Global overview of the state of the epidemic and new
strategies of Response
Peter Godfrey-Faussett, Senior Science Adviser, UNAIDS
Karl Dehne, Chief, Prevention, UNAIDS
National Consultation on Combination Prevention,
Lima , Peru
12-14 November 2014
Adults and children estimated to be living with HIV2013
North America and Western and Central Europe
Eastern Europe &
Central Asia
2.3 million
1.1 million
[980 000– 1.3
[2.0 million – 3.0
million]
million]
Middle East & North Africa
230 000
Caribbean
[160 000 – 330
250 000
Asia and the Pacific
[230 000 – 280
000]
4.8 million
000]
[4.1
million – 5.5
Sub-Saharan Africa
million]
Latin America
24.7 million
1.6 million
[23.5 million – 26.1
[1.4 million – 2.1
million]
million]
Total: 35.0 million [33.2 million – 37.2 million]
Source: UNAIDS
Chapter One
A disease sin nombre
1981
Pneumocystis pneumonia Slim’s disease
1984
1983
Prologue
Man and the Environment
Chapter Two
“Before the life boat”
www.youtube.com/watch?v=7kYrMw14cDQ
First regimen to
reduce MTCT of HIV
First cases of unusual immune deficiency are
identified among gay men in the USA June 1981
Acquired Immune Deficiency Syndrome
(AIDS) defined
Millions
45
The first HIV antibody test
becomes available
35
Global Network of People
living with HIV/AIDS (GNP+)
30
The WHO launches the
Global Programme on
AIDS
25
President Bush
announces
PEPFAR
The first therapy for
AIDS - zidovudine/
AZT - is approved for
use in the USA
20
15
WHO and UNAIDS
launch the
"3 x 5" initiative
Brazil becomes the
first developing
country to provide
ART
HIV identified as
cause of AIDS May 1983
40
• Epidemic of fear and
stigma
• Social mobilisation
• Activism
• Peer-support
• Social justice
• Solidarity
• Beyond Health
• UNAIDS, NACs
HAART
launched
A heterosexual AIDS epidemic is revealed
in Africa
50
Global Fund to fight
AIDS, TB and Malaria
The UN General Assembly
Special Session on
HIV/AIDS
UNAIDS
created
10
2010 International AIDS
Conference in Durban
5
People living with HIV
0
1980 ‘81
‘82
‘83
‘84
‘85
‘86
‘87
‘88
‘89
‘90
‘91
‘92
‘93
‘94
‘95
‘96
‘97
‘98
‘99
‘00
‘01
‘02
‘03
‘04
The chronology above summarises the ‘BIG Picture’ of AIDS – from the UNAIDS website
Source: UNAIDS 2008
‘05
Chapter Three
Beyond the triumph of biomedicine
First regimen to
reduce MTCT of HIV
First cases of unusual immune deficiency are
identified among gay men in the USA June 1981
Global Fund to fight
AIDS, TB and Malaria
Acquired Immune Deficiency Syndrome
(AIDS) defined
Millions
WHO and UNAIDS
launch the
"3 x 5" initiative
HAART
launched
A heterosexual AIDS epidemic is revealed
in Africa
50
45
Brazil becomes the
first developing
country to provide
ART
HIV identified as
cause of AIDS May 1983
40
The first HIV antibody test
becomes available
35
Global Network of People
living with HIV/AIDS (GNP+)
30
The WHO launches the
Global Programme on
AIDS
25
President Bush
announces
PEPFAR
The first therapy for
AIDS - zidovudine/
AZT - is approved for
use in the USA
20
15
The UN General Assembly
Special Session on
HIV/AIDS
UNAIDS
created
10
2010 International AIDS
Conference in Durban
5
People living with HIV
0
1980 ‘81
‘82
‘83
‘84
‘85
‘86
‘87
‘88
‘89
‘90
‘91
‘92
‘93
‘94
‘95
‘96
‘97
‘98
‘99
‘00
‘01
‘02
‘03
The chronology above summarises the ‘BIG Picture’ of AIDS – from the UNAIDS website
Source: UNAIDS 2008
‘04
‘05
Chapter Four
Treatment and Global Solidarity
Global number of people living with HIV
& HIV-related deaths: Changes post-2005
40
5
4
30
25
3
20
2
15
10
1
5
0
1990
1995
2000
2005
Source: UNAIDS Global Report 2014
2010
0
2015
Estimated AIDS deaths (millions)
Estimated number of people living with
HIV (Millions)
35
Chapter Five
A Prevention Revolution?
