HIV in Women: A Global View of the HIV Epidemic

HIV in Women: A Global View of the HIV Epidemic George Schmid, M.D., M.Sc. Department of HIV/AIDS World Health Organization Geneva, Switzerland Schmidg@who.int Training Course in Sexual and Reproductive Health Research

The Problem of the HIV Epidemic Why Is it Occurring? What Can We Do About the It?

Global estimates for adults and children, 2007 People living with HIV New HIV infections in 2007 Deaths due to AIDS in 2007 33.2 million [30.6 36.1 million] 2.5 million [1.8 4.1 million] 2.1 million [1.9 2.4 million]

p64 GLOBAL ESTIMATES FOR ADULTS AND CHILDREN, 2006 People living with HIV New HIV infections in 2006 Deaths due to AIDS in 2006 39.5 million [34.1 47.1 million] 4.3 million [3.6 6.6 million] 2.9 million [2.5 3.5 million] The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information.

Global summary of the AIDS epidemic, December 2007 Number of people living with HIV in 2007 Total Adults Women Children under 15 years 33.2 million [30.6 36.1 million] 30.8 million [28.2 33.6 million] 15.4 million [13.9 16.6 million] 2.5 million [2.2 2.6 million] People newly infected with HIV in 2007 Total 2.5 million [1.8 4.1 million] Adults 2.1 million [1.4 3.6 million] Children under 15 years 420 000 [350 000 540 000] AIDS deaths in 2007 Total 2.1 million [1.9 2.4 million] Adults 1.7 million [1.6 2.1 million] Children under 15 years 330 000 [310 000 380 000]

Adults and children estimated to be living with HIV, 2007 North America 1.3 million [480 000 1.9 million] Caribbean 230 000 [210 000 270 000] Latin America 1.6 million [1.4 1.9 million] Western & Central Europe 760 000 [600 000 1.1 million] Middle East & North Africa 380 000 [270 000 500 000] Sub-Saharan Africa 22.5 million [20.9 24.3 million] Eastern Europe & Central Asia 1.6 million [1.2 2.1 million] East Asia 800 000 [620 000 960 000] South & South-East Asia 4.0 million [3.3 5.1 million] Oceania 75 000 [53 000 120 000] Total: 33.2 (30.6 36.1) million

Estimated number of adults and children newly infected with HIV, 2007 North America 46 000 [38 000 68 000] Caribbean 17 000 [15 000 23 000] Latin America 100 000 [47 000 220 000] Western & Central Europe 31 000 [19 000 86 000] Middle East & North Africa 35 000 [16 000 65 000] Sub-Saharan Africa 1.7 million [1.4 2.4 million] Eastern Europe & Central Asia 150 000 [70 000 290 000] East Asia 92 000 [21 000 220 000] South & South-East Asia 340 000 [180 000 740 000] Oceania 14 000 [11 000 26 000] Total: 2.5 (1.8 4.1) million

Estimated adult and child deaths from AIDS, 2007 North America 21 000 [18 000 31 000] Caribbean 11 000 [9800 18 000] Latin America 58 000 [49 000 91 000] Western & Central Europe 12 000 [<15 000] Middle East & North Africa 25 000 [20 000 34 000] Sub-Saharan Africa 1.6 million [1.5 2.0 million] Eastern Europe & Central Asia 55 000 [42 000 88 000] East Asia 32 000 [28 000 49 000] South & South-East Asia 270 000 [230 000 380 000] Oceania 1200 [<500 2700] Total: 2.1 (1.9 2.4) million

Figure 4, p14 Estimated number of annual new infections and AIDS-related deaths among adults (15+) in relation to the stabilizing trend of estimated prevalence rate among adults (15 49), Lesotho, 1990 2005 New infections AIDS deaths HIV prevalence 45 45 40 40 35 35 Number of new HIV infections and AIDS-related deaths (thousand) 30 25 20 15 30 25 20 15 % HIV prevalence 10 10 5 5 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 0 Sources: Government of Lesotho/UNAIDS, 2006. 2.1

Over 6800 new HIV infections a day in 2007 More than 96% are in low and middle income countries About 1200 are in children under 15 years of age About 5800 are in adults aged 15 years and older of whom: almost 50% are among women about 40% are among young people (15-24)

