HSS4331 – International Health Theory
HIV/AIDS
Nov 3, 2008
SUNSIH Conference
Who went?
Some More Seminar Opportunities…
• Tuesday Nov 4th, 4pm-5pm
• RGN Amphitheatre B (2215)
• Cocktail party in the Atrium afterward
• “Can Anti-Retroviral Therapy Be Used as a Chemical
Condom?” by Dr. Paul MacPherson and Dr. Bill Cameron
• Yes, you may write a 1-page summary on this seminar
And another…
• Wednesday Nov 5th at 4:30pm
• Fauteux Hall, Gowlings Moot Court, FTX 147
• “Renewing the Rules of the Game: Creating Collective Power
Through the Law” by Dr. Ashraf Ghani
• Yes, you may write a 1-page summary on this seminar
Streaming Web-based Seminar
•
•
•
“Closing the Gap in a Generation: Health Equity through Action on the Social
Determinants of Health” – a 2day free symposium in London, UK, hosted by the
Secretary for State of England
Nov 6 9:AM Greenwich (4:AM Ottawa) to Nov 7 5:pm Greenwich (noon Ottawa)
Register to watch online here:
– http://www.csdhconference.org/countdown/
Any two hours of this 2 day
event are eligible for your 1page seminars
Global Health research opportunity
Are you interested in Global Health? Dr Anne McCarthy of the Division of
Infectious Disease at the Ottawa Hospital is looking for students to assist
in Global Health research. There are three projects for which assistance is
needed.
•ACTION Global Health Network - website development: Ongoing
developments: new user interface, educational tools, blogging, etc
•Global Health needs assessment: Research paper on ethics in trainee
global health projects. Results to be used to inform global health
curriculum
•Global Health Elective curriculum development: With a global health
needs assessment completed last year, the global health curriculum team is
looking to develop learning modules to be published online and to be used
as content for a global health project manual.
If you are interested, please contact Andrew Petrosoniak
(apetr069@uottawa.ca) by Monday, November 3rd (TODAY) in order to organize a
meeting to discuss the projects further.
Bursary Opportunity
• Association of professors of the University of
Ottawa (APUO) is offering 50-60 awards of
$750 each to students
• Application forms are available on line:
www.apuo.ca/Info/studentaward/bourses.htm
• Deadline is Nov 14, 2008
Today….
• HIV/AIDS
• Africa
HIV/AIDS
• The basics
– “Acquired Immune Deficiency Syndrome”
– Caused by “Human Immunodeficiency Virus”
–
–
–
–
Evidence of infection before 1970
Current pandemic started in late 1970s, early 1980
AIDS defined in 1982
First identified in gay community in USA
• Originally called “GRID” – gay-related immune deficiency
Transmitted via…
–
–
–
–
–
Sex
Needle sharing
Blood transfusions
Mother-to-infant
Any other activity that allows
meaningful contact of body
fluids
Timeline…
• 1983: Pasteur Institute in France
discovers HIV – “Human
Immunodeficiency Virus”
– If not treated, those with HIV will
develop AIDS in 8-10 years
• 1995: protease inhibitors
dramatically increase survival of HIV
patients with access
Alternative Theory
• A minority of scientists question the link
between HIV and AIDS
• http://www.orgonelab.org/hiv_aids.htm
Treatment
• “Cocktail”
– “highly active anti-retroviral therapy” –
HAART
– ARV = anti retroviral therapy
– Serious side effects
– Regimens can be complicated
– Can be very expensive
Affordability of ARV drugs
-gone down from $10,000/year to
$200/year
Last year, the European Commission
ruled that EU countries are free to
make available generic versions of
patented drugs for export to poor
countries which lack their own
manufacturing facilities.
