The Global HIV Epidemic: Women in Africa and Haiti

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

None Conflicts of Interest

Outline A) Epidemiology of HIV in Women B) PMTCT Haiti C) HIV and Coinfections Zambia and Rwanda Cameroon D) UN AIDS Targets F) Resources

Epidemiology

https:// unaids.org

unaids.org

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

New HIV infections among young women (aged 15 24 years), 2005 2015 Number New HIV infections Global target Source: UNAIDS 2016 estimates.

Percentage of people living with HIV (aged 15 49 years) who have ever been tested for HIV and received the results, men and women, 21 countries, 2011 2015 Men living with HIV (aged 15 49 years) Women living with HIV (aged 15 49 years) Source: Demographic and Health Surveys, 2011 2015. *Includes Dominican Republic and Haiti. unaids.org

Percentage of young women (aged 15 24 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, 2012 2015 Percentage (%) Lesotho Namibia Kenya Rwanda South Africa* Nigeria Zambia Comoros Source: Population-based surveys, 2012 2015. * Data for South Africa refers to condom use at last sex among young women aged 15-24 who reported being sexually active. unaids.org

Demand for family planning satisfied by modern methods among young women (aged 15 24 years), by country, 2010 2015 Percentage (%) Source: Demographic and Health Surveys, 2010-2015. unaids.org

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

HIV Susceptibility in Women Surface Area Exposure Time Higher HIV VL in semen HIV co-receptors on the cervix Microabrasions

CID 2015

Cycle of HIV transmission, a phylogenetic study, KwaZulu-Natal, South Africa, 2016 Source: Centre for the AIDS Programme of Research in South Africa, 2016.

PMTCT Preventing Mother to Child Transmission

Antenatal Treatment & MTCT Transmission Rate (%) 25 20 15 10 5 0 none AZT mono dual therapy HAART Cooper JAIDS 2002;29

sd-nvp sc AZT + Sd-NVP Daily Infant NVP Maternal therapeutic ART Maternal ART prophylaxis Courtesy of Lynne Mofenson, NICHD

Stringer JAMA 2010;304

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

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

Cohort of 2800 HIV-infected adults March 2009 - November 2012 463 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

Dionne AIDS Research and Treatment 2016

Dionne AIDS Research and Treatment 2017

So, What?

Busza JAIS 2012

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

HIV and Coinfection in Women

Important HIV Coinfections Globally Malaria Tuberculosis Hepatitis B/C Sexually Transmitted Infections

Chico JAMA 2012

Zambia INDICATORS ZAMBIA US Population (million) 13 310 Life Expectancy (y) 38.9 (52 in 1980) 78.2 Literacy (%) Female 75 Male 87 99 Parity 5.1 2.06 Infant Mortality (per 1000 live births) 99.9 6.14 HIV Prevalence (%) 16.5 0.6 Syphilis Prev (%) 7 0.67 Unemployment (%) 50 9.3 Roads/Paved (km) 91,440/20,117 6.5m/4.2m Physicians 646 (2006) 853,000 (2002) Nurses 6096 (2006) 2,900,000 (04) Medical Schools 1 133 www.cia.gov

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)

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.

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.

Dionne CID 2013

Antenatal Infections in Cameroon; 2015 Dionne ID OB GYN 2016

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

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 1 2-4 5+ 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

UN AIDS Target: End the Epidemic by 2030

The Resource Allocation Debate: Population-level or Targeted Interventions??

Population Level Interventions Contraceptive Practices in Cameroon by HIV Status; 2007-2013 Budhwani CFAR Symposium 2016

Targeted Populations Incident HIV infections have flat lined since 2010 at 1.9 million. 45% of incident cases occur in members of key populations.

HIV Key Populations Sex Workers MSM Injection Drug Users Transgender Prisoners

Female Sex Workers

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. 2016. National sexual rights law and policy database. (http://sexualrightsdatabase.org/page/welcome, accessed 13 November, 2016)

Cameroon New Life Club Formed in 2004 500 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)

Resources

Investments in the AIDS responses of low- and middle-income countries, by source of funding, 2000 2015 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 2016 - UNAIDS-Kaiser Family Foundation. Financing the response to AIDS in low- and middle-income countries till 2015 - OECD CRS last accessed June 2016.

Quote from Cameroon - 2001 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.

Washington Post 4/7/17

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.

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 K23-1K23HD090993 CDC Division of STD Prevention