Figure 1, p4 Percent of adults (15+) living with HIV who are female (%), 1990 2006 Percent Female (%) 70 60 50 40 30 20 10 Sub-Saharan Africa Caribbean GLOBAL Latin America Asia Eastern Europe and Central Asia 0 1990 1992 1994 1996 1998 2000 2002 2004 2006

Regional HIV/AIDS statistics and features, end of 2002 Epidemic started Adults & children living with HIV/AIDS Adults & children newly infected with HIV Adult prevalence rate * % of HIVpositive adults who are women Main mode(s) of transmission for those living with HIV/AIDS ** Sub-Saharan Africa North Africa & Middle East late 70s early 80s late 80s 29.4 million 550 000 3.5 million 83 000 8.8% 0.3% 58% 55% Hetero Hetero, IDU South and South-East Asia late 80s 6.0 million 700 000 0.6% 36% Hetero, IDU East Asia & Pacific late 80s 1.2 million 270 000 0.1% 24% IDU, Hetero, MSM Latin America Caribbean Eastern Europe & Central Asia late 70s early 80s late 70s early 80s early 90s 1.5 million 440 000 1.2 million 150 000 60 000 250 000 0.6% 2.4% 0.6% 30% 50% 27% MSM, IDU, Hetero Hetero, MSM IDU Western Europe North America Australia & New Zealand TOTAL late 70s early 80s late 70s early 80s late 70s early 80s 570 000 980 000 15 000 42 million 30 000 45 000 500 5 million 0.3% 0.6% 0.1% 1.2% 25% 20% 7% 50% MSM, IDU MSM, IDU, Hetero MSM * The proportion of adults (15 to 49 years of age) living with HIV/AIDS in 2002, using 2002 population numbers ** Hetero: heterosexual transmission IDU: transmission through injecting drug use MSM: sexual transmission among men who have sex with men

The global view of HIV, end 2001 Recent trends in HIV infection, 1996 2001 94% of all persons living with HIV/AIDS are in developing countries + 1 300% + 20% + 20% + 100% + 160% + 40% + 60% HIV prevalence in adults, end 2001 15 39% 5 15% 1 5% 0.5 1.0% 0.1 0.5% 0.0 0.1% not available + 30% In 7 countries, >20% of all adults are infected with HIV + 20% Source: UNAIDS/WHO July 2002

11.8 million young people (aged 15 24) living with HIV/AIDS 7.3 million young women and 4.5 million young men Latin America & Caribbean 560,000 Industrialized countries 240,000 Central and Eastern Europe, Commonwealth of Independent States and Middle East & North Africa 160,000 Baltic States 430,000 South Asia 1.1 million East Asia & Pacific 740,000 Source: UNICEF/UNAIDS/WHO, 2002. Sub-Saharan Africa 8.6 million

HIV prevalence (%) HIV prevalence rate among teenagers by age in Kisumu, Kenya 35 30 25 20 15 10 5 0 15 16 17 18 19 Age in years boys girls Source: National AIDS Programme, Kenya, and Population Council, 1999

The Impact of HIV/AIDS

Changes in life expectancy in African countries with high and low HIV prevalence: 1950-2005 Life expectancy (years) 65 60 55 50 45 40 35 with high HIV prevalence: Zimbabwe South Africa Botswana with low HIV prevalence: Madagascar Senegal Mali 30 1950 1955 1955-1960 1960-1965 1965-1970 1970-1975 1975-1980 1980-1985 1985-1990 1990-1995 1995-2000 2000-2005 Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision.

Leading causes of death in Africa, 2000 25.0 22.6 20.0 % of Total 15.0 10.0 10.1 9.1 6.7 5.5 5.0 4.3 3.6 3.1 2.9 2.3 0.0 HIV/AIDS Malaria Perinatal conditions Tuber culosis Cerebro vascular disease Lower respiratory infections Diarrhoeal disease Measles Ischaemic Heart disease Maternal conditions Source: The World Health Report 2001, WHO

Risk of dying of AIDS Lifetime risk of AIDS death for 15-year-old boys, assuming unchanged or halved risk of becoming infected with HIV, selected countries risk halved over next 15 years current level of risk maintained 100% Botswana 80% Zimbabwe South Africa Botswana 60% Zambia 40% Cambodia Côte d Ivoire Kenya Kenya Zimbabwe South Africa Zambia 20% Burkina Faso Cambodia Burkina Faso Côte d Ivoire 0% 0% 5% 10% 15% 20% 25% 30% 35% 40% Current adult HIV prevalence rate Source: Zaba B, 2000 (unpublished data)

Why Is the HIV Epidemic Occurring?

