The Global HIV Epidemic: Women in Africa and Haiti
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1 The Global HIV Epidemic: Women in Africa and Haiti Jodie Ann Dionne-Odom, MD Assistant Professor Division of Infectious Diseases University of Alabama at Birmingham June 2017
2 None Conflicts of Interest
3 Outline A) Epidemiology of HIV in Women B) PMTCT Haiti C) HIV and Coinfections Zambia and Rwanda Cameroon D) UN AIDS Targets F) Resources
4 Epidemiology
5 unaids.org
6 unaids.org
7 Proportion of new HIV infections by sex, global and eastern and southern Africa, 2015 Percentage (%) Men Women Age (years) global Age (years) eastern and southern Africa Source: UNAIDS 2016 estimates. unaids.org
8 New HIV infections among young women (aged years), Number New HIV infections Global target Source: UNAIDS 2016 estimates.
9 Percentage of people living with HIV (aged years) who have ever been tested for HIV and received the results, men and women, 21 countries, Men living with HIV (aged years) Women living with HIV (aged years) Source: Demographic and Health Surveys, *Includes Dominican Republic and Haiti. unaids.org
10 Percentage of young women (aged years) reporting use of a condom at last sexual intercourse with a non-regular partner in the 12 months prior to the survey, eight countries in sub-saharan Africa, Percentage (%) Lesotho Namibia Kenya Rwanda South Africa* Nigeria Zambia Comoros Source: Population-based surveys, * Data for South Africa refers to condom use at last sex among young women aged who reported being sexually active. unaids.org
11 Demand for family planning satisfied by modern methods among young women (aged years), by country, Percentage (%) Source: Demographic and Health Surveys, unaids.org
12 Why the Disparity? Are Risk Factors Unique to Women in SSA? Structural Factors Poverty, marriage, gender-based violence Concurrent sexual relationships Sexual Factors Age at debut, rate of partner change Partner HIV status and ART access Circumcision status, condom use Biologic cofactors STI, genital tract inflammation HIV subtype C (mixed data) McKinnon Curr HIV/AIDS Reports 2016
13 HIV Susceptibility in Women Surface Area Exposure Time Higher HIV VL in semen HIV co-receptors on the cervix Microabrasions
14 CID 2015
15 Cycle of HIV transmission, a phylogenetic study, KwaZulu-Natal, South Africa, 2016 Source: Centre for the AIDS Programme of Research in South Africa, 2016.
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17 PMTCT Preventing Mother to Child Transmission
18 Antenatal Treatment & MTCT Transmission Rate (%) none AZT mono dual therapy HAART Cooper JAIDS 2002;29
19 sd-nvp sc AZT + Sd-NVP Daily Infant NVP Maternal therapeutic ART Maternal ART prophylaxis Courtesy of Lynne Mofenson, NICHD
20 Stringer JAMA 2010;304
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23 Haiti PMTCT Cascade 100,000 HIV positive women in Haiti 57% tested for HIV in pregnancy 58% received PMTCT WHO 2010 AIDS Progress Report UNAIDS Haiti 2010 Progress Report
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25 Les Cayes Hospital Since 2004, 37,000 patients have been HIV tested, and 3934 (11%) infections identified. (Syphilis in 7%) About 1500 patients in active care on ARVs. Excellent access to ART, no stock outs. 19 community health workers with HIV focus 5 community health workers with general health focus About 300 deliveries per month. 4 obstetricians on staff, 16% c-section rate. Limited radiology, laboratory services
26 Cohort of 2800 HIV-infected adults March November women with pregnancies January 2013: 217 women retained in care (46.9%) 23 women were lost to follow up July 2013: 194 women retained in care (89% of above group). January 2013: 246 women lost to follow up (53.1%) 27 women re-engaged in care July 2013: 219 women remained LFU (89% of above group). Dionne AIDS Research and Treatment 2016
27 Dionne AIDS Research and Treatment 2016
28 Dionne AIDS Research and Treatment 2016
29 Dionne AIDS Research and Treatment 2016
30 Dionne AIDS Research and Treatment 2017
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32 Dionne AIDS Research and Treatment 2017