Trade Related Intellectual Property Rights (TRIPS)
Death
• People don’t “die from AIDS”
• AIDS allows “opportunistic infections”
– Leading cause of death of AIDS patients is
bacterial infection
• Tuberculosis
– Fungal infections
– Pneumonia
Co-infection with TB
• 1/3 of the world is currently infected with
TB, though most are not “active” cases
– 5-10% will develop active TB disease
– Only 25% have access to treatment
• TB accounts for 13% of all AIDS deaths
• HIV is the strongest known risk factor for a
TB carrier to progress to full TB disease
Co-infection with STDs
• In the presence of an STD, chance
of acquiring HIV increases 5X
• Puts sex workers at even greater
risk
Diagnosis
• Bloodtest
– Looking for HIV antiobodies
• Cheek swab
– Not saliva, but “oral mucosal transudate”, a
fluid produced by cheek cells
• “Visual”
– In 1985, WHO developed the “Bangui
Definition” for use in countries without
antibody testing technology
– Sometimes more informal… “Slim disease”
Bangui Definition
•
Exclusion criteria
– Pronounced malnutrition
– Cancer
– Immunosuppressive treatment
•
Inclusion criteria with the corresponding score
– Weight loss exceeding 10% of body weight 4
– Protracted asthenia
4
– Continuous or repeated attacks of fever for more than a month
– Diarrhoea lasting for more than a month
3
– Cough
2
– Pneumopathy
2
– Oropharyngeal candidiasis
4
– Chronic or relapsing cutaneous herpes
4
– Generalized pruritic dermatosis
4
– Herpes zoster (relapsing)
4
– Generalized adenopathy
2
– Neurological signs
2
– Generalized Kaposi's sarcoma
12
The diagnosis of AIDS is established when the score is 12 or more.
•
3
CD4 Count
• A proxy measurement of the strength of a patient’s immune system
• CD4 count goes down as HIV infection progresses
• Used in coordination with…
Viral Load Test
• The amount of HIV virus in the blood, lymph, spleen, and other body
parts
• Viral load goes up as HIV infection progresses
HIV/AIDS in the Developed World
Case study: USA
HIV/AIDS Around the World
To get current data, go to:
http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp
UNAIDS 2008
*detection bias?
New AIDS Cases Per Year
Per 100,000 Population
35
Caribbean
30
25
20
North America
15
10
Latin America
5
0
90
91
92
93
94
95
96
2000
Millions
Estimated number of adult and child deaths
due to AIDS globally, 1990–2007
3.0
2.5
2.0
1.5
1.0
0.5
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
This bar indicates the range around the estimate
5.3
The red bits are
what we call
“Sub-Saharan
Africa”
Estimated number of people living with HIV and adult HIV
prevalence
Global HIV epidemic, 1990‒2005*
Number of people
living with HIV (millions)
HIV epidemic in sub-Saharan Africa,
1985‒2005*
% HIV prevalence,
adult (15‒49)
50
5.0
40
4.0
30
3.0
20
2.0
10
1.0
0
0.0
1990
1995
2000
2005
Number of people
living with HIV (millions)
30
15.0
25
12.5
20
10.0
15
7.5
10
5.0
5
2.5
0
0.0
1985
1990
Number of people living with HIV
% HIV prevalence, adult (15-49)
This bar indicates the range around the estimate
06/06 e
% HIV prevalence,
adult (15‒49)
1995
2000
2005
*Even though the HIV prevalence rates have
stabilized in sub-Saharan Africa, the actual
number of people infected continues to grow
because of population growth. Applying the
same prevalence rate to a growing population
will result in increasing numbers of people living
with HIV.
