Epidemiology (eg318)
following
its
recogni.on
32
years
ago,
the
HIV/AIDS
epidemic
has
evolved
to
become
the
greatest
challenge
in
global
health
34
million
people
currently
living
with
HIV,
approximately
similar
number
have
died
(jalmost
unparalleled)
3rd
most
common
reason
of
death
for
adults
globally,
5th
most
common
for
children
under
age
of
5
in 1981, GoNlieb and colleagues reported ve young healthy MSM treated for Pneumocys.c carinii/ jirovecii infec.on
normally
seen
in
severe
immunodeciency
(only
in
context
of
leukaemia
and
rarely
in
these
days
transplanta.on)
cases
in
sex
partners
along
with
results
of
a
na.onal
case-control
study
strongly
suggested
a
sexually
transmiNed
infec.on
1983:
female
partners
also
aected,
retrospec.ve
recogni.on
of
aected
infants
(1982)
1982:
blood-borne
spread
to
haemophiliacs,
via
transfusion
blood
products
oXen
sourced
from
Hai.
(payments
for
dona.ng
blood)
1983:
rst
1000
cases
reported
to
CDC,
39%
mortality
almost all were MSM, IDUs, persons with haemophilia, or recent immigrants from Hai. with undetermined risk factors
trends suggested 'gradual extension of an infec.ous agent into new popula.ons - not understood
spread to countries in Southern Africa in 1980s this expansion was most intense from 1990s onwards
AIDS
spread:
more
than
20
million
people
es.mated
to
be
living
with
HIV/
AIDs,
vast
majority
in
sub-Saharan
Africa
most
transmission
due
to
heterosexual
contact
(accounted
for
at
least
three
quarters
of
all
new
infec.ons)
women
account
for
40%
of
aected
adults
lack of circumcision
prolonged
breast-feeding
in
Sub-Saharan
Africa
(overall
mother-to-child
transmission
30-45%)
-
however
this
represents
only
safe
way
to
feed
baby
dicult
to
give
proper
advice
however, on the whole not successful as public health strategy (many parameters, e.g. women not empowered enough)
Thailand:
100%
condom
campaign
targeted
at
sex
workers,
very
successful
(cultural
barriers
not
as
high)
through
WHO
and
donor
leadership
in
priori.zing
na.onal
blood
transfusion
services,
numerous
HIV
infec.ons
were
averted
each
year
in
Sub-Saharan
Africa
Senegal:
predominance
of
HIV-2,
concentra.on
of
HIV-1
in
high-risk
groups,
universal
nature
of
male
circumcision,
tradi.onal
and
religious
cultures
limited
HIV
spread
rst
HIV
drugs
were
used
as
sequen.al
monotherapy
however,
this
facilitates
development
of
resistance
1996:
advent
of
HAART,
combining
three
medica.ons
at
the
same
.me
(but
s.ll
caused
severe
sight
eects,
sparked
rumours
that
MSMs
and
IDUs
were
being
'poisoned')
drawbacks:
expensive
(while
HIV
is
oXen
a
disease
of
poverty),
needs
to
be
prescribed
properly
and
adhered
to
healthcare
workers:
post-exposure
prophylaxis
2.7
million
people
es.mated
to
have
been
infected
over
previous
year,
including
390
000
children
over
2/3
in
sub-Saharan
africa,
which
accounts
for
80%
of
women
and
90%
of
children
living
with
HIV
South
and
South-East
Asia
4
million
aected
Caribbean
3
million
people
aected
Cuba
has
almost
no
HIV
(aected
people
were
locked
up)
severe
secondary
epidemic
of
HIV-associated
tuberculosis,
with
an
es.mated
350
000
deaths
among
the
1
100
000
persons
aected
by
both
infec.ons
in
2010
having HIV is risk factor for not responding to TB treatment, more likely to get mul.ple and extended drug resistance
nine
countries
in
Southern
Africa
account
for
less
than
2%
of
world's
popula.on,
but
represent
about
1/3
of
global
HIV
infec.ons
and
almost
half
of
the
world's
HIV-associated
tuberculosis
HIV/
AIDS:
Now
and
in
the
future
early-and
wide
spread
introduc.on
of
ART
(Standard
an.retroviral
therapy)
could
substan.ally
reduce
sexual
transmission
in
generalized
HIV
epidemics
e.g. even in US, only 28% of HIV-infected persons are es.mated to be on treatment and have suppressed viral loads
Mothers
e.g.
in
Malawi,
all
expectant
mothers
are
treated
with
HAART
irrespec.ve
of
CD4+
count
(HIV
test
itself
by
measuring
CD4
cells
is
very
expensive)
stop
congenital
transmission?
