Epidemiology of HIV/AIDS

Objectives
Review the current statistics of HIV/AIDS epidemic globally, in Africa, and in Nigeria Describe the various types of HIV and the major differences between them Review the molecular epidemiology of HIV Understand how HIV is transmitted

Global epidemic update

Estimated 33.4 million persons living with HIV/AIDS as at the end of 20082 Fourth leading cause of death in lowincome countries after LRIs, CHD, and diarrheal diseases1 About one-third are between 15-24 years old Most people are unaware they are infected Young women are more vulnerable
1

WHO 2008 2 WHO/UNAIDS Global HIV Update 2009

Global summary of the AIDS epidemic, 2008

Number of people living with HIV in 2008 People newly infected with HIV in 2008 AIDS-related deaths in 2008
Total Adults Women (aged 15 and above) Children under 15 years 33.4 million [31.1 35.8 million] 31.3 million [29.2 33.7 million] 15.7 million [14.2 17.2 million] 2.1 million [1.2 2.9 million]

Total Adults Children under 15 years

2.7 million [2.4 3.0 million] 2.3 million [2.0 2.5 million] 430 000 [240 000 610 000]

Total Adults Children under 15 years

2.0 million [1.7 2.4 million] 1.7 million [1.4 2.1 million] 280 000 [150 000 410 000]

WHO/UNAIDS Global HIV Update 2009

Despite efforts in prevention, education, treatment and advocacy

Estimated number of adults and children newly infected with HIV, 2008
Western & Eastern Europe Central Europe & Central Asia North America

30 000

110 000

55 000
[36 000 61 000]

[23 000 35 000]

[100 000 130 000] East Asia

Caribbean

20 000
[16 000 24 000]

Middle East & North Africa

75 000

[58 000 88 000]

35 000
[24 000 46 000]

South & South-East Asia

Sub-Saharan Africa Latin America

170 000
[150 000 200 000]

1.9 million
[1.6 2.2 million]

280 000
[240 000 320 000] Oceania

3900
[2900 5100]

Total: 2.7 million (2.4 3.0 million)

WHO/UNAIDS Global HIV Update 2009

Over 7400 new HIV infections a day in 2008

More than 97% are in low- and middle-income countries About 1200 (16%) are in children under 15 years of age About 6200 (84%) are in adults aged 15 years and older, of whom: almost 48% are among women (60% in SSA) about 40% are among young people (1524)
WHO/UNAIDS Global HIV Update 2009

Antiretroviral Treatment (ART)

ART coverage rose from 7% in 2003 to 42% in 2008
especially high coverage achieved in eastern and southern Africa (48%)

Rapid expansion of access to ART

helping to lower AIDS-related death rates contributing to increases in HIV prevalence

WHO/UNAIDS Global HIV Update 2009

Sub-Saharan Africa
Most affected region HIV is now the leading cause of death Estimated 1.9 million new HIV infections in 2008 Estimated 22.4 million Africans live with HIV By 2010, an estimated 106 million children under age 15 are projected to have lost one or both parents, with 25 million of this group orphaned due to HIV/AIDS

ART Coverage: Sub-Saharan Africa

In 2002, only around 50,000 people in subSaharan Africa were receiving ART.
Risen to an estimated 310,000 by the end of 2004 Risen to estimated 2.9 million by the end of 2008

However, only 44% of individuals estimated to be in need of ART are receiving ART
6.7 million people are still in need of antiretroviral therapy

WHO (2009) "Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector"

HIV/AIDS Status - Nigeria

National Median HIV prevalence Estimated No. of people living with HIV/AIDS Annual HIV positive birth Cumulative AIDS death toll Annual AIDS death toll Number requiring ART New HIV infection Total AIDS orphans 4.1% 3.1 million 56,681 2.99 million (males: 1.38 million, females 1.61 million) 192,000 (males 86,178; females 105,822) 857,455 (adults 754,375; children 103,080 336,379 (males 149,095; females 187,284) 2,175,760

Trend In HIV Prevalence Over Time In Nigeria (1991-2010)

5.4 4.5 3.8

5.8 5 4.4 4.6 4.1

1.8

1991

1993

1995

1999

2001

2003

2005

2008

2010

HIV Prevalence (%) by State (HSS 2010)

Benue Akwa-Ibom Bayelsa Anambra FCT Plateau Nasarawa Abia Cross River Rivers Kogi Taraba Borno Edo Enugu Kaduna Lagos Gombe Delta Niger Adamawa Kano Ebonyi Sokoto Ogun Oyo Imo Osun Ondo Kwara Zamfara Yobe Bauchi Katsina Jigawa Ekiti Kebbi 0.0 12.7 10.9 9.1 8.7 8.6 7.7 7.5 7.3 7.1 6.0 5.8 5.8 5.6 5.3 5.1 5.1 5.1 4.2 4.1 4.0 3.8 3.4 3.3 3.3 3.1 3.0 3.0 2.7 2.3 2.2 2.1 2.1 2.0 2.0 1.5 1.4 1.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0

