Prevention and Control Programs

for HIV/AIDS
ERE LEE Q. SALANG
Epi 203: Communicable Disease Control
 2015
Epidemiology of HIV

38

Global Data of adults and children 2000 2003 2006 2009 2012 2015
Estimated people living w/ HIV 28.7 31.7 32.8 34 35.3 38.8
AIDS-related deaths 1.7 2.2 2.3 2 1.6 1.2
Newly infected w/HIV 3.5 3.1 2.8 2.6 2.3 2.5

• Declining new infections by 34% in 2012 and 29% in 2015 from 2000
• Expansion of ART coverage dramatically improved survival among people living with HIV
resulting in an increase in the number of PLHIV
• Increasing HIV prevalence in nearly every geographic region in the world, mostly
because of deaths averted from ART
Global Epidemiology of HIV
Infect Dis Clin N Am 28 (2014) 323–337
http://dx.doi.org/10.1016/j.idc.2014.05.001
 Epidemiology of HIV
HIV Incidence at peak in 1997: 3.3
million (CI 3.1M, 3.4M)

New infections HIV/AIDS Related Deaths

1980 1990 2000 2010

People Living with HIV/AIDS Proportion of PLWH under ART
Wang, H., et al., 2016. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015:
the Global Burden of Disease Study 2015. The Lancet HIV, 3(8), pp.e361-e387.
Epidemiology of HIV
Vast majority of people living with
HIV are located in LMICs

Highest: Sub0Saharan Africa

(estimated 25.5 million; 19.4 million
are from East and Southern Africa
and 44% of new HIV infections
globally in 2016)

South Asia accounts for 8.5% of new

infections per year
Southeast Asia accounted for 4.7%
of global infections in 2015
East Asia accounted for 2.3%.

https://www.avert.org/global-hiv-and-aids-statistics
UNAIDS (2017) 'Ending AIDS: Progress towards the 90-90-90 targets'
33 per day:
Average number of
people newly diagnosed
w/ HIV in 2018
ART Coverage 32.57% per 100 people living w/
HIV in 2015 (Global Estimates WHO 2015)
 Epidemiology of HIV
Transmission Acquisition
Heterosexual contact - main mode of HIV transmission in sub-
Saharan Africa
1st most
Injection drug use - major risk factor in Eastern Europe, Central
common Asia, North Africa, and the Middle East.
> 75% Homosexual contact (MSM) highest risk for infection in many
countries of North America, Western Europe, and Oceania.
2nd

2,450,920
38,802,500 new Risk of Transmission
people w/
infections blood transfusion – greatest risk, followed by vertical
HIV as exposure, sexual exposures, and other parenteral
2015 exposures (needle sharing drug use and percutaneous-
needle stick).

HIV/AIDS
deaths
Sexual exposure risks ranged from low for oral sex to 138
1,192,570 infections per 10 000 exposures for receptive anal
intercourse.
Wang, H., et al., 2016. Estimates of global, regional, and
Patel, P., Borkowf, C.B., Brooks, J.T., Lasry, A., Lansky, A. and Mermin, J., 2014.
national incidence, prevalence, and mortality of HIV, 1980–
Estimating per-act HIV transmission risk: a systematic review. Aids, 28(10),
2015: the Global Burden of Disease Study 2015. The Lancet
pp.1509-1519.
HIV, 3(8), pp.e361-e387.
 Risk Factors for HIV
• INDIVIDUAL (Behavioral and Biomedical)
directly affect individual and individual has
control in change
• SOCIOCULTURAL
norms that encourage high-risk sexual behavior
• INFRASTRUCTURAL
Directly/indirectly facilitate HIV, individual has
very little control
• STRUCTURAL
Developmental issues, both the individual and
the health system have very little control

Interacting Causes of HIV Risk and Vulnerability

Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences (1996)
Chapter: 5 PRIMARY HIV-PREVENTION STRATEGIES
Brief Overview of HIV

Infectious agent: a lentiretrovirus “human

immunodeficiency virus”
Mode of transmission: intimate exposure to
blood and bodily fluids through sexual,
parenteral, and mother-to-infant exposure
 Brief Overview of HIV
CASE DEFINITION
An individual with HIV infection
irrespective of clinical stage (including
severe or stage 4 clinical disease, also
known as AIDS) confirmed by
laboratory criteria according to
country definitions and requirements
(WHO)

