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Catherine Hankins MD MSc CCFP FRCPC Chief Scientific Adviser to UNAIDS

HIV 101 History of the Epidemic. Catherine Hankins MD MSc CCFP FRCPC Chief Scientific Adviser to UNAIDS Office of the Deputy Executive Director, Programme. AIDS Vaccine 2011 Conference Journalist Scholarship Program Bangkok, Thailand, September 11, 2011.

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Catherine Hankins MD MSc CCFP FRCPC Chief Scientific Adviser to UNAIDS

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  1. HIV 101 History of the Epidemic Catherine Hankins MD MSc CCFP FRCPC Chief Scientific Adviser to UNAIDS Office of the Deputy Executive Director, Programme AIDS Vaccine 2011 Conference Journalist Scholarship Program Bangkok, Thailand, September 11, 2011 Zero new HIV infections Zero discrimination Zero AIDS-related deaths

  2. HIV 101: History of the Epidemic • Milestones, new concepts, scientific breakthroughs • Prevalence • Incidence • Tracking structural determinants of HIV transmission and measuring behaviour change • Antiretroviral treatment coverage and impact • Commitments

  3. 2011 – A year of milestones • 30 years of AIDS since 1981 • WHO Global Program on AIDS 1984-1995 • Creation of Joint UN Programme on AIDS 1995 • 15 years of triple combination antiretroviral therapy (ART) • 10 years implementing the Declaration of Commitment on HIV – UNGASS 2001 • 10 years of Millennium Development Goals (MDGs) and 5 more years to achieve them • 5 years of Universal Access (UA) – 2006 Political Declaration on HIV • High Level Meeting (HLM), New York, June 2011 and 2nd Security Council Resolution (first was in 2000)

  4. 2001 2011 Epidemic Endemic Minimal response Increasing services Increasing funding Flat-lined funding “A,B,Cs” Combination prevention Emergency response Sustained response • Treatment vs prevention HPTN 052 (treatment for prevention); Treatment and Prevention • AIDS exceptionalism AIDS leads the way • Criminals Citizens

  5. Number of people living with HIV and scientific breakthroughs, 1981–2011 iPrEX trial in men who have sex with men in Peru, Ecuador, Brazil, Thailand, USA and South Africa reports 44% reduced HIV acquisition in men taking a single daily tablet of FTC/TDF First combination pill uniting three drugs (AZT/3TC/ abacavir) approved CAPRISA 004 trial in South Africa shows that vaginal tenofovir gel reduces women’s risk of HIV acquisition by 39% over 30 months First cases of unusual immune deficiency identified among gay men Short-course AZT and single-dose nevirapine reduce vertical HIV transmission Combination treatment with at least three antiretroviral drugs Clinical trials in Kisumu, Kenya, and in Rakai, Uganda, confirm efficacy of male circumcision for HIV prevention RV144 vaccine trial in Thailand shows 31% protection First HIV antibody tests developed Revised surveillance case definition for AIDS Mio 40 30 20 10 0 1981 1985 1990 1995 2000 2005 2010 2011 Human immunodeficiency virus (HIV) identified as the cause of AIDS Zidovudine (AZT) approved for treatment ACTG protocol 076 shows that AZT prophylaxis reduces vertical transmission Effectiveness of needle exchange programmes established Rapid HIV test approved Clinical trial of male circumcision in Orange Farm, South Africa, shows reduced HIV transmission IMAGE intervention of combined microfinance and training results in reduced risk behaviour among young women Kesho Bora study in Burkina Faso, Kenya, & South Africa reveals triple ART halves the risk of HIV transmission through breastfeeding; Partners PrEP and TDF-2 trials show 63-73% reduction in HIV acquisition; HPTN 052 trial finds ART reduces HIV transmission 96% in serodiscordant couples

  6. Singapore, 1994 All the smartest bodies in town are wearing rubber. Design: Action for AIDS, Singapore. Museum für Gestaltung Zürich