Risk Factors (for Women) Unsafe transfusion Unsafe injection practices Unsafe injection drug use Unsafe sex

Distribution of AIDS cases by the route of transmission Eastern Europe 100% 80% 60% 40% 20% 0% <1984 85 87 89 91 93 95 97 99 2000 MSM IDU Homo/Bisexual Haemophilia Transfusion Heterosexual Other/including MTCT

Concept of Bridging Populations in HIV Transmission Concentrated epidemics Generalized epidemics Core (risk) group Bridging population General population IDUs, sex workers, MSMs Sex partners of IDUs, sex workers, MSMs 1. Sexual norms 2. STIs

Sexual Transmission of STIs, Including HIV 1 R o =β c D R o = reproductive rate β =transmission efficiency C=rate of partner change D=duration of infectiousness 1 among people having sex Anderson and May

Male to Female Transmission Efficiency Study Per 1000 acts Padian et al (1987) 0.8-1 Peterman et al (1988) 0.5-2.3 1 Wiley et al (1989) 0.8-1 1 Duerr et al (1994) 0.6-2.6 Downs et al (1996) 0.5-1.2 Leynaert et al (1998) 0.6-0.8 Shiboski et al (1998) 0.6-0.9 Gray et al (2001) 0.9 1 Combined male to female with female to male

ß (Transmission efficiency) Cofactors Cofactor effect of STIs Cofactor effect of young age Cofactor effect of hormonal contraceptives Negative cofactor effects of condom use Negative cofactor effect of microbicides (we hope!) Negative cofactor effect of circumcision (we think but now March 2007 we are sure!)

ß (Transmission efficiency) Model Concentration of virus in seminal secretions 1 Viral phenotype Number of receptors for HIV in endocervix (or vagina) 1 Chakraborty H et al. AIDS 2001;15:621

Seminal Fluid Characteristics, 132 Samples CD4 count 5-1240 Semen volume (ml) Median 2.4 Minimum 0.1 Maximum 7.3 NSI HIV-1 RNA count per sample Median 4,904 Mean 522,656 Minimum 42 Maximum 27,870,835 Chakraborty H et al. AIDS 2001;15:621

CCR5 Receptor Cell Count, Endocervix Median 184/mm 3 Mean 176/mm 3 Minimum 13/mm 3 Maximum 450/mm 3 Chakraborty H et al. AIDS 2001;15:621

Probability of Transmission by Seminal Viral Load, Number of Receptor Cells, or Proportion of HIV Virions that are NSI 0.02 100% NSI or many receptor cells 0.01 0 Seminal viral load, log 10 Chakraborty H et al. AIDS 2001;15:621 50% NSI or few receptor cells

ß (Transmission efficiency) Cofactors again Amount of seminal secretions Young age STIs, Etc. Review! Coombs RW et al. AIDS 2003;17:455

Presence of HIV in Ulcer Secretions Disease PCR for HIV (Pos./Tested) Chancroid 2 6/7 (86%) Chancroid 3 2/6 (33%) Syphilis 1/2 (50%) Unknown 2/3 (67%) Genital herpes 1/3 (33%) Genital herpes 4 25/26 (96%) 1 Kreiss J et al. J Infect Dis 1989;160:380 2 Plummer FA et al. J Infect Dis 1990;161:810 3 Mertz KJ et al. J Infect Dis 1998;178:1795 Schacker T et al. JAMA 1998;280:61

HIV prevalence rate and frequency of sexually transmitted infection (STI) episodes, Carletonville miners, South Africa, 1991-1998 HIV prevalence (%) 90 70 50 30 10 1 2-4 5-9 10+ Number of STI episodes Source: Ballard R, 2000 (unpublished data).

If These Transmission Efficiencies are so Low, Why is there an HIV Epidemic?