1,200
4.0
Number of new HIV infections
(Millions)
1,000
3.5
3.0
800
2.5
600
2.0
1.5
400
1.0
200
0.5
0.0
1990
1995
2000
2005
2010
0
2015
Estimated number new HIV infections in
children (thousands)
4.5
COMBINATION Prevention for Maximum Effect
Biomedical tools
& Interventions
Structural
changes &
political
Combination
HIV/STI Testing
& Linkage to
Care
prevention
Community
driven
approaches &
movements
Individual &
Small Group
behavioral
strategies
Adapted from Coates Lancet; 2008
HIV Prevention: Increasing Choices
Decrease Source
of HIV Infection
Barrier protection
Blood screening
Harm reduction for PWID
ART
Maternal-to-child transmission
Decrease partner’s viral load
Treatment of acute HIV infection
Decrease Host Susceptibility
to HIV Infection
●Barrier protection
●Circumcision
●PreP
- Oral
- Topical (Gel, Film, Ring)
- Injectable
Alter Behavior:
Exposure, Adherence
.
●Condom promotion
●Individual-level interventions
●Couples interventions
●Community-based interventions
●Structural interventions
ARV
prophylaxis
Male
circumcision
Auvert B, PloS Med 2005
Gray R, Lancet 2007
Bailey R, Lancet 2007
Treatment of
STIs
Grosskurth H, Lancet 2000
Microbicides
for women
Female Condoms
Abdool Karim Q, Science 2010
Oral pre-exposure
prophylaxis
Male Condoms
HIV
PREVENTION
HIV Counselling
and Testing
Grant R, NEJM 2010 (MSM)
Baeten J , NEJM 2012 (Couples)
Paxton L, NEJM 2012 (Heterosexuals)
Choopanya K, Lancet 2013 (IDU)
Post Exposure
prophylaxis (PEP)
Scheckter M, 2002
Coates T, Lancet 2000
Sweat M, Lancet 2011
Treatment for
prevention
Cohen M, NEJM, 2011
Donnell D, Lancet 2010
Tanser, Science 2013
Behavioural
Intervention
-
Abstinence
Be Faithful
Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included – this is on sexual
transmission
Consider….
pills
• Consider a future time
in which there are
multiple prevention
options available
• And those who use
prevention tend to use
consistently, but not
everyone is perfect
condoms
injectable
none
other
consistent users
inconsistent users
long gaps in use
Chapter Six
HIV in 2014
Despite impressive progress,
the spread of HIV has yet to be controlled!
In 2013, there were:
1.5 million HIV deaths
35 million living with HIV
2.1 million new infections
Source: UNAIDS Global Report 2014
34 years on: AIDS is still far from over
3 Key Challenges
1. Dysfunctional health systems
– Failing to convert efficacious treatment & prevention
interventions fully for maximum effectiveness
2. Most new HIV infections now occur in Key
Populations – the highest prevention priority
– Young women in Africa
– Sex Workers
– MSM & Transgender individuals
– IDU
3. Stigma, discrimination & legislative hurdles
– Major obstacle to prevention & care
Despite Scientific Progress,
Insufficient Decline in New Infections Globally
Sexual health
promotion
Combination
prevention
Advocacy
for
prevention
revolution
Accelerated
action, focus and
innovation
Targets
Two global sub-targets are being proposed:
1. By 2020, new infections in key populations will be reduced by
75%
2. By 2020, new infections in young women and girls will be
reduced by 75%
75% Reduction in New Infections:
Can Peru make it?
