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Spectrum 2007 Overview and New Changes. UNAIDS Reference Group on Estimates, Model and Projections 2007. Purpose. Determine the consequences of the prevalence estimates made with EPP or Workbook New infections, HIV+ population, AIDS deaths Need for treatment and effects of treatment - PowerPoint PPT Presentation
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Spectrum 2007Overview and New Changes
UNAIDS Reference Group on Estimates, Model and Projections
2007
Purpose
• Determine the consequences of the prevalence estimates made with EPP or Workbook– New infections, HIV+ population, AIDS deaths– Need for treatment and effects of treatment– Orphans and vulnerable children
New Features
1. New treatment options• Adults: 1st and 2nd line ART• Children: ART and cotrimoxazole
2. Updated progression periods• New infection to need for treatment• Need for treatment to AIDS death w/wo treatment
3. Expanded PMTCT options4. Calibrate to multiple national surveys5. Uncertainty analysis
Inputs required
Country data• Demographic data• Adult prevalence-------------------------• MTCT program
description• PMTCT coverage• Adult ART coverage• Child treatment
coverage
Epidemic patterns• Effect of HIV on fertility• Progression from infection to
need for treatment and to AIDS death
• Sex ratio of prevalence• Age distribution of infection• Mother-to-child transmission
rates by regimen and feeding options
• Effect of child treatment
Creating a new projection
Population Projection
Population Projection
Population Projection
The first year of the projection must be before the start of the AIDS epidemic, usually 1980
Population Projection
The last year of the projection can be anything up to 50 years, but it is best to match the prevalence estimate (2012 for EPP, 2007 for the Workbook)
Population Projection
Population Projection
Population Projection
Creates a projection using the UN Population Division’s World Population Prospects
Entering data
Selecting inputs to edit
Adult HIV Prevalence
Adult HIV Prevalence
Documenting sources
Effect of HIV on fertility
Effect of HIV on fertility
15-19: 50% increase
20-49: 30% decrease
TFR of HIV- adjusted to leave population TFR unchanged
Age and Sex Ratio of HIV Prevalence
Ratio of prevalence at each to prevalence at 25-29 : Females
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1980 1985 1990 1995 2000 2005 2010
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 +
Ratio of prevalence at each to prevalence at 25-29 : Males
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1980 1985 1990 1995 2000 2005 2010
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
Age and Sex Ratio of HIV Prevalence
Sex ratio of HIV prevalence
Sex ratio of HIV prevalence
Ratio of Female to Male HIV Prevalence
0.0
0.5
1.0
1.5
2.0
2.5
0 5 10 15 20 25
Years Since the Start of the Epidemic
Cameroon DHS
Zambia DHS
Kenya DHSGhana DHS
Burkina Faso DHS
Kapiri Mposhi 98
Masaka 89-97Rwanda 86
Uganda 88
Mali DHS
DR DHS
Uganda 2004-05
Rwanda DHS
Senegal DHS
Guinea DHS
Tanzania DHS
Lesotho DHS
South Africa HSRC
Cote d'Ivoire DHS
Malawi 2004
Ethiopia DHS
Zim
Progression from HIV Infection to AIDS Death (Adults)
New HIV Infection
Need for Treatment
First Line ART
AIDS Death
Second Line ART
Need for 2nd Line
Net survival adjusted to age 25-29
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 1 2 3 4 5 6 7 8 9 1 1
Kisesa
Masaka
Rakai
SA miners
Thai military
0 1
Source: Zaba and Todd, Alpha network
Time from AIDS or CD4<200 to death in the absence of HAART
Time measured from
Published studies from resource-poor settings (median, range)
Estimates from the Swiss HIV cohort study (median, 95% CI)
AIDS
CD4 count <200 (median 100)
150< CD4< 250 (median 200)
11 (7 – 19)
11 (7 – 38)
35 (estimated)
17.6 (15.9 – 19)
24.0 (22.0 – 29.0)
77.0 (52.0 – 92.0)
Source: Zwahlen and Egger
Time from CD4 < 350 to death, and from CD4 < 350 combined with WHO stage III or IV to death in resource limited settings
Time measured from
Natural history of untreated patients
Bayesian synthesis analysis
200 < CD4 < 350
WHO stage III or IV and CD4 < 350
4 – 5 years 5.4 (1.9 – 15.7 years)
2.7 (0.76 – 9.6 years)
Source: Zwahlen and Egger
Incidence (%) of Death After Starting ART
3 months 6 months 12 months 24 monthsBrainstein 2006 5.1 [3.3 – 7.7] 5.1 [3.3 – 7.9] 2.7 [1.9 – 4.0]Etard 2006 12.5 [9.4 – 16.7] 6.6 [4.3 – 10.0]Jerene 2006 37.3 [N M]Lawn 2006 19.1 [14.4-25.2] 2.9 [1.8-4.8] 1.3 [0.4-3.9]Lawn 2005 19.4 [13.0-28.9] 6.2 [2.8-13.9] 2.9 [1.1-7.8]
Source: Dabis et al, ISPED
Progression from HIV Infection to AIDS Death (Adults)
New HIV Infection
Need for Treatment
First Line ART
AIDS Death
Second Line ART
Normal M 7.5yrs/F 8.5yrs, fast 6.1/6.9
3 years
15%/5%
Need for 2nd Line
15% FY / 5% SY3 years
Progression from HIV Infection to AIDS Death (Children)
New HIV Infection
Need for Treatment
First Line ARTAIDS Death
Age-dependent
>5 = 3 years<1, 0.80
>1, 0.9 first year, else 0.95
Marston and Newell, median = 2 years
Adult Male Progression without Treatment
0
20
40
60
80
100
0 2 4 6 8 10 12 14 16 18 20
Years Since Infection
Need TreatmentDead
Adult Male Progression with Treatment
0
10
20
30
40
50
60
0 2 4 6 8 10 12 14 16 18 20
Years Since Infection
On FLOn SLDead
The Need for ART will change from 2005 estimate!
0
50,000
100,000
150,000
200,000
250,000
300,000
1980 1985 1990 1995 2000
2007
2005
Projections of Adult ART Coverage
0102030405060708090
100
2000 2002 2004 2006 2008 2010 2012
Linear Trend Unmet Need % Target Unmet Need Trend
Orphans
% women 15-19 never married: 38%-94% (71%)
% married women in monogamous union: 45%-96% (71%)
Spectrum outputs
Various displays are available
Comparing effects
• Display up to four projections at one time
• Open same projection twice and rename to create comparison scenarios
Estimates of Need
Adult ART •Adults progressed to need for treatment•Simulates WHO guidelines
Child ART Children progressed to moderate-to-severe disease
Cotrimoxazole •Early detection–All HIV+ children
•No early detection–Children born to HIV+ mothers until 18 months–All HIV+ children over 18 months
PMTCT All births to HIV+ women
Plausibility Bounds
Plausibility Bounds
• Uncertainty around prevalence curve– EPP: read sampled curve from EPP .spu file– Workbook: generate 1000 logistic curve fits
by varying annual estimates according to data quality
Summary Table – Plausibility Bounds
Exercise
• Create a new demographic projection using EasyProj
• Read prevalence estimate from EPP or Projections Workbook
• Select appropriate patterns for Progression and Age/Sex Ratios
• Add data on coverage of PMTCT, ART and child treatment programs
• Review key indicators• Do uncertainty analysis