j2j 2006 optimized Jon Cohen

Slide1: 

The World of HIV/AIDS Photos (good ones) by Malcolm Linton

Overview*: 

Overview* History and Epidemiology Existing prevention strategies Existing treatment strategies Future treatment and prevention strategies * Heavily spiced with politics, economics, ethics, odd ideas and opinions

Slide3: 

90% of infections in SSA, Asia, and LatAm and Carib Total: 38.6M Sub-Saharan Africa: 24.5 M Asia: 8.3M LatAm and Carib: 1.9M End of 2005, UNAIDS

*First report in MMWR on June 5, 1981* 11 MMWRReports by September 1982: 

*First report in MMWR on June 5, 1981 * 11 MMWR Reports by September 1982

The “Race” is On: April 23, 1984: 

The 'Race' is On: April 23, 1984 PREDICTIONS Blood test, widely available 6 months YES 'We hope to have such a vaccine ready for testing in approximately two years,' HHS Secretary Margaret Heckler YES, BUT NO 'What we have at the moment is not particularly of great benefit to people who have the disease…but it hopefully will be in a short while,' Asst. Sec. of Health, Edward Brandt NO

The #1 Problem: 

The #1 Problem If HIV were TB, a cure would exist If HIV were HBV or polio, a vaccine would exist today 9 subtypes

Get Inside the Enemy’s Head: 

Get Inside the Enemy’s Head HIV’s Profile Objectives: Copy and Spread Body Type: Retrovirus, RNA Attributes: No brains, morals or political agenda Desired residence: Anywhere Turn Ons: Anal Sex, Vaginal Sex, Injecting Drugs, Pregnancy Turn Offs: Condoms, ARVs, Clean needles, Immune System

We Aren’t the World: 

We Aren’t the World Countries, companies, research institutions have different agendas and needs Organizing scientists is like herding cats Politics continues to trump science

The Big Logistical Problems: 

The Big Logistical Problems Most HIV+ don’t know infected Only 1.3 million of 5.5 million in need receive ARVs as of 12/05 Scaling up treatment: monitoring, training, FDCs Not much $ in vaccines, microbicides, generics Prevention efforts woefully lacking

What Drives HIV’s Spread?: 

What Drives HIV’s Spread?

Sub-Saharan Africa has 10 countries with adult prevalence >10% : 

Sub-Saharan Africa has 10 countries with adult prevalence andgt;10% Botswana: 24.1% CAR: 10.7% Lesotho: 23.2% Malawi: 14.1% Mozambique: 16.1% Namibia: 19.6% South Africa: 18.8% Swaziland: 33.4% Zambia: 17.0 % Zimbabwe: 20.1%

Why the high Prevalence in Sub-Saharan Africa?: 

Why the high Prevalence in Sub-Saharan Africa? Concurrent sexual partnerships both male and female Intergenerational sex: Sugar daddies Migration and poverty Concurrent untreated STDs (HSV-2) Lack of circumcision Sex work and clients

Slide13: 

General Population Multi-Partner Sex in Last Year UNAIDS

Age and gender specific prevalence of HIV infection in rural South Africa: 

Source : Abdool Karim Q et al, AIDS 1992 Epidemiology: Gender differences 0 andlt;9 10-14 JUN/JUL 92 15-19 20-24 25-29 30-39 40-49 2 4 6 8 10 Male Female Prevalence (%) Age and gender specific prevalence of HIV infection in rural South Africa

HSV-2 and Circumcision: 

(Buve, AIDS, 2001) HSV-2 and Circumcision 2 high prevalence cities, 2 low ~1000 males and ~1000 females in each

Circumcising Adults?: 

Circumcising Adults? Orange Farm, South Africa, August 2005

Asia: 

Asia Huge populations in India and China: andgt;1/3 of world Injecting drug use: heroin producing Sex work Thai Success

India: 

India Different epidemics 5.7 million HIV+ Adult prevalence: 0.9%

China: 

China Blood plasma scandal IDUs

Southeast Asia: 

Southeast Asia Thailand: sex workers and IDUs Myanmar/Burma: big heroin producer Cambodia: No IDUs Vietnam: IDUs

HIV Moves with Heroin: 

HIV Moves with Heroin

Slide22: 

Preventing an IDU epidemic slows or averts a sex work epidemic…Projected epidemic in Jakarta with and w/o IDUs: 

Preventing an IDU epidemic slows or averts a sex work epidemic… Projected epidemic in Jakarta with and w/o IDUs Pisani, FHI Indonesia

Doubling number of clients produces more rapidly growing epidemic: 