WHO Case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children,
WHO Publication 2007
 • HIV wasting
Brief Overview of HIV syndrome
• Pneumocystis
pneumonia
• Recurrent severe
or radiological
bacterial
• Weight loss >10% of pneumonia
body weight • Chronic herpes
• Weight loss < 10% of • Unexplained chronic simplex infection
body weight diarrhoea > 1 month • Esophageal
• Minor • Unexplained candidiasis
mucocutaneous prologned fever 1 • Extrapulmonary
• Herpes zoster w/in 5 month TB
years • Oral candidiasis • Kaposi sarcoma
• Recurrent upper RTIs • Oral hairy leukoplakia • CNS
• Asymptomatic • Seborrhoeic • Pulmonary TB toxoplasmosis
• Asymptomatic • HIV
• Persistent generalized dermatitis • Sever bacterial
• Acute retroviral encephalopathy
lymphadenopathy (PGL) • Fungal nail infections infections
syndrome • Others

Primary HIV
Clinical Stage 1 Clinical Stage 2 Clinical Stage 3 Clinical Stage 4
Infection
Let Us Know About HIV and AIDS Achieving Triple Zeros Handbook on HIV AIDS for Public Healthcare workers; National STD/AIDS Control Programme,
Ministry of Health, Nutrition & Indigenous Medicine, in Partnership with the United Nations Population Fund; October 2016
Natural History of HIV

✓ median incubation period of 8-

10 years
✓ characterized by progressive
depletion of CD-4 positive T
lymphocytes and other effects
to the cells in the immune and
central nervous system
✓ Communicability period

Lewthwaite, P. and Wilkins, E., 2009. Natural history of HIV/AIDS. Medicine, 37(7), pp.333-337. | Harries, A.D., Maher, D.
and Graham, S., 2004. TB/HIV: a clinical manual. World Health Organization. | HIV & AIDS - signs, symptoms,
transmission, causes & pathology (downloaded video from YouTube.com).
 Natural History of HIV

HIV progression
Acute HIV Infection Persistent Advancing
(infection to HIV
Exposure Asymptomatic infection generalized immuno-
4-12 wks related disease)
lymphadenopathy suppression
AIDS
Harries, A.D., Maher, D. and Graham, S., 2004. TB/HIV: a clinical manual. World Health Organization.
Multiple programme components combined to reduce HIV incidence

Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections; A UNAIDS Discussion Paper, 2010
Prevention and Control: Program Components

UNAIDS (2010) Combination HIV Prevention

https://www.avert.org/professionals/hiv-programming/prevention
 Prevention and Control: Program Components

“rights-based, evidence-informed, and community-owned

programmes that use a mix of biomedical, behavioural, and
structural interventions, prioritised to meet the current HIV
prevention needs of particular individuals and communities,
so as to have the greatest sustained impact on reducing new
infections”
UNAIDS (2010) Combination HIV Prevention
https://www.avert.org/professionals/hiv-programming/prevention
Prevention and Control: Program Components
Examples:
• Information provision
(sex education)
• Counselling and other
forms of psycho-social
support
• Safe infant feeding
guidelines
• Stigma and
discrimination
reduction programmes
• Cash transfer
programmes

UNAIDS (2016) Prevention Gap Report

Prevention and Control: Program Components
Examples:
• Sex and reproductive
health services and
materials
• Voluntary medical male
circumcision
• antiretroviral drugs, pre-
exposure prophylaxis,
post-exposure prophylaxis
and treatment
• HIV testing and
counselling
• testing and treatment of
sexually transmitted
infections
• needle and syringe
programmes
• opioid substitution
therapy
Padian, N.S. et al (2008) 'Biomedical interventions to prevent HIV infection: evidence, • blood screening
challenges, and way forward' The Lancet 372(9638):585-599
 Prevention and Control: Program Components
• Strengthen
legislation, law
enforcement and
programmes to
end intimate
partner violence.
• Increase girls’
access to
secondary
education.
• Use cash
transfers to
empower women
economically
(school/health
Rao, G. et al (2008) 'Structural approaches to HIV prevention' The Lancet 372(9640):764-775 choices)
UNAIDS (2016) Prevention Gap Report
 Prevention and Control: Program Components
• Remove third-party
authorization
requirements and
other barriers for
accessible HIV and
sexual and
reproductive health
services.
• Decriminalize same-
sex relationships,
cross-dressing, sex
work and drug
possession and use
for personal
consumption.
• community
empowerment and
other programmes to
reduce stigma,
discrimination and
marginalization,
Rao, G. et al (2008) 'Structural approaches to HIV prevention' The Lancet 372(9640):764-775 including in health
UNAIDS (2016) Prevention Gap Report care settings.
Primary Secondary Tertiary