Cohort study, Nairobi 73 HIV-negative men with an STD All men had had one act of sexual intercourse with a prostitute The men were counseled, given condoms, told to avoid sex with prostitutes, and followed every 2 weeks for three months for HIV seroconversion 85% of prostitutes were HIV-positive Cameron WD et al. Lancet 1989;2:403 Cameron D et al. Lancet 1989;2:403

Proportion of Men Developing HIV Infection After a Single Act of Sexual Intercourse Circumcised Uncircumcised Unstratified Urethritis Ulcer Urethritis Ulcer 13% 0% 7% (6*) 0% 43% (15) Standard Error Attributable risk due to lack of circumcision and genital ulcer=98% Cameron WD et al. Lancet 1989;2:403

An Outbreak of HIV Infection, United States Of 42 teenaged girls having only vaginal sex with one teenaged boy, 13 (31%) became infected Of 15 girls with a brief time period of sexual activity, seven (47%) became infected. Infected girls, compared to uninfected girls, had more exposures: Partners Infected Uninfected Median 3 1 Range 2-6 1-2 MMWR 1999;48:413

Alternately, Maybe Something Else is Going On?

Unsafe Injections in the Developing World WHO estimates that 5% of all infections, worldwide, are from unsafe injections (2.5% in sub- Saharan Africa)

Injections Given with Sterile and Unsafe Equipment Worldwide South America Central Europe West Africa China and Pacific South East Asia East and Southern Africa Injections given with equipment re-used in the absence of sterilization Injections given with sterile equipment Eastern Europe and Central Asia South Asia Middle East Crescent 0 2 4 6 8 10 12 Number of injections per person and per year

Dr Tanu Singhal, London School of Hygiene and Tropical Medicine

The Solution to Pollution is Dilution

In Addition, HIV Acts Like an STI

Percent infected Figure 1 HIV prevalence by age and sex, Addis Ababa, Ethiopia, 1994 (ref. 52) Men Women 20 15 10 5 0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age group

Percent infected Figure 2A HIV and HSV-2 prevalence by age and sex in Kisumu, Kenya 90 80 70 60 50 40 30 20 10 0 15-19 20-24 25-29 Age group HIV men HSV-2 men HIV women HSV-2 women

Figure 4 Infection Rates, by Gender, Carletonville, South Africa

What Can We Do About the HIV Epidemic?

The HIV Epidemic Should Be Easily Controlled 1. Don t have unsafe transfusions 2. Don t have unsafe injections 3. Don t inject drugs (if you do, do it safely) 4. Don t have sex (if you do, do it safely)

Stopping the HIV Epidemic Personal Responsibility Giving people the means to effect personal responsibility

Don t have sex (if you do, do it safely) 1. Education

Percentage who do not know Percentage of 15-19 girls who do not know that an HIV-infected person may look healthy, 1994-1999 100 90 80 70 60 50 40 30 20 10 0 Sources: UNICEF, DHS surveys and other nationwide surveys, 1994-99.

Risk perception percentage of sexually active women (15-19) who perceive themselves to be at no risk of getting AIDS Nicaragua Nepal Colombia Bolivia Guatemala Brazil Dominican Rep. Niger Benin Chad Mali Cameroon Togo Haiti CAR Kenya Uganda Zambia Zimbabwe HIV Prevalence (at time of survey *) Percentage of 15-19 year old girls who think they are not at risk of AIDS *HIV prevalence in women attending antenatal care clinics in major urban areas Sources: UNICEF, DHS surveys, 1994-1999

Benin Cameroon Central Arican Republic Chad Kenya Malawi Mali Niger United Republic of Tanzania Togo Uganda Zambia Zimbabwe Brazil Dominican Republic Percentage of men who used a condom with a recent non-regular partner, by level of formal education: 1995-2000 100 80 60 None Primary Secondary or more 40 20 0 Source: Macro International (1995-2000) Demographic and Health Surveys; UNICEF

Don t have sex (if you do, do it safely) 1. Education 2. Change societal norms

Pre-marital sex % of women (age 20-24) that report pre-marital sex, various countries in Eastern Europe 100 80 % 60 40 20 0 Georgia (1999) Moldova (1997) Romania (1999) Ukraine (1999) Russia (1999) Czech Republic (1993)

Two "Drivers" of the HIV Epidemic

Male Circumcision--1 (which may require changing norms) A biologic intervention Probably the intervention with the strongest and most consistent evidence that it works ~60% reduction in HIV infection in circumcised men* Women will benefit: Lower population prevalence Women may be protected (although, biologically, how is uncertain) *March 2007 WHO/UNAIDS conference www.who/hiv/en for summary mid-march

Avoid Concurrent Partnerships--2 (may require changing norms) Concurrent partnerships, as opposed to sequential partnerships, are particularly dangerous.