  7. Adults and children estimated to be living with HIV  2009 Eastern Europe & Central Asia 1.4 million [1.3 million – 1.6 million] Western & Central Europe 820 000 [720 000 – 910 000] North America 1.5 million [1.2 million – 2.0 million] East Asia 770 000 [560 000 – 1.0 million] Middle East&North Africa 460 000 [400 000 – 530 000] Caribbean 240 000 [220 000 – 270 000] South & South-East Asia 4.1 million [3.7 million – 4.6 million] Sub-Saharan Africa 22.5 million [20.9 million – 24.2 million] Central & South America 1.4 million [1.2 million – 1.6 million] Oceania 57 000 [50 000 – 64 000] Total: 33.3 million[31.4 – 35.3 million]

  8. HIV Prevalence: 33.3 million [31.4 –35.3] in 2009, compared to 26.2 million [24.6–27.8] in 1999 (27% increase) • HIV Prevalence Proportion: constant at 0.8% of the global population since 2001 Source: UNAIDS.

  9. Global summary of the AIDS epidemic  2009 Total Adults Women Children (<15 years) Total Adults Children (<15 years) Total Adults Children (<15 years) 33.3 million[31.4 –35.3 million] 30.8 million [29.2 –32.6 million] 15.9 million [14.8 –17.2 million] 2.5 million [1.6 –3.4 million] 2.6 million[2.3–2.8 million]2.2 million [2.0 –2.4 million]370 000 [230 000–510 000] 1.8 million[1.6 million–2.1 million]1.6 million[1.4 million–1.8 million]260 000 [150 000–360 000] Number of people living with HIV People newly infected with HIV in 2009 AIDS deaths in 2009

  10. Figure 2.6 Trends in women living with HIV Proportion of people 15 years and older living with HIV who are women, 1990–2009. 70 Sub-Saharan Africa 60 Caribbean 50 GLOBAL 40 30 Eastern Europe and Central Asia 20 Central and South America 10 Asia % ‘91 ‘92 ‘93 ‘94 ‘96 ‘97 ‘98 ‘99 ‘01 ‘02 ‘03 ‘04 ‘06 ‘07 ‘08 ‘09 ‘90 ‘95 ‘00 ‘05 Western and Central Europe and North America Source: UNAIDS.

  11. Estimated number of adults and children newly infected with HIV  2009 Eastern Europe & Central Asia 130 000 [110 000 – 160 000] Western & Central Europe 31 000 [23 000 – 40 000] North America 70 000 [44 000 – 130 000] East Asia 82 000 [48 000 – 140 000] Middle East&North Africa 75 000 [61 000 – 92 000] Caribbean 17 000 [13 000 – 21 000] South & South-East Asia 270 000 [240 000 – 320 000] Sub-Saharan Africa 1.8 million [1.6 million – 2.0 million] Central & South America 92 000 [70 000 – 120 000] Oceania 4500 [3400 – 6000] Total: 2.6 million [2.3 – 2.8 million]

  12. HIV Incidence Annual number of people newly infected with HIV decreased by 19% from 3.1 million [2.9–3.4] in 1999 to 2.6 million [2.3–2.8] in 2009 4.0 3.5 3.0 M I L L I O N S 2.5 2.0 1.5 1.0 0.5 0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Dotted lines represent ranges, solid lines represent the best estimate.

  13. Young people are leading the prevention revolution by taking definitive action toprotect themselves from HIV • HIV prevalence in young people aged 15-24 has declined in 22 high burden countries in sub-Saharan Africa (by 25% in 15 of these countries): • delaying onset of sex • fewer partners • correct and consistent condom use

  14. Figure 2.5 Global HIV trends, 1990 to 2009 Number of people living with HIV Number of children living with HIV Adult and child deaths due to AIDS Number of orphans due to AIDS Dotted lines represent ranges, solid lines represent the best estimate. Source: UNAIDS.