Goals of Levels of Prevention for HIV

• Primary HIV prevention reduces the incidence of transmission
[fewer people become HIV infected]
• Secondary HIV prevention reduces the prevalence and severity of the
disease through early detection and prompt intervention
[fewer HIV-positive people progress to AIDS]
• Tertiary prevention directed to HIV-infected clients
HIV clients in substance abuse treatment goals are:
(1) living substance free and sober
(2) slowing or halting the progression of HIV/AIDS
(3) reducing HIV risk-taking
Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons with HIV/AIDS. Rockville (MD): Substance Abuse and Mental Health Services Administration
(US); 2000. (Treatment Improvement Protocol (TIP) Series, No. 37.) Chapter 4—Primary and Secondary HIV Prevention.
Prevention and Control: Level of Prevention
Primary Secondary Tertiary
Formal Sex education
institution- STI control
HIV testing of transfused blood
based Universal precautions (safe handling of body fluids
programs from patients w/ HIV)
Postexposure Prophylaxis
Syringe-Sharing Risk Reduction (syringe exchange
programs)
Community- Awareness and life-skills education Voluntary Testing and counselling Antiretroviral therapy for HIV
based Condom promotion and distribution and IEC services clients
Sex-education Rapid HIV Testing
programs Reduction of mother-child transmission (ART, young
women; Prenatal and Perinatal preventions)
Vaccination for EPI: for asymptomatic HIV-infected
children and Symptomatic HIV-infected children
should not receive BCG or yellow fever vaccine
Population- Physical protection from violence and abuse
based Protection of health care workers
HIV Awareness celebrations (health promotion)
programs Media campaigns for HIV support programs

Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences (1996); Chapter: 5 PRIMARY HIV-PREVENTION STRATEGIES
Communicable Disease control in emergencies, A field Manual, WHO 2005
Health Promotive Disease Preventive strategies Screening and Counselling effectively identifies
strategies STI control PLWH and directs them to appropriate therapy
Sex education HIV testing of transfused blood
Universal Pre and Postexposure Prophylaxis Counseling on Risk Reduction, Disclosure of HIV
precautions Syringe-Sharing Risk Reduction Serostatus and Partner Notification
Health policies, MTC transmission Antiretroviral Therapy ~ reduces viral load and
media campaigns Harm reduction injection use partially enables immune restoration)
Voluntary male circumcision

Healthy Stage of Susceptibility Stage of Subclinical Disease Stage of Clinical Disease

Prevention and
Control
Strategies to
Stage in Natural
History of HIV

Bertozzi, S., Padian, N.S., Wegbreit, J., DeMaria, L.M., Feldman, B., Gayle, H., Gold, J., Grant, R. and Isbell, M.T., 2006. HIV/AIDS prevention and treatment. Disease control priorities
in developing countries, 2, pp.331-370. | Jeanne M. Marrazzo, MD, et al., HIV Prevention in Clinical Care Settings 2014 Recommendations of the International Antiviral Society–USA
Panel, JAMA. 2014;312(4):390-409. doi:10.1001/jama.2014.7999
 General interventions relevant to all modes of transmission:
• Information, education, and communication
• School-based sex education
Interventions to prevent sexual transmission:
• Voluntary counseling and testing
• Condom promotion, distribution, and social
• Peer-based programs marketing
• STI screening and treatment

Prevention of Mother-to-Child Transmission:

• Avoidance of unwanted pregnancies among infected mothers
• Use of antiretroviral therapy
Prevention and
Control • Feeding substitution
Strategies to Dx
Transmission Prevention of Bloodborne Transmission:
process
• Harm reduction for injecting drug users
• Implementation of blood safety practices
• Universal precautions.

Bertozzi, S., Padian, N.S., Wegbreit, J., DeMaria, L.M., Feldman, B., Gayle, H., Gold, J., Grant, R. and Isbell, M.T., 2006. HIV/AIDS
prevention and treatment. Disease control priorities in developing countries, 2, pp.331-370.
 Prevention and
Control
Strategies to Dx
Transmission
process

Bertozzi, S., Padian, N.S., Wegbreit, J., DeMaria, L.M., Feldman, B., Gayle, H., Gold, J., Grant, R. and Isbell, M.T., 2006. HIV/AIDS
prevention and treatment. Disease control priorities in developing countries, 2, pp.331-370.