HIV/AIDSHIV/AIDSThe Epidemic in The Epidemic in

ANE and E&EANE and E&ESo what do we do now?So what do we do now?

Paul De LayPaul De Lay

Senior Advisor on Senior Advisor on HIV/AIDSHIV/AIDS

Office of HIV/AIDSOffice of HIV/AIDS

Factors that influence Factors that influence the spread of HIVthe spread of HIV

The VirusThe Virus The HostThe Host The Role of BehaviorThe Role of Behavior

The VirusThe Virus

Time of introduction into a Time of introduction into a populationpopulation

HIV subtypesHIV subtypes Levels of viremiaLevels of viremia

ASIA & OCEANIA

CAMBODIA

THAILAND

BURMA

PAKISTAN

LAOS

INDIA

VIETNAM

LAC

HAITI

HONDURAS

GUYANA

BRAZIL

BELIZE

DOMINICAN REP.

ARGENTINA

BARBADOS

JAMAICA

TRIN. & TOB.

0 10 20 30 40 50

% Seropositive

AFRICA

BOTSWANA

SOUTH AFRICA

LESOTHO

MALAWI

SWAZILAND

ZIMBABWE

ZAMBIA

NAMIBIA

RWANDA

BURUNDI

ETHIOPIA

KENYA

UGANDA

TANZANIA

COTE D'IVOIRE

CAR

LIBERIA

MOZAMBIQUE

BURKINA FASO

TOGO

NIGERIA

CHAD

CONGO

CAMEROON

GABON

BENIN

CONGO, (ZAIRE)

0 10 20 30 40 50

% Seropositive

HIV-Seroprevalence among Pregnant HIV-Seroprevalence among Pregnant women from Capital or Major Urban women from Capital or Major Urban

Centers in Selected CountriesCenters in Selected Countries

The Host (Us)The Host (Us)

The presence of a sexually The presence of a sexually transmitted diseasetransmitted disease

The age of the personThe age of the person Immunologic characteristicsImmunologic characteristics Male circumcisionMale circumcision

June 1998 UNAIDS/WHO Estimates of HIV Seroprevalence in

South/South-East Asian Countries

< 20% Circumcised > 80% Circumcised

Cambodia 2.40 Pakistan 0.09

Thailand 2.23 Philippines 0.06

Myanmar 1.79 Indonesia 0.05

India 0.82 Bangladesh 0.03

Nepal 0.24[From Halperin D, Bailey R. “Male Circumcision and HIV Infection: Ten Years and Counting,” Lancet 1999; 354: 1813-5]

Elements of HIV/AIDS Elements of HIV/AIDS ProgramsPrograms

PreventionPrevention Blood safetyBlood safety Universal Universal

precautionsprecautions Sexual risk reductionSexual risk reduction Harm reductionHarm reduction Condom social Condom social

marketingmarketing STI managementSTI management Voluntary Voluntary

Counseling and Counseling and TestingTesting

Stigma reductionStigma reduction Preventing MTCTPreventing MTCT Surveillance and Surveillance and

M&EM&E

Care and MitigationCare and Mitigation Palliative carePalliative care Psychosocial supportPsychosocial support Improve nutritionImprove nutrition Effective Treatment of Effective Treatment of

Opportunistic InfectionsOpportunistic Infections Use of Highly Active Use of Highly Active

Anti-Retroviral Therapy Anti-Retroviral Therapy Orphans and Orphans and

Vulnerable ChildrenVulnerable Children Other mitigation Other mitigation

activitiesactivities

Complex Epidemics In Complex Epidemics In Rapidly Changing Rapidly Changing

SocietiesSocietiesSerious localized fociSerious localized foci

Blood IDU MSM Hetero

Bangladesh X X X

Cambodia X X

India X X X X

Indonesia X X X X

Nepal X X X

Russia X X X

CAR X X X

Comparison of average number of Comparison of average number of clients per sex worker versus % of clients per sex worker versus % of young men to utilized sex workersyoung men to utilized sex workers

0

0.5

1

1.5

2

2.5

3

3.5

4

0 10 20 30 40 50 60

% males using sex workers

Ave

rag

e #

of

CS

cli

ents

/day

Indonesia

Philippines

Cambodia

Thailand

Behavior change Behavior change interventionsinterventions

IDU IDU Reduce drug use/harm reductionReduce drug use/harm reduction

MSMMSM Stigma, accessStigma, access

Commercial sex workers and Commercial sex workers and their clientstheir clients Stigma, accessStigma, access

ImplicationsImplications

In South and South-East Asia, condom In South and South-East Asia, condom promotion and STI interventions for sex promotion and STI interventions for sex workers top priorityworkers top priority

In Central and Eastern Asia, Europe, In Central and Eastern Asia, Europe, LAC and North America, programs for LAC and North America, programs for injecting drug users, MSM and, to lesser injecting drug users, MSM and, to lesser extent sex workers, top priorityextent sex workers, top priority

Providing antiretroviralsProviding antiretrovirals

Of the 40 million persons infected, Of the 40 million persons infected, about 6-7 million would qualify for ARV about 6-7 million would qualify for ARV RxRx

250,000 persons in developing world 250,000 persons in developing world are on combination ARVare on combination ARV

WHO has set a target of 3 million WHO has set a target of 3 million persons on ARV Rx by 2005persons on ARV Rx by 2005

Barcelona updateBarcelona update

Should USAID be Should USAID be supporting ARV therapy supporting ARV therapy

in ANE and E&E countriesin ANE and E&E countries

Better health infrastructureBetter health infrastructure ?? Stronger private sector?? Stronger private sector ?Smaller numbers?Smaller numbers Drug production capacityDrug production capacity

Preventing Mother-To-Child Preventing Mother-To-Child HIV Transmission (PMTCT)HIV Transmission (PMTCT)

Over 100 programs in 11 countriesOver 100 programs in 11 countriesIssues:Issues:

stigmastigma controversies over safe infant controversies over safe infant

feedingfeeding treatment of parentstreatment of parents

Will MTCT reduce stigma and Will MTCT reduce stigma and increase use of VCT, Rx????increase use of VCT, Rx????

The Next Five YearsThe Next Five YearsBasic AssumptionsBasic Assumptions

Unlikely to have an effective vaccineUnlikely to have an effective vaccine Microbicide candidates will still be in Microbicide candidates will still be in

Phase III testingPhase III testing Continued growth of epidemic in some Continued growth of epidemic in some

settings in all regions-beware slow growthsettings in all regions-beware slow growth Deterioration/collapse of key social and Deterioration/collapse of key social and

economic sectors in hard hit countrieseconomic sectors in hard hit countries Massive orphan problemMassive orphan problem Increasing # PWAs needing ARV RxIncreasing # PWAs needing ARV Rx Increasing number of success stories at Increasing number of success stories at

national levelnational level

The Next Five YearsThe Next Five Years

Prevention works! Still key to winning the war. Prevention works! Still key to winning the war. Increase care/treatmentIncrease care/treatment Synergy between strategy elementsSynergy between strategy elements Invest in human capacityInvest in human capacity Advances: e.g. microbicides, rapid TB Advances: e.g. microbicides, rapid TB

diagnosisdiagnosis Impact on health infrastructure and other Impact on health infrastructure and other

sectorssectors Improved coordinationImproved coordination