33 So, What?
34 Busza JAIS 2012
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36 PMTCT in Low-Income Settings Ensure universal antenatal HIV testing Point of care tests (CD4, HIV viral load) Maintain constant drug supply Task-shifting but facility delivery Improve retention in care from day #1 Involve partners, family, other support Integrate maternal and pediatric care Define safety outcomes with ART exposure in utero
37 HIV and Coinfection in Women
38 Important HIV Coinfections Globally Malaria Tuberculosis Hepatitis B/C Sexually Transmitted Infections
39 Chico JAMA 2012
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41 Zambia INDICATORS ZAMBIA US Population (million) Life Expectancy (y) 38.9 (52 in 1980) 78.2 Literacy (%) Female 75 Male Parity Infant Mortality (per 1000 live births) HIV Prevalence (%) Syphilis Prev (%) Unemployment (%) Roads/Paved (km) 91,440/20, m/4.2m Physicians 646 (2006) 853,000 (2002) Nurses 6096 (2006) 2,900,000 (04) Medical Schools
42 Rwanda Population: 10.2 million About the size of Maryland Life Expectancy: 49.8 years Literacy: 70% Total health expenditure per capita: $19 Total Number of physicians: 432 Circumcision Rate: 15% HIV Prevalence: 3.1% (PEPFAR 2008) (70% of those meeting WHO criteria are on ARVs) Clade A RPR+ Prevalence: 5% F, 7% M (CVCT site 2007)
43 CDC Syphilis Treatment Guidelines Primary, Secondary, Early Latent Syphilis Late Latent or Syphilis of Unknown Duration 2.4 mu benzathine penicillin x1 2.4 mu benzathine penicillin weekly x3 Irrespective of HIV status.
44 Syphilis Treatment Case reports of coinfected patients failing standard therapy for early syphilis Limited available comparative data demonstrate no enhanced efficacy of additional doses of BPG, amoxicillin, or other antibiotics in early syphilis, regardless of HIV status.
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46 Dionne CID 2013
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48 Dionne CID 2013
49 Antenatal Infections in Cameroon; 2015 Dionne ID OB GYN 2016
50 Malaria in Pregnancy in 7647 women with recent pregnancy (DHS 2011) 5% HIV prevalence 34% owned a bed net 17% used a bed net on the night prior to the survey 62% took medication to prevent malaria Cameroon Dionne Malaria Journal 2017
51 Characteristics of 133 Pregnant Women with HIV in Cameroon: Malaria Prevalence and Prophylaxis Characteristic n (%) Timing of HIV Diagnosis With Current Pregnancy 1-2 years ago 3+ years ago Prescribed ART Yes No Prescribed CTX Yes No Bed Net Ownership Yes No Bed Net Condition Good Torn Bed Net Usage Yes No 1 st ANC Visit Timing 1 st 2 nd 3 rd Gravida Malaria Infection Yes No 42 (32.3) 22 (16.9) 66 (50.8) 133 (99.3) 1 (0.7) 84 (63.2) 49 (36.8) 101 (75.9) 32 (24.1) 78 (78.8) 21 (21.2) 58 (45) 71 (55) 26 (20) 93 (71.5) 11 (8.5) 18 (13.7) 90 (68.7) 23 (17.6) 5 (3.8) 128 (96.2) Preliminary data
52 UN AIDS Target: End the Epidemic by 2030
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62 The Resource Allocation Debate: Population-level or Targeted Interventions??
63 Population Level Interventions Contraceptive Practices in Cameroon by HIV Status; Budhwani CFAR Symposium 2016
64 Targeted Populations Incident HIV infections have flat lined since 2010 at 1.9 million. 45% of incident cases occur in members of key populations.
65 HIV Key Populations Sex Workers MSM Injection Drug Users Transgender Prisoners
66 Female Sex Workers
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68 Criminalization of any aspect of sex work, 2016 Selling and buying sexual services criminalized Selling sexual services criminalized Buying sexual services criminalized Partial criminalization Other punitive regulation Not subject to punitive regulation /not criminalized Issue determined /differs at subnational level Data not available Source: Sexual Rights Initiative National sexual rights law and policy database. ( accessed 13 November, 2016)
69 Cameroon New Life Club Formed in active members in 11 groups 2015 HIV prevalence: 11.2% Challenges Stigma, fear of exposure Drug abuse Linkage to HIV and care services Expenses (3500 CFA/night for room)
70 Resources
71 Investments in the AIDS responses of low- and middle-income countries, by source of funding, US$ (billion) Domestic (public and private) United States (bilateral) Other bilateral governments Other multilaterals and foundations Global Fund to Fight AIDS, Tuberculosis and Malaria Source: UNAIDS estimates, June UNAIDS-Kaiser Family Foundation. Financing the response to AIDS in low- and middle-income countries till OECD CRS last accessed June 2016.
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73 Quote from Cameroon What are you really doing here, looking into HIV? What is going to come out of this for us? People who look just like you come and go every single week around here, and yet, look at us, things are only getting worse.
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80 Washington Post 4/7/17
81 Conclusions Women globally are vulnerable to HIV infection due to a combination of modifiable and non-modifiable risk factors. Highly effective treatment and prevention is now available at lower cost than ever and ART adherence in SSA is excellent. Ongoing resources are needed with bilateral support and a political commitment to improving the health of women and girls everywhere. This improves community health. HIV/AIDS Elimination is attainable but will require significant resources and new innovations to reach populations in need.
82 Thank You Rwanda Zambia HIV Research Group Susan Allen Dartmouth Haiti PEPFAR team and GHESKIO Peter Wright Cameroon Health Initiative at UAB and CBCHS Alan Tita, Tom and Edie Welty UAB 1917 HIV Clinic Funding NIH/NICHD K23-1K23HD CDC Division of STD Prevention
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