  15. J A K B CRF01_AE C CRF02_AG D CRF03_AB F Other CRFs G URFs H Regional distribution of HIV-1 subtypes and recombinants (2004-2007)

  16. Intertwined epidemiology • People are injecting drugs in 148 countries: • 16 million [11-21] people worldwide(largest populations of people who inject drugs are in USA, Russia, Brazil) • 5 million in 13 PEPFAR focus countries: Cambodia, China, Indonesia, Vietnam, Georgia, Kazakhstan, Kyrgyzstan, Russia, Tajikistan, Ukraine, Kenya, Tanzania, and South Africa • Among people who inject drugs, HIV has been documented in 120 countries: • 3 million [0.8-6.6 million] people • 10% of people living with HIV • 30% of people living with HIV outside sub-Saharan Africa Source: Mathers, Degenhardt, Phillips et al for the 2007 UN Reference Group on HIV and Injecting Drug Use. Lancet Sept 24, 2008

  17. Table 3.1 Countries in which HIV infections among people who inject drugs represent 20% or more of the total number of people living with HIV Azerbaijan Canada China Estonia Georgia Indonesia Islamic Republic of Iran Italy Kazakhstan Kyrgyzstan Malaysia New Zealand Pakistan Russian Federation Spain Tajikistan Ukraine United States of America Uzbekistan Source: Mathers et al. (12).

  18. 0 Caribbean (4) Central and South America (10) Eastern Europe and Central Asia (12) Middle East and North Africa (7) Sub-Saharan Africa (39) Western and Central Europe (9) South and South East Asia (13) ART Coverage Prevention prioritising key populations Insufficient data available from North America,Oceania, East Asia. Countries setting universal access targets, by region 2004–2010 % of countries setting targets 100 80 60 40 20

  19. Countries criminalizing same-sex sexual activities between consenting adults, 2009

  20. * Ever-married women who experienced physical or sexual violence from their most recent spouse or co-resident partner. Violence against women in 2009*

  21. Used a condom at last higher risk sex – females Countries with prevalence more than 2%, 1995–2010 1) identifies statistically significant decrease in high-risk sex 2) indicates statistically significant increase in high-risk sex. Source: Demographic and Health Surveys, and other national surveys

  22. Number of people receiving ART in low- and middle-income countries by region 2002–2009 2010 > 6 million people AIDS-related deathsdecreased from 2.1 million [1.9–2.3] in 2004 to 1.8 million [1.6–2.1] in 2009 Souce: WHO/UNAIDS Universal access Report 2010

  23. Coverage of antiretroviral therapy at the end of 2009 (WHO 2010 Guidelines, CD4<350)

  24. Treatment benefits are clear…. Since 1996 the availability of effective treatment, has saved some 2.9 million lives… The number of AIDS-related deaths has declined by over 10% over the past five years…

  25. The epidemic has changed • tremendous progress in stabilizing or reducing new infections in nearly 60 countries • rampant stigma and discrimination continues to contribute to rising HIV infections among key populations at higher risk and to the vulnerability of women and girls • many countries still have laws, regulations or policies that present obstacles for populations at higher risk or other vulnerable populations to access prevention, treatment, care and support

  26. 50%  in sexual transmission of HIV 50%  of HIV among people who inject drugs 50% TB deathsin people living with HIV Ensure no children are born with HIV and reduce AIDS-related maternal deaths 15 million on antiretroviral treatment Bold new targets for 2015

  27. Security Council Resolution number 1983 • Reaffirms significance of epidemic to individual, national and global security • Respects and promotes human rights in conflict/post-conflict • Recognizes link between HIV and violence against women • Recognizes contribution of UN peacekeeping operations to integrated response to HIV

  28. UNAIDS Strategy: Getting to Zero Vision and goals: Strategic directions: Zero new infectionsRevolutionize prevention Zero AIDS-related deathsCatalyze the next phase of treatment, care and support Zero discriminationAdvance human rights and gender equality for the HIV response

  29. Overview of the state of the HIV epidemic • Milestones, new concepts, scientific breakthroughs to 2011 • Prevalence: increased 27% in 10 years • Incidence: decreased 19% in 10 years • Tracking structural determinants of HIV transmission and measuring behaviour change: need to address stigma and discrimination, criminalisation, intimate partner violence, and gender inequality • Antiretroviral treatment coverage and impact: increasing • Commitments: 50% transmission reductions and ‘15 by 15’.

  30. VISION ZERO NEW HIV INFECTIONS. ZERO DISCRIMINATION.ZERO AIDS-RELATED DEATHS.

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