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The Globalization of HIV

The Globalization of HIV. Tanya D.I. Zangaglia, MD New York/Virgin Islands AIDS Education and Training Center. HIV is present in virtually every country. WHO: In Point of Fact, #86, 5/95. Africa Botswana 25% Kenya 12 Malawi 15 Mozambique 14 Namibia 20 Rwanda 13

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The Globalization of HIV

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  1. The Globalization of HIV Tanya D.I. Zangaglia, MD New York/Virgin Islands AIDS Education and Training Center

  2. HIV is present in virtually every country WHO: In Point of Fact, #86, 5/95

  3. Africa Botswana 25% Kenya 12 Malawi 15 Mozambique 14 Namibia 20 Rwanda 13 South Africa 13 Zambia 19 Zimbabwe 26 Other Countries Brazil 0.43% Cambodia 2.40 China 0.06 France 0.37 Haiti 5.17 India 0.82 Mexico 0.35 Thailand 2.23 United States 0.18 A Plague on Many Countries Percent of Adults (15-49) living with HIV/AIDS

  4. Worldwide HIV/AIDS is negating all of the public health prevention efforts instituted over the past decades in the areas of nutrition, immunizing of children and controlling disease David Satcher, MD Surgeon General of the United States, 4-28-99-Vol. 261, No. 16

  5. By the Year 2015… HIV/AIDS will reduce life expectancy from 64 to 47 in the following countries: Botswana Malawi Namibia Kenya Mozambique Rawanda South Africa Zambia Zimbabwe David Satcher, MD Surgeon General of the United States, 4-28-99-Vol. 261, No. 16

  6. Life Expectancy Changes in Select African Nations Since the Onset of the HIV/AIDS Epidemic

  7. Worldwide, as many as 5-10 million children may have lost their mothers or both parents to AIDS WHO: In Point of Fact, #86, 5/95

  8. By the year 2015 there will be an estimated 16 million children orphaned by AIDS in Africa alone HIV/AIDS “AIDS Orphans”

  9. HIV/AIDS in India • Currently, it is estimated that upwards of 5 million people are infected with HIV, with as many as 100,000 cases of full-blown AIDS. • By the year 2010, India is expected to have the greatest number of HIV/AIDS. In other words, 30 million Indians could be infected with HIV a decade from now – today’s worldwide total. A & U, 1/99

  10. HIV/AIDS in India Groups at risk • Migrant workers • Truckers • Commercial sex workers • Married women??? • 10% of housewives in Bombay • Intravenous drug users • The gay community A & U, 1/99

  11. HIV/AIDS in India • India has more people than the continents of Africa, Australia and Latin America combined, 970 million • India accounts for 20% of the HIV/AIDS cases globally • By the mid-1980s, 3 million people have died of AIDS in India

  12. HIV/AIDS in India by Region • Bombay has the most rapid and well documented spread of HIV • Calcutta (east) and New Delhi have shown only a 2 percent prevalence rate of HIV infection among commercial sex workers • Sexual education has been extremely successful in these provinces • In Manipur (northeast) 55% of IVDUs are infected with HIV

  13. Commercial Sex Workers and HIV/AIDS in India • Women and teenage girls can be bought for ten rupees (approximately 28 US cents) • In Mumbai, half of the CSWs are young women brought into the country from Nepal and then raped, tortured and held captive in brothels as slaves • These Nepalese women are highly sought by brothels in Mumbai because of their light skin color Human Rights Watch

  14. Commercial Sex Workers and HIV/AIDS in India • The women/girls are lured from remote rural areas with promises of marriage or jobs, then sold for dollars • The average age of recruits from Nepal is 10 • Condoms are rarely used Human Rights Watch

  15. The Crisis of HIV/AIDS in India • AIDS patients are left abandoned because of fear • Sometimes after an AIDS death the family will not return to claim the body • Ancient superstitions and Hindu tradition contribute to the epidemic • When the first reports of HIV appeared a decade ago, they were ignored by state governments • The virus is mainly spread though unprotected heterosexual intercourse

  16. Truck Drivers, India and HIV • 10% of truckers are estimated to carry HIV • Approximately 9 in 10 visit prostitutes • The vast majority have never used a condom • They serve as links between the general population and other high risk groups