Transmission efficiency Mathematical models estimate the average probability of male female transmission of HIV-1 per unprotected coital act to be between 0.0005 and 0.003% during chronic HIV infection, which in itself would not sustain an epidemic. -Pao et al, AIDS (2005)

Don t have sex (if you do, do it safely) 1. Education 2. Change societal norms 3. Enable safe behaviours

Condoms per man per year Condom gap in sub-saharan African countries in 1999 30 25 20 15 10 5 0 Additional condoms needed to get all countries to the level of 16.9 = 1.9 billion per year Average condom procurement of top 6 countries = 16.9 Six countries with highest condom procurement rate 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Countries in sub-saharan Africa, ordered by condom procurement rate Source: Shelton JD, Johnston B (2001) Condom gap in Africa: evidence from donor agencies and key infromants, British Medical Journal

Concept of Bridging Populations in HIV Transmission Concentrated epidemics Generalized epidemics HIV+ HIV- HIV- HIV+ HIV- HIV+ Core (risk) group Bridging population General population 1. Sexual norms 2. STIs

Concept of Bridging Populations in HIV Transmission Concentrated epidemics Generalized epidemics? HIV+?? Core (risk) group Bridging population General population 1. Sexual norms 2. STIs

Concept of Bridging Populations in HIV Transmission Testing Care "Provider Initiated Testing & Counseling"--2007? HIV+?? Core (risk) group Bridging population General population 1. Sexual norms 2. STIs

Care Purposes (benefits) Medical, psychological, social care Altering behaviour Challenges Decreasing stigma Streamlining counseling and testing Financial Operational

Women's access to HIV treatment, June 2006 Mozambique Uganda Nigeria Malawi Zimbabwe Zambia Central African Republic Botswana Kenya Côte d'ivoire Namibia Rwanda United Republic of Tanzania Burundi South Africa 10% 20% 30% 40% 50% 60% 70% Percentage of adults on ART who are women Percentage of HIV-infected persons who are women

Children's access to HIV treatment, June 2006 Africa Median: 8% Latin America Median: 8% Asia Median: 5 %

(Percentage coverage) Access to PMTCT services in sub-saharan Africa, 2005 80 70 60 50 40 30 20 10 Togo Namibia Zambia Guinea Bissau Benin Central African Republic Swaziland Burundi Uganda Percentage of HIV-infected pregnant women receiving ARV prophylaxis for PMTCT Gabon Rwanda Kenya Zimbabwe Lesotho Mozambique Côte d'ivoire

Success Story (Why?)

Prevalence Prevalence among pregnant women in major urban areas, Uganda 35 30 25 20 15 10 5 0 1985 86 87 88 89 90 91 92 93 94 95 96 97 98 99 2000 Source: Uganda National AIDS Programme

Ugandans aged 15-19 reporting virginity, 1989-1995 60 50 40 30 20 10 0 1989 1995 Male Female

ABC trends in Uganda Sexual deferral important, in itself and as determinant of subsequent sexual behavior Later sexual debut may be associated with fewer partners in adulthood

Ugandan females reporting no casual sex in past year, 1989-1995 Urban Rural 25 20 15 10 5 0 1989 1995

Condom use among men with non-regular partners over time in selected sub-saharan African countries: 1994-2000 % 60 50 40 Malawi Tanzania Uganda Zambia 30 20 1994 1995 1996 1997 1998 1999 2000 Source: Macro International (1994-2000) Demographic Health Surveys; Measure Evaluation

Summary 1. HIV/AIDS is a HUGE problem in the world 2. Women make up ½ of cases 3. Altering the course of the epidemic is theoretically simple, but operationally difficult

Thank you!