Intravenous
drug
users
most
aected
by
epidemic
were
IDUs
in
southern
Europe
and
in
parts
of
South
and
South-East
Asia
where
STDs
are
highly
s.ma.sed,
oXen
no
diagnosis
study about HIV prevalence in IDUs in a Ukrainian city: less than 2% in one year, then 50% in less than a year ('superspreader')
MSM
because
of
treatment
advances,
HIV
preven.on
may
seem
less
important
to
MSM
in
high-income
se^ngs
today
than
in
earlier
decades
in
the
United
States,
HIV
incidence
in
young
MSM,
especially
young
black
MSM,
con.nues
to
increase
24%
of
black
MSM
aged
2029
years
were
HIV-posi.ve
World
Bank
have
es.mated
that
MSM
may
account
for
7.5%14%
of
all
new
HIV
infec.ons
in
Nigeria
in
low-income
and
middle-income
countries,
however,
HIV
in
MSM
is
just
beginning
to
be
addressed
Conclusions
although
heterosexual
transmission
remains
dominant
mode
of
spread
worldwide,
we
have
witnessed
encouraging
trends
in
Africa's
generalized
epidemics
Standard AnEretroviral Therapy (ART)-based prevenEon approaches have potenEal to reduce all modes of transmission
massive scale-up of HIV tes.ng, surveillance and appropriate interven.on and implementa.on science are cri.cal to success
much
more
can
be
done
to
prevent
and
treat
HIV
infec.on
in
IDUs
and
sex
workers
mother-to-child
transmission
is
largely
preventable
although
con.nued
eorts
are
needed
to
improve
blood
safety
and
reduce
healthcare-associated
infec.ons,
blood
transfusion
and
medical
injec.ons
are
not
major
modes
of
transmission
strikingly,
HIV
amongs
MSM
(issue
that
rst
brought
AIDS
to
aNen.on)
remains
largely
refractory
a
disease
that
is
here
to
stay
following
discovery
of
HIV
as
in
cause
of
AIDs,
great
op.mism
reinforced
by
discovery
of
HAART
following
the
discovery
of
HIV
as
the
cause
of
AIDS,
there
was
great
op.mism
-
reinforced
by
the
discovery
of
HAART
E
as
in
emergency,
E
as
in
PEPFAR
(US
President's
Emergency
Plan
for
AIDS
Relief)
global
solidarity:
HIV
incidence
and
HIV-related
mortality
are
declining,
with
the
notable
excep.ons
of
the
former
Soviet
republics
and
old
and
new
epidemics
in
MSM.
new
study:
to
cure
HIV
by
bone-marrow
transplant,
remove
from
latency
in
many
areas
of
world,
HIV
epidemic
has
just
begun
e.g.