Programmatic Targets that need to be reached to
achieve 75% reduction (UNAIDS modelling results)
• Key populations reached with comprehensive
service packages, including condoms
85%
– Assumed to translate in 80-90% consistent condom
use
• MSM and sex workers access PrEP
10%
• Viral suppression of all PWHIV
70%
– 90:90:90 cascade
Possible factors sustaining high HIV
incidence in gay men and other MSM
• Insufficient programme coverage of traditional
outreach programmes
• Expansion of social and sexual networks – those
newly connected hardly reached
• Systemic conditions (like persistent stigma)
• Possible changes in perception of HIV among MSM
Too few MSM reached by HIV prevention services
80%
70%
60%
43%
40%
40%
25%
12%
20%
0%
Latin America
Caribbean
Eastern
Europe
Source: the World Bank
Asia, Pacific,
Middle East
Africa
National cohort of
Persons seen for HIV care
= Prevalence of diagnosed HIV
infection
(Almost) all persons attend an NHS
clinic
•
Annual follow up data (cd4, VL, ART)
(SOPHID)
•
Linked by soundex to previous years to
form national cohort
Data used to inform
•
•
•
•
•
29
Diagnosed Prev trends
Clinical outcomes
Testing policies
Undiagnosed infection
TAsP
HIV care provided through the National Health Service, UK
Among 81,500 persons living with diagnosed HIV
• 97% are linked to care after diagnosis within 3 months
• 95% are retained in care annually
• 92% of persons in need of treatment are on treatment (87% of all diagnosed)
• 95% of persons on treatment achieve VL<200 copies/ml
30
HIV in the UK: 2013
HIV diagnoses, AIDS & deaths
•
•
•
•
6,000 new HIV diagnoses reported
42% diagnosed late
319 reports of AIDS
577 deaths – 75% are late diagnosed
•
Incidence in MSM remains high with no
sign of a decline (Birell, Phillips)
Presentation title - edit in Header and Footer
People living with HIV by diagnostic and treatment status, and
number with detectable viral load, UK, 2006-2012
100000
90000
Diagnosed and treated
Diagnosed and untreated
Undiagnosed
Number with VL>50 copies
80000
70000
60000
50000
40000
30000
20000
10000
27%
26%
24%
23%
22%
2008
2009
2010
2011
2012
0
Whole system approach to
prevention and care
Evidence that
particularly sexual
risk taking behaviour
can only be
addressed by
tackling syndemic
factors including
depression,
substance use,
violence, sexual
stigma, homophobia
and poverty
Syndemic conditions associated with increased HIV
risk in a global sample of MSM
Substance use
Socio-political context
35
•
Legal (human rights, anti-discrimination, drug laws, access to
healthcare)
•
High level of stigma and discrimination despite human rights laws
•
Access to ARV – cost, procurement process, stock-outs, limited
regiments
•
Affordable diagnostics and resistance testing
•
Structural barriers – greater need for integrated health care aimed at
most at risk communities, provision of sex education in schools
•
Cultural barriers – providing friendly, non judging services in
partnership with NGOs
Community engagement
• Stigma and discrimination remains major barrier to testing, link and
retention in care and prevention efforts
• Need greater engagement of PLHIV and affected communities at
every level
• Tailored messages for individuals recognising diverse nature of
community
• Supporting peer-led initiatives and outreach programs
• Sustained funding for NGOs
• Provision of integrated and welcoming, non judging services in
partnership with NGOs
36
Changes in perception of HIV?
Gay health summit looks at life beyond HIV (14 Nov 2013)
A speaker stressed the importance of intergenerational dialogue, and recalled an
exchange:
“The older men were chastising the younger men who admitted they chose not to use
condoms regularly since they perceived that condoms were a barrier to the intimacy they
sought in sex,” he said. “One of the older men said in response to this that ‘every time you
do that you are asking to die.’ “So one of the younger men countered, ‘we can’t keep being
afraid of sex because you were. We can’t carry the burden of everyone who died before
us.’