  17. Homosexuality, Lijras, India and HIV • Strong social taboos against homosexuality cuts across all classes and cases • HIV infection rates are approximately 70% among gay men • Lijras, ritually castrated males, are also reporting more sex work with males, hence a correspondingly high seroconversion rate A & U, 1/99

  18. Beginning HIV PreventionActivities in India • Mobilization of media resources to spread HIV prevention news on the radio and television in each of the 16 geographical dialects • Free HIV testing • Mandatory HIV screening at blood banks and donor camps A & U, 1/99

  19. Beginning HIV PreventionActivities in India • Mandatory health education in high schools and colleges • AIDS literature distribution at bazaars, hotels and movie theaters • Free condom distribution through schools and brothels, barbers, coffee shops, etc. A & U, 1/99

  20. AIDS in Africa • The U.S. spends $880 million a year fighting HIV/AIDS in the face of 40,000 new cases annually • Africa deals with 4 million new cases a year and spends between $149 million and $160 million

  21. AIDS in Africa • “Some 200,000 people, most of them women and children died in 1998 as a result of armed conflict on the African continent, and yet 2 million Africans were killed by AIDS in that same year” • “These countries need income support, debt relief and strong social safety nets” Carol Bellamy, UNICEF Executive Director XIth International Conference on AIDS and STDs” Lusaka, Zambia, 9/15/99

  22. AIDS in Africa • “AIDS is Africa’s real foe and Africa gets little aid” • “AIDS is Africa’s most terrible undeclared war, it has turned sub-Saharan Africa into a killing field” Carol Bellamy, UNICEF Executive Director XIth International Conference on AIDS and STDs” Lusaka, Zambia, 9/15/99

  23. Africa is the target of the world AIDS cartel. They want to pin it on us, to destroy us with it Balfour Ankomah Ghanaian Publisher, New Africa

  24. In the United States: Tuskegee study (syphilis knowingly not treated in African American though US government health care officials were aware of the epidemic Distrust of the Health Care System as a Cofactor in HIV Transmission • In South Africa: Apartheid government’s reported inoculation of blacks with poisons in biological warfare tests

  25. HIV/AIDS in Zambia • In Zambia, the average life expectancy has dropped from 56 to 37 • In other southern African countries such as Zimbabwe, Namibia, Malawi and South Africa, the impact of HIV/AIDS is quite similar • Well paid Zambians receive $50 per month, so AZT remains unaffordable • The average amount spent on healthcare for Zambians is $8 per year A & U, 8/99

  26. HIV/AIDS in Zambia • Tribal/ethnic taboos discourage open discussion about sex • Birth control is unpopular, especially in the villages (the more children a family has, the better its social standing • Homosexuality is illegal in Zambia • “Death his so commonplace that coffins are sold out of vans on the roadside” A & U, 8/99

  27. Orphans in Zambia:HIV’s Impact • Zambia has the highest concentration of AIDS orphans (in Africa, there are over 35 million orphans) • Some 90,000 children live on the streets, sole survivors of families wiped out by the virus • More than 50% of all Zambian children have lost at least one parent, most to AIDS • They survive with the help of underfunded community groups such as the Fountain of Hope which gives out nissha and whatever else it can afford A & U, 8/99

  28. Orphans in Zambia:HIV’s Impact • Children as young as 8 will sell their bodies • Five year olds are found to have sexually transmitted disease • To number their misery, the “orphans turn to: A & U, 8/99

  29. Orphans in Zambia:HIV’s Impact • No one knows how many orphans are infected because testing would do no good “…testing would depress the children and there is not treatment to offer” A & U, 8/99

  30. AIDS in African Youth • A multisite study conducted in 1997 and 1998 in Africa demonstrated dramatically high levels of HIV in teenage girls • The study showed that 15-23% of girls between 15-23 years old are infected with HIV in the 4 countries studied: Zambia, Kenya, Benin and Cameroon Study Group on Heterogeneity of HIV Epidemics, XIth International Conference on AIDS and STDs, 9/00 Lusaka, Zambia

  31. AIDS in African Youth • Only 3-4% of boys the same age in the four African nations are infected with HIV • Among men 25 or older, the rate of HIV infection was between 26-40% Study Group on Heterogeneity of HIV Epidemics, XIth International Conference on AIDS and STDs, 9/00 Lusaka, Zambia