China,
India,
Russia
global
solidarity:
HIV
incidence
and
HIV-related
mortality
are
declining,
with
the
notable
excep.ons
of
the
former
Soviet
republics
and
the
new
epidemics
in
MSM
s.ll
enormous
gaps
between
ecacy
and
real-world
eec.veness
con.nued
funding
needed
but
actually
there
has
been
a
serious
decline
in
nancing
of
the
AIDS
response
since
2010
an
es.mated
96,000
(90
800
102
500)
people
were
living
with
HIV
in
the
UK
by
the
end
of
2011,
an
increase
from
91,500
in
2010
overall
prevalence
in
2011
was
1.5
per
1000
popula.on,
with
the
highest
rates
reported
among
MSM
(47
per
1000)
and
the
black
African
community
(37
per
1000)
24%
of
people
living
with
HIV
were
unaware
of
their
infecEon
in
2011,
the
same
proporEon
as
seen
in
2010
in
2011,
6280
people
were
newly
diagnosed
with
HIV
in
the
UK,
a
21%
decline
from
the
peak
in
new
diagnoses
in
2005
decrease
is
largely
due
to
a
reduc.on
in
number
of
diagnoses
reported
among
those
born
outside
the
UK
new
diagnoses
among
MSM
have
been
increasing
since
2007
with
3010
reports
in
2011,
represen.ng
an
all-.me
high
direct
and
indirect
measures
of
incidence
show
that
the
rate
of
HIV
transmission
in
this
populaEon
remains
high
>50% of the 2990 heterosexual men and women diagnosed in 2011 probably acquired infec.on in UK, compared to 27% in 2002
73,660
people
living
with
diagnosed
HIV
received
care
in
2011,
represen.ng
a
58%
increase
from
2002
(decrease
in
AIDS,
end-stage
HIV)
less
than
1%
of
infants
born
to
women
diagnosed
withHIV
prior
to
delivery
acquired
perinatal
infec.on
in
2010/11
overall
perinatal
transmission
rate
for
infants
born
to
both
diagnosed
and
undiagnosed
mothers
is
es.mated
as
ca.
2%
also
no
blood
transfusion-associated
HIV
in
UK
healthcare
workers
are
s.ll
being
infected,
needles.ck
injury
carries
0.03%
risk
of
infec.on,
also
depends
on
whether
'donor'
has
treatment
or
not
there
has
been
a
slow
but
signicant
decline
in
the
proporEon
of
people
diagnosed
late
(CD4
cell
count
<350
cells/
mm3)
over
the
past
decade,
par.cularly
among
MSM
note
this
number
has
gone
up
in
the
past,
200
cells/
mm3
was
used
as
'late'
and
oXen
treatment
wasn't
started
at
this
point
Safe
sex
programmes
promo.ng
condom
use
and
HIV
tes.ng
remain
a
priority
for
MSM
and
black
African
and
Caribbean
communi.es
to
reduce
ongoing
transmission
and
undiagnosed
infec.on
HIV
tes.ng,
which
is
free
and
conden.al
at
services
such
as
STI
clinics,
should
be
promoted
among
higher
risk
groups
to
ensure
individuals
are
aware
of
their
HIV
status
specically:
MSM should have HIV/STI screen at least annually, and every 3 months if having unprotected sex with new or casual partners
Black
Africans
and
Caribbeans
should
have
HIV
test,
regular
HIV/STI
screening
if
having
unprotected
sex
with
new
or
casual
partners
5
Public
Health
Outcomes
Framework
includes
the
late
HIV
diagnosis
indicator
all
local
authori.es
and
Na.onal
Health
Service
(NHS)
bodies
can
reduce
late
HIV
diagnoses
through
using
their
Joint
Strategic
Needs
Assessment,
to
priori.se
and
inform
the
provision
of
appropriate
HIV
tes.ng
services
local
authori.es
and
NHS
bodies,
with
a
diagnosed
HIV
prevalence
greater
than
2
per
1,000
popula.on
of
15-59
years,
can
implement
rouEne
HIV
tesEng
for
all
general
medical
admissions
as
well
as
new
registrants
in
primary
care
clinicians
should
take
every
opportunity
to
oer
and
recommend
HIV
tes.ng
to
those
known
to
be
at
higher
risk
of
HIV
infec.on.
Every
eort
should
be
made
to
reduce
health
service
barriers
to
HIV
tes.ng
universal
oer
of
an
HIV
test
should
be
given
to
all
pa.ents
diagnosed
with
TB
and
all
people
living
with
HIV
should
be
rou.nely
screened
for
TB
evidence
that
ART
reduces
risk
of
onward
transmission
should
be
discussed
with
all
people
receiving
HIV
care
ART
should
be
started
for
those
with
a
CD4
cell
count
>350
cells/mm3
who
wish
to
reduce
the
risk
of
transmission
to
their
sexual
partners,
in
line
with
the
2012
BHIVA
guidelines
monitoring
of
key
clinical
indicators
should
con.nue
in
order
to
ensure
the
current
high
quality
of
HIV
medical
care
is
maintained