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HIV

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

data in lecture reect 2012 for whole world, 2011 for UK

The World HIV epidemic

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

1983: breakthrough: virus is iden.ed


1985: screening of blood products is started

deferral of seroposi.ve persons from plasma and blood dona.on

heat treatment of clo^ng factors prepara.ons to inac.vate the virus

guidelines: avoid occupa.onal exposure, aected mothers avoid having babies

1983-5: cases in Europe, HaiE, Africa


iniEal studies in Africa revealed large numbers of cases in heterosexual paEents in central African ciEes such as Kinshasa, Zaire
(now Democra.c Republic of Congo), and Kigali, Rwanda
fears of casual contact transmission like Malaria?

1986-88: no casual transmission, no mosquito transmission (studies), some fears alleviated


virus cannot survive inside mosquitoes

next decade: pandemic of uncertain magnitude


virus thought to have entered human popula.ons in early twen.eth century, likely through cross-species transmission of related
chimpanzee retroviruses found in Western equatorial Africa
spread of HIV-1 infec.on from Africa to Hai. in 1960s and later introduc.on to US but mul.ple introduc.ons were likely

silent spread of HIV from Central Africa began in late 1970s

spread to countries in Southern Africa in 1980s this expansion was most intense from 1990s onwards

dierent regions, Senegal spared

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

in Zimbabwe, at least half were infected with HIV


MSM transmission predominates in West

co-factors aiding transmission:

other sexually transmiNed diseases, par.cularly chancroid/ HSV2

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

HIV-2 appearance complicates control


control strategies:

Sub-Saharan Africa: 'ABC' strategy 'abstain, be faithful, use condoms'

fall in HIV prevalence in childbearing women in Uganda

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

1987: zidovudine (AZT) approved


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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

China: just emerging, rela.vely recent

commercial blood trade infected 250,000 rural villagers

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)

HIV & Tuberculosis

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

global incidence peak in 1997


in many countries, incidence has
remained stable (e.g. USA)
disease has come 'out of fashion', not a
huge problem in developed countries

determinants of current and future HIV/


AIDS epidemiology include the natural
history of regional and local epidemics
themselves, social and behavioural
trends, and eects of public health and
medial interven.on

HAART as pre-exposure prophylaxis and


post-exposure prophylaxis (prophylaxis
aXer sexual intercourse 'morning-
aXer' pill for HIV)
one paper was promising real-life study
in Subsaharan Africa
however, two other papers showed
showed up problems: many people
didn't take drugs as prescribed, can produce drug resistance
adherence must be 99% for this strategy to succeed not likely

early-and wide spread introduc.on of ART (Standard an.retroviral therapy) could substan.ally reduce sexual transmission in
generalized HIV epidemics

extent to which these interven.ons can be brought to scale remains uncertain

e.g. even in US, only 28% of HIV-infected persons are es.mated to be on treatment and have suppressed viral loads

Mothers

WHO recommenda.ons are complex and dicult, oXen not followed

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

3 million IVDUs are es.mated to be infected

accounts for almost one-third of HIV incidence outside of sub-Saharan Africa

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

also countries of former Soviet Union - never had eec.ve funding

study about HIV prevalence in IDUs in a Ukrainian city: less than 2% in one year, then 50% in less than a year ('superspreader')

expansion of ART among HIV-infected drug injectors has a preven.on benet

MSM

liNle evidence of sustained preven.on success


HIV has become endemic in MSM popula.ons in the industrialized world; annual HIV incidence rates around 23% are common, as
are prevalence rates of 1030%

symbolic ac.ons, culture of lack of fear

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

cau.ous op.mism is jus.ed

con.nued funding, intensied program implementa.on

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

AIDS fa.gue, decreased leadership


a protracted epidemic has become endemic
a highly eec.ve vaccine is years away
a cure enabling elimina.on of the reservoir is missing
societal drivers of HIV spread have not diminished
s.gma, weak systems and civil unrest and wars are formidable obstacles
the AIDS2031 consor.um recommended a series of changes in approaches to AIDS
response
mul.year nancial commitments from both high-income and aected low-income
countries
focusing preven.on eorts on popula.ons at highest risk
inves.ng more in programme evalua.on
sustained research
capacity strengthening
seeking synergies with other programmes for service delivery
op.mizing an.retroviral drug treatment to increase coverage, reduce costs and avoid
development of drug resistance

HIV in the UK: 2012 overview

'tailing o' is probably ar.factual due to backlog in recording


aected people now live longer as treatments are more eec.ve
prevalence (blue line) will increase

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)

88% of people where treatment was indicated received ART in 2011

87% of people receiving care were virally suppressed, unlikely to be infec.ous


most deprived areas in UK also have highest HIV prevalence this health inequality
is par.cularly evident in London where diagnosed HIV prevalence is as high as 8 per
1000 in the most deprived areas and <1.5 per 1000 in the least deprived areas
rates of new HIV diagnoses and HIV prevalence con.nue to be signicantly higher in
London than elsewhere in the UK London has 18 of the 20 local authori.es with
highest prevalence of HIV infec.on
epidemic concentrated in poorer areas, London and Midlands, high in Scotland due
to immigra.on

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

propor.on of HIV paEents >50 years old is increasing (decreased mortality


from infec.on)
new challenges for treatment: have many comorbidi.es, also increases
risk of cancer, mul.ple medica.ons

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

recogni.on of importance of early treatment

viral load as measured by PCR should be undetectable during


treatment, 96% of treated pa.ents are in this area
nevertheless, the overall propor.on of late diagnoses remained high in 2011 (47%) strategies so far are of limited eec.veness,
many pa.ents don't return for results of their HIV test
people diagnosed late have a 10-fold increased risk of dying within the year of diagnosis

the incidence of tuberculosis among people diagnosed with HIV has


declined over the past decade
nevertheless, TB incidence among heterosexuals living with
diagnosed HIV was substan.ally greater than that in the general
popula.on in 2010
incidence rates were highest among those diagnosed late and those
not on ART
in 2011, 70% of all sexually transmiNed infec.on clinic aNendees
received an HIV test
highest coverage among MSM (83%)
almost 2/3 of MSM newly diagnosed as HIV-infected at an STI clinic
had not aNended that clinic for tes.ng in the previous three years
there has been very liNle commissioning of rou.ne HIV tes.ng in
general medical admissions and general pracEce seangs
a trial to inves.gate the public health eec.veness of pre-exposure prophylaxis in preven.ng HIV transmission among MSM has
begun in the UK

Health ProtecEon Agency recommendaEons

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
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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