By 2030, 13.2% of males, 5.4% of females HIV+ Doubling number of clients produces more rapidly growing epidemic Brown/Wiwat, East-West Center

But prevention must be sustained..: 

But prevention must be sustained.. If condom use falls, HIV rises, even in Thailand Supposing condom use drops to 60% starting 1998

Latin America and Caribbean: 

Latin America and Caribbean Caribbean: highest prevalence outside Sub-Saharan Africa Latin America: Similar to Asia, but little IDU Drivers: Migration Poverty Sex tourism Clients of sex work MSM Contrasts Abound

Evolution of Epidemic: 

Evolution of Epidemic Starts in Haiti, 1982 cases surface

The Caribbean:Heterosexual: 

The Caribbean: Heterosexual

Haiti’s Successes: 

Haiti’s Successes Lowered prevalence Pioneered treatment of poor

Dominican Republic’s Challenges: 

Dominican Republic’s Challenges Bateyes Sex work Treatment programs

Puerto Rico: 

Puerto Rico IDU driven Topnotch research Topnotch care--for non-IDUs

Mexico and Central America: 

Mexico and Central America MSM Migration Wars, Gangs Special populations Sex Work

Honduras Hotspot: 

Honduras Hotspot Garifunas Migration Regional wars MSM Sex workers Prisons

Mexico: 

MSM Anti-homophobia campaign Migration Mexico

Guatemala:Treatment and Care Uneven: 

Guatemala: Treatment and Care Uneven Centralized Drug supply Discrimination Transition issues

South America: 

South America Brazil andgt; ½ cases Andean region MSM Southern cone was IDU

Brazil: 

Brazil Pioneered universal access Escalating costs Sex-positive prevention

Argentina : 

Argentina Epidemics change Was IDU cocaine and MSM Now primarily heterosexual

Peru: 

Peru Research magnet MSM Leading researchers from community

One Size Doesn’t Fit All: 

One Size Doesn’t Fit All

Prevention Efforts Woefully Lacking: 

Prevention Efforts Woefully Lacking Scattershot targeting of high-risk groups Treatment benefits prevention 9 billion more condoms/year needed Harm reduction for 3.6% of IDUs ARVs for 3% of pregnant HIV+

Treatment Issues: Rich vs. Poor: 

Treatment Issues: Rich vs. Poor AZT d4T ddI ddC NVP EFV IND SQV 3TC FTC T-20 RT NRTI NNRTI PI FI CD4 CCR5 VL

The Cocktails Work: 

Percentage of Patient-days on HAART Deaths per 100 Person-Years Frank Palella/HOPS The Cocktails Work

Resistance and Side Effects: 

Resistance and Side Effects

Other Treatment Limitations for Rich and Poor Countries Alike: 

Other Treatment Limitations for Rich and Poor Countries Alike Many HIV+ don’t know infected Adherence: Simpler regimens needed Training of clinicians Proper monitoring No cure exists

The Story of Henan: 

The Story of Henan Henan Province had 20% dropout first year, no 3TC, and NVP resistance in first 9 months was 20%-30%.

Solution: Direct Observation of Treatment Strategy (DOTS): 

Solution: Direct Observation of Treatment Strategy (DOTS)

Solution: FDC(Fixed Dose Combination): 

Solution: FDC (Fixed Dose Combination)

Solution: Proper training and monitoring: 

Solution: Proper training and monitoring

New Players: 

New Players President’s Emergency Plan for AIDS Relief (PEPFAR) $150 Million To Fund, andgt;$500 Million to HIV Vaccine $15 billion/5 years $5.5 Billion Committed

Mind the Gap: 

Mind the Gap

Future Treatment Possibilities: 

Future Treatment Possibilities New Targets: Integrase, APOBEC-3B

The Search for an AIDS Vaccine: A Long Battle: 

The Search for an AIDS Vaccine: A Long Battle WPost, 6/21/88 Discover, September 1990 WPost, 5/21/90 Nature, 6/23/88

Evidence that an AIDS vaccine is possible: 

Evidence that an AIDS vaccine is possible Exposed, uninfected Protected monkeys Longterm nonprogressors

Global HIV Vaccine Enterprise: 

Global HIV Vaccine Enterprise Serious new money from Gates and NIH (Total: andgt;$500 million) Shared strategic plan Greater collaboration

Future Prevention Possibilities: 

Future Prevention Possibilities Circumcision Drugs as Prophylaxis PrEP Acyclovir Microbicides Acute Infection

Meeting slammed as circus…It is the greatest show on Earth: 

Meeting slammed as circus…It is the greatest show on Earth