Andrew Shopland says many of the young men who he works with at Mpowerment long for
community. Really what we’re looking for is connection and acceptance, he told the
summit. http://dailyxtra.com/vancouver/news/gay-health-summit-looks-at-life-beyondhiv?market=210
Connectedness with gay subculture in repeated web surveys:
behavioural surveillance among MSM in Germany
What % of MSM is using dating apps/web-based dating in
Peru?
New media technology
•
•
•
•
Where people meet partners
Where people get information
Apps may enhance self-assessment of risk
Monitoring PrEP adherence
Optimized service delivery: All-in-One Chain model
Example of the city-approach in Chengdu city, China
Testing
Prevention
•
•
•
Out reach
Peer
education
Venue &
Internet
based
intervention
•
•
Community
VCT
Venue
based rapid
testing
Follow up
• Psychological
support
• Community
follow up
• Partner test
promotion
• CD4 test
Treatment &
Care
• Compliance
education
• Guide for
medicine &
nutrition
• Positive
prevention
Integrating community systems
•
•
•
•
•
•
Mapping of available services
Provider Sensitization
Capacity building of community-based organizations
Formalize referral system
Linkages with interactive internet - based platforms
Collaborate with gay community on monitoring of
quality of services
• Collaborate on advocacy and programming within local
government
Missing links and typical gaps
• Reach of young gay men, hidden/unknown
networks, those only connected virtually, not
gay self-identified MSM, outside main cities
• Retention in programs of those testing
negative
• Condoms and lubricants!
• Link to anal health and other clinical services
• PreP, as part of comprehensive combination
strategy
Possible results framework
Coverage with
Service coverage through
Community-led outreach
Outreach coverage
with service
packages including
condoms and lubs
Reach with
interactive new
media and
referrals
Communitybased testing
and retention
facility-based services
Facility-based
HTC
Community empowerment and mobilization, other
enablers and synergies
PrEP
ART
Conclusion
• Ambitious prevention targets achievable in principle!
• Concept of combination prevention remains valid!
• Wide programme gaps – need to expand reach and keep
those reached engaged
• Condoms and lubs remain cornerstone of combination
prevention, but additional options, PreP (and early
initiation of treatment) needed!
• Social and digital media
• Strengthen linkages between community and facility
based services and virtual space
• Community empowerment critical
• Domestic funding, including city approach!
Chapter Seven
HIV beyond 2015
Choosing a future… The End of AIDS
• “The End of AIDS” is an aspirational vision
• Epidemiological concepts of elimination and
eradication not readily applicable to AIDS as millions
are living with HIV and no cure available
• Key step to “The End of AIDS” is epidemic control
– Epidemic control - Reduction of disease incidence, prevalence,
morbidity or mortality to a locally acceptable level as a result of
deliberate intervention measures
– Point where HIV no longer represents a public health threat and
no longer among the leading causes of country’s disease burden
– Mathematically defined as the point at which the reproductive
rate of infection (R0) is below 1
What will it take to reach the ambitious
target of epidemic control?
• Act on knowledge of detailed local epidemiology
• Build on successes
….learn from failures
….implement to scale
• As the HIV epidemic changes – so too should our programs &
interventions. Adapt with the changes!
• Target hotspots, pockets and key populations that continue to
sustain high HIV incidence – will need combinations of
appropriate prevention strategies
• Deal with underlying drivers such as legal barriers, stigma &
social norms simultaneously
• Continued funding & greater program efficiency
• Biomedical, socio-behavioural and implementation science, incl.
innovations
Epilogue
A world without HIV?
Acknowledgements
Salim Abdool Karim, Chair, UNAIDS Science Panel
Valerie Delpech, Epidemiologist Public Health England
Jared Baeten, Partners PrEP, University of Washington