2010 National HIV Prevalence (%) by Age group

5.7% 5.4% 4.9% 4.6%

3.6% 3%

15-19

20-24

25-29

30-34

35-39

40-49

HIV prevention and treatment coverage in Nigeria

ART adults
30-35% of need

ART pediatrics
5-10% of need

PMTCT
11-15% of need

Pediatric ART Targets and Coverage

120000 100000

80000

60000

Number of Children Requiring ARVs Pediatric ART Targets Number of Children on Treatment

40000

20000

0 2004 2005 2006 2007 2008 2009 2010

Types of HIV
HIV-1 and HIV-2
Both transmitted through sexual contact and blood

HIV-1
predominant virus globally and in Nigeria
Slides in presentation will refer to HIV-1 unless indicated otherwise

95% of HIV worldwide mutates rapidly due to high replication rates

HIV-2
less transmissible longer period between infection and illness

HIV-2
Human retrovirus that causes similar immune deficiency due to depletion of CD4 cells Confined primarily to West Africa Compared to HIV-1: - Less transmissible - Associated with less viral burden - Slower rate of cell decline and clinical progression - Does not respond to NNRTIs (e.g. nevirapine) In 2003 sentinel survey in Nigeria, only 3 samples out of 27,708 were of HIV-2 (0.01% prevalence, and 0.2% of all HIV+ people)

HIV-1 subtypes
Different HIV-1 subtypes and Circulating Recombinant Forms (CRFs) dominate regional epidemics
All HIV subtypes exhibit similar clinically relevant transmission and treatment characteristics Studies ongoing to determine clinical significance of subtype differences

Subtype C is largely predominant in southern and eastern Africa, India and Nepal.
Is responsible for around half of all global infections.

Subtype B - most common in Europe, the Americas, Japan and Australia.

Most studied subtype

Subtype A and CRF A/G predominate in west and central Africa Subtype G/AG predominate in Nigeria

Prevalence of HIV and distribution of major clades

From: Spira S, Wainberg MA, Loemba H, et al. J Antimicrob Chemother. 2003 Feb;51(2):229-40.

Modes of transmission
Sexual contact
Male-to-female, female-to-male, male-to-male, and female-tofemale. Worldwide, sexual transmission is the predominant mode accounting for over 80% of transmission

Parenteral
Blood transfusion, IDU through needle-sharing, needle stick accidents. 2.8% of transmission

Perinatal
In utero, during labor/delivery, postpartum through breastfeeding. 2.6% of transmission

HIV cannot be transmitted by casual contact, surface contact, or insect bites

Socio-Economic Factors Facilitating Transmission

Social Mobility Global economy HIV/AIDS follows routes of commerce

Stigma and Denial Denial prevents acknowledgment of risk Stigma People may feel isolated and rejected Prevents risk reduction efforts and care-seeking

People in Conflict Context of war and struggle of power spreads AIDS

Socio-Economic Factors,continued
Cultural Factors
Traditions, beliefs and practices affect understanding of health and disease and acceptance of conventional medical treatment Culture can create barriers which prevent people, and especially women, from taking precautions
For instance, pressure to breastfeed may expose more infants Spousal inheritance Pressure to bear children inhibits condom promotion

Poverty
Lack of information needed to understand and prevent HIV Poor nutritional status Commercial sex for income Reduced access to health care services

Socio-Economic Factors,continued
Gender Inequalities In many cultures men are expected to have many sexual relationships Women suffer gender inequalities, often economic in nature Women may not feel empowered to negotiate whether sex happens at all or to negotiate condom use Drug Use and Alcohol Consumption Impaired judgment Sharing of needles and equipment

Other risk factors

Early age of coitus Multiple sex partners (unprotected sex) among males or females
Keep in mind that a person who is a virgin before marriage (and/or is HIV-negative before marriage), but does not get the spouse tested, can contract HIV during marriage even if the spouse does not cheat

Mode of exposure
Anal sex: risk higher than vaginal

Risk of transmission (sexual)

Transmission of HIV occurs more frequently through penile-anal intercourse and penilevaginal intercourse than other routes Sexual activity that is associated with exposure to infected blood increases the risk of transmission, as does the presence of genital ulcers or STDs Serum HIV viral load is strongly associated with heterosexual transmission between HIVserodiscordant African sexual partners, where transmission was noted to be rare at viral loads <1,500 copies/mL

Risk of transmission (percutaneous)

The risk from occupational needle sticks to health care workers from known HIV-positive source patients in case series performed prior to the availability of potent ART was found to be 0.33-0.5% This is compared with the percutaneous transmission rate for other infectious agents
HBV: 30% (22-31%) HCV: 1.8% (range 0-7%)

Risk of transmission (MTC)

In the absence of interventions, mother-to-child transmission occurs in approximately 25% of live births to HIV-infected mothers. ART can reduce the rate of perinatal transmission by 50% or more Breast-feeding is also a risk factor for HIV transmission. Approximately 1/3 of cases of MTC transmission result from breast-feeding, and the risk increases with the duration of breast-feeding. Thus, interventions to prevent MTC transmission at delivery may be largely negated if mothers are not provided with safe alternatives to breast-feeding

Take home points

The HIV/AIDS epidemic continues to challenge efforts in prevention, care and treatment Nigerias epidemic is characterized by the HIV-1 virus In Nigeria, transmission of HIV-1 occurs predominately through sexual contact Multiple socio-economic factors facilitate spread of HIV-1 among individuals and communities

Questions