HIV - A tutorial

7/29/2019 HIV - A tutorial

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HIV/AIDS Prevention and Care

Nancy S. Padian, PhD, MPHProfessor, Obstetrics, Gynecology & Reproductive SciencesAssociate Director for Research, Global Health Sciences andAIDS Research Institute: University of California, San Francisco

Stefano M. Bertozzi, MD, PhDDirector, Health Economics and Evaluation, National Institute ofPublic Health, Mexico; Part-time faculty CIDE and University ofCalifornia, Berkeley


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Adults and children estimated to beliving with HIV as of end 2005

Total: 40.3 (36.7 45.3) million

Western & CentralEurope

720 000[570 000 890 000]

North Africa & Middle East

510 000

[230 000

1.4 million]

Sub-Saharan Africa

25.8 million[23.8 28.9 million]

Eastern Europe& Central Asia

1.6 million[990 000 2.3 million]

South & South-East Asia7.4 million[4.5 11.0 million]

Oceania

74 000[45 000 120 000]

North America

1.2 million[650 000 1.8 million]

Caribbean

300 000[200 000

510 000]

Latin America

1.8 million[1.4 2.4 million]

East Asia

870 000[440 000 1.4 million]

Source: UNAIDS. AIDS Epidemic Update 2005


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Prevention


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Potential of HIV prevention:

National Success Stories Thailands 100% condom program

Ugandas remarkable decrease