  32. AIDS in African Youth • The study’s conclusion was that girls are getting infected by older men, not boys their own age • Prevention agendas must focus on changing male sexual behavior to stem the spread of HIV/AIDS Study Group on Heterogeneity of HIV Epidemics, XIth International Conference on AIDS and STDs, 9/00 Lusaka, Zambia

  33. Botswana Lesotho Namibia Malawi Mozambique South Africa Swaziland Tanzania Zambia Zimbabwe Southern Africa The countries and kingdoms of Southern Africa

  34. In many Southern African countries HIV/AIDS has become an unprecedented emergency with 20% to 26% of people between the ages of 15-49 infected with the virus David Satcher, MD, Surgeon General of the United States, JAMA 4-28-99, Vol. 281, No. 16

  35. HIV spreads rapidly in Africa because many STDs go untreated. Untreated STDs break down natural barriers that prevent transmission David Satcher, MD, Surgeon General of the United States, JAMA 4-28-99, Vol. 281, No. 16

  36. “If you wanted to spread an STD, you’d take thousands of young men away from their families, isolate them in single-sex hostels, and give them easy access to alcohol and commercial sex. Then, to spread the disease around the country, you’d send them home every once in a while to their wives and girlfriends. And that’s basically the system we have with the mines.” Mark Lurie, Scientist Medical Research Council, South Africa, Village Voice, May 4, 1999, pgs. 46-49

  37. Between 27% to 41% of miners around the town of Carletonville, South Africa are HIV-positive • Two-thirds of the women in the surrounding squatter camps are also HIV-positive Village Voice, May 4, 1999, pgs. 46-49

  38. 22.8% to 30% of South African women attending prenatal clinics are infected with HIV Village Voice, May 4, 1999, pgs. 46-49

  39. HIV-2 • HIV-2 is capable of causing the same clinical syndrome as HIV-1 • CD4 cell depletion and opportunistic infections occur in some people • Inaggregate HIV-2 has a less aggressive biological behavior than HIV-1

  40. HIV-2 • HIV-2 is transmitted less efficiently by heterosexual intercourse or from mother to child than is HIV-1 • The rate of CD4 cell count decline is less • There is a lower viral burden in persons infected with HIV-2

  41. HIV-2 • A lower level of viral replication is present in HIV-2 therefore there are lower rates of evolution of genetic sequence variation over time • In cell culture, HIV-2 is less cytopathic • Undetectable plasma viremia is common with HIV-2 infection among patients with high CD4 percentages (>28%)

  42. HIV-2 • With advanced immunodeficiency, viral load measurements are similar in both infections • The major serologic difference between HIV-1 and HIV-2 resides in the envelope glycoproteins • First reported in 1986

  43. HIV-2 • HIV-2 has a more limited geographic distribution; more so in West Africa and in countries with social and economic ties to West Africa (i.e, France, Portugal) • Most HIV-2 infected patients will be identified as “HIV positive” using HIV-1 assays but some cases are missed using HIV-1 reagents

  44. HIV-2 • The NYC DOG and the American Association of blood banks uses a combined HIV-1/HIV-2 EIA for screening • Treatment strategies for HIV-2 are being developed, the virus does respond in vitro to NRTIs and protease inhibitors but not to NNRTIs

  45. Case Study R.A., a 33 year old pregnant woman from Ghana, West Africa presented for routine prenatal HIV counseling and testing during her second trimester. The test was positive. She reported testing negative 2 years ago in Ghana as part of her immigration application process. Her CD4 count was 573 cells/mm3 and her HIV-RNA was undetectable (<400 copies/ml by Roche PCR) on two occasions

  46. Case Study AZT/3TC was prescribed to prevent perinatal transmission. R.A. never filled the prescriptions being unconvinced that she was HIV-positive. She was asymptomatic and thriving. She delivered a healthy baby in 2/99. The newborn screening of the baby mandated by NYS revealed: • a positive HIV-1 antibody test (enzyme immunoassay, EIA) • a negative HIV-1 PCR for proviral DNA • an equivocal HIV-1 western blot

  47. Case Study • Subsequent evaluation of R.A.’s blood by NYC DOH revealed infection with HIV-2. This explained why her viral load was undetectable by both PCR and bDNA.

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