2.2
Regional HIV and AIDS statistics and features, 2006
Adults & children
living with HIV
Sub-Saharan Africa
Middle East & North Africa
South and South-East Asia
East Asia
Latin America
Caribbean
Eastern Europe & Central
Asia
Western & Central Europe
North America
Oceania
TOTAL
12/06 e
24.7 million
[21.8 – 27.7 million]
Adults & children
newly infected with
HIV
2.8 million
[2.4 – 3.2 million]
460 000
68 000
[270 000 – 760 000]
[41 000 – 220 000]
7.8 million
860 000
[5.2 – 12.0 million]
[550 000 – 2.3 million]
Adult (15‒49)
prevalence [%]
5.9%
[5.2% –
6.7%]
0.2%
Adult & child
deaths due to
AIDS
2.1 million
[1.8 – 2.4 million]
36 000
[0.1% –
0.3%]
[20 000 – 60 000]
[0.4% –
1.0%]
[390 000 – 850 000]
0.6%
590 000
750 000
100 000
0.1%
43 000
[460 000 – 1.2 million]
[56 000 – 300 000]
[<0.2%]
[26 000 – 64 000]
1.7 million
140 000
[1.3 – 2.5 million]
[100 000 – 410 000]
250 000
27 000
[190 000 – 320 000]
[20 000 – 41 000]
1.7 million
270 000
[1.2 – 2.6 million]
[170 000 – 820 000]
740 000
22 000
[580 000 – 970 000]
[18 000 – 33 000]
1.4 million
43 000
[880 000 – 2.2 million]
[34 000 – 65 000]
81 000
7100
[50 000 – 170 000]
[ 3400 – 54 000]
39.5 million
4.3 million
[34.1 – 47.1 million]
[3.6 – 6.6 million]
0.5%
65 000
[0.4% –
1.2%]
[51 000 – 84 000]
[0.9% –
1.7%]
[14 000 – 25 000]
[0.6% –
1.4%]
[58 000 – 120 000]
[0.2% –
0.4%]
[ <15 000]
[0.6% –
1.1%]
[11 000 – 26 000]
[0.2% –
0.9%]
[2300 – 6600]
[0.9% 1.2%]
[2.5 – 3.5 million]
1.2%
0.9%
0.3%
0.8%
0.4%
1.0%
19 000
84 000
12 000
18 000
4000
2.9 million
Table 1b
Percentage of the Adult
(ages 15-49) population
with HIV/AIDS, 2003
Percent of adults (15+) living with HIV who are female
1990–2007
70
Sub-Saharan Africa
60
GLOBAL
50
Caribbean
Percent 40
female
(%)
30
Asia
Latin America
20
Eastern Europe
& Central Asia
10
0
1990 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 2000 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 2007
2.4
Haiti – HIV Seroprevalence: gender split
Proportions of HIV infections in different population groups
by region, 2005
Eastern Europe and
Central Asia
Latin
America
South and South-East
Asia*
MSM 26%
CSW
4%
CSW
client
s 13%
MSM 4%
CSW 5%
IDU 67%
CSW
client
s 7%
All
others
17%
IDU
19%
CSW clients
41%
CSW 8%
MSM 5%
All
others
38%
IDU
22%
All
others
24%
IDU:
Injecting Drug
Users
MSM: Men having sex with men
CSW: Commercial Sex Workers
* India was omitted from this analysis because the scale of its HIV epidemic (which is largely
heterosexual) masks
the extent to which other at-risk populations feature in the region’s epidemics.
12/06 e
Figure 2
Why “MSM”?
• Sexuality is culturally defined
• Men having sex with men do not necessarily
self-identify as homosexual
• Sociologically:
– MSM refers to the sexual relationship between
two men
– Homosexuality refers to broader relationships
between men, beyond the sexual
Truck Drivers
• Yes, truck drivers
• The spread of HIV in Africa is linked to the
movement of labour between rural and urban
centres
• Geographical link between HIV clusters and
road networks
• Truck drivers have high-risk behaviour of
sleeping with prostitutes and a tendency to
spread the infection along trade routes
Impact of AIDS on Sub-Saharan Africa
• 2/3 of all people with HIV live in this region
– 75% of all AIDS deaths occur here
• (region comprises only 10% of world population)
• Each year, >2 million people died of AIDS in this
region
• In this region, direct medical treatment related to
AIDS (not including ARV) = US$30 per person per
year
– Overall public health spending is <US$10 per
person per year*
* UNAIDS 2002 Report on the Global AIDS Epidemic
Impact…
• Hospitals
– People with HIV occupy half of all hospital beds
– Shortage means only people in later stages are
admitted, resulting in lessened treatment success
• Health Care Workers
– Large numbers are HIV or AIDS positive
– Dwindling numbers
– Providing ARVs requires more training
*UNAIDS, 2006 Report on the Global AIDS Epidemic,
chapter 4: The impact of AIDS on people and societies
Household Impact
• Wage earners killed off -> impoverished
families
• Young forced into prostitution -> increased
disease transmission
• AIDS has erased much of the anti-poverty
progress made over the past 6 decades
• Basic necessities not being provided
• There are entire communities with no adults
left -> households led by small childen
– No transfer of knowledge from adults to children
Food Production
• Not enough labour to work fields
– In Malawi, Botswana, Zimbabe, agricultural output
will drop 14%-20% by 2020 due to AIDS
• The use of ARV requires proper nutrition
– Vicious cycle:
• AIDS -> poor food production -> poor nutrition -> more
AIDS
Anti Retrovirals
Millions
Number of people receiving antiretroviral drugs
in low- and middle-income countries, 2002−2007
3.0
2.8
2.6
2.4
2.2
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
North Africa and
the Middle East
Eastern Europe and
Central Asia
East, South and
South-East Asia
Latin America and
the Caribbean
Sub-Saharan
Africa
end2002
end2003
end2004
Year
5.2
Source: Data provided by UNAIDS & WHO, 2008.
end2005
end2006
end2007
Gender Disparity
• The impact of AIDS in Africa is felt
disproportionately by women
• In many circles, AIDS is no longer a “gay
disease”, but a “woman’s disease”, since >50%
of all cases are borne by heterosexual women
• Women function as family care givers, and are
now the sole providers
– Leading to neglect in care-giving
AIDS “Virgin Myth”
• It is believed that an HIV-infected man will be
cured if he has unprotected sex with a virginal
female
• -> epidemic of child rape
• -> emerging epidemic of rape of the disabled
• Global movement to re-educate those at risk
– South African group “Love Life”
– www.lovelife.org.za
Circumcision
• Some studies suggest that male circumcision
can reduce HIV transmission (via sex) by >50%
• Presently, there are vocal advocates to make
circumcision mandatory in high risk
communities
• Global teams offering free, safe circumcisions
in Swaziland, Botswana and elsewhere
Nice Summary
• Of some of the AIDS impacts is found here:
– http://www.avert.org/aidsimpact.htm
Orphans: A Lost Generation
• Numbers are large and growing
• Social support systems are overwhelmed
• Risk of a lost generation:
– little or no education
– poor socialization
– social upheaval
– economic underclass
Debt
-Kenya pays 17X more on
debt repayment than on HIV
control
Economic Growth Impact of HIV (1990-97)
(Data from 80 developing countries)
Reduction in growth rate GDP
per capita (%, per year)
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
-1.4
-1.6
0
5
10
15
20
25
30
HIV Prevalence Rate (%)
Source: R. Bonnel (2000) Economic Analysis ofHIV/AIDS, ADF2000 Background paper,
World Bank
35
“There are two refrains which I’ve regularly (and painfully)
heard over the last three years traveling in Africa, always
coming from young [African] women with their children in
tow: ‘What will happen to my children when I die?’ and ‘You
have drugs to treat people in your country; why can’t I have
drugs to stay alive in my country?’
-Stephen Lewis
Even if we made ARVs dirt cheap, would this solve the problem?
•Bill Clinton: "90% of HIV positive
people in the developing world are
unaware of their [disease] status.“
•Bill Gates: "The capacity to treat [AIDS]
is not so much gated by access to drugs
as it is by the availability of trained
personnel."