroin
producer
 Cambodia: No IDUs
 Vietnam: IDUs
HIV Moves with Heroin
 Rapid Increase of HIV among
Injecting Drug Users
HIV prevalence
80%
1989

70%
1990 1989
1990 1996
60%

50%
1988
40%

30%

20%
1989
1989
10%
1987 1988 1995
1988
0%
Yunnan Manipur Myanmar Bangkok, Chiang Nikolayev,
Province, State, Thailand Rai, Ukraine
China India Thailand
 Preventing an IDU epidemic
slows or averts a sex work
epidemic…
Projected epidemic in Jakarta with and w/o IDUs

120,000
s

Pisani, FHI Indonesia

Doubling number of clients produces
more rapidly growing epidemic
By 2030,
13.2% of
males,
5.4% of
females
HIV+

80

Brown/Wiwat, East-West Center

 But prevention must be
sustained..
If condom use falls, HIV rises, even in Thailand

Supposing condom
use drops to 60%
starting 1998

1400
 Latin America and
Caribbean
Caribbean: highest
prevalence outside Sub-
Saharan Africa

Latin America: Similar to

Asia, but little IDU

Drivers:
• Migration
• Poverty
• Sex tourism
• Clients of sex work
Contrasts Abound • MSM
 Evolution of Epidemic

 Starts in Haiti, 1982 cases surface

 The
Caribbean:
Heterosexual
 Haiti’s Successes

 Lowered prevalence
 Pioneered treatment of poor
 Dominican Republic’s
Challenges

 Bateyes
 Sex work
 Treatment programs
 Puerto Rico

 IDU driven
 Topnotch research

 Topnotch care--for non-IDUs

Mexico and Central America

 MSM
 Migration
 Wars, Gangs
 Special
populations
 Sex Work
 Honduras Hotspot

 Garifunas  MSM
 Migration  Sex workers
 Prisons
 Regional wars
 Mexico

 MSM
 Anti-homophobia campaign
 Migration
 Guatemala:
Treatment and Care Uneven
 Centralized
 Drug supply
 Discrimination
 Transition
issues
South America

 Brazil > ½
cases
 Andean
region MSM
 Southern
cone was IDU
 Brazil

 Pioneered universal access  Sex-positive

 Escalating costs prevention
 Argentina

 Epidemics change
 Was IDU cocaine and MSM
 Now primarily heterosexual
 Peru

 Research magnet
 MSM
 Leading researchers from community
One Size Doesn’t Fit All
Prevention Efforts Woefully
Lacking

 Scattershot targeting of high-risk groups

 Treatment benefits prevention
 9 billion more condoms/year needed
 Harm reduction for 3.6% of IDUs
 ARVs for 3% of pregnant HIV+
 Treatment Issues: Rich vs.
Poor

AZT
d4T RT
ddI NRTI
ddC NNRTI
NVP PI
EFV FI
IND CD4
SQV CCR5
3TC VL
FTC
T-20
The Cocktails Work

40

Frank Palella/HOPS
Resistance and Side Effects
 Other Treatment Limitations
for Rich and Poor Countries
Alike
 Many HIV+ don’t know infected
 Adherence: Simpler regimens needed
 Training of clinicians
 Proper monitoring
 No cure exists
 The Story of Henan

Henan Province had 20% dropout first year, no 3TC,

and NVP resistance in first 9 months was 20%-30%.
Solution: Direct Observation of
Treatment Strategy (DOTS)
 Solution: FDC
(Fixed Dose Combination)
Solution: Proper training and
monitoring
 New Players

$5.5 Billion
Committed
President’s Emergency
Plan for AIDS Relief
$15 billion/5 years
(PEPFAR) $150
Million
To Fund,
>$500
Million to
HIV
Vaccine
Mind the Gap
 Future Treatment
Possibilities
New Targets: Integrase, APOBEC-3B
 The Search for an AIDS
Vaccine: A Long Battle

Discover, September 1990

WPost,
6/21/88

WPost, 5/21/90 Nature, 6/23/88

Evidence that an AIDS vaccine
is possible

 Exposed,
uninfected
 Protected
monkeys
 Longterm
nonprogressor
s
 Global HIV Vaccine
Enterprise

 Serious new money from Gates and

NIH (Total: >$500 million)
 Shared strategic plan
 Greater collaboration
Future Prevention
Possibilities
• Circumcision
• Drugs as
Prophylaxis
• PrEP
• Acyclovir
• Microbicides
• Acute Infection
Meeting slammed as
circus…It is the
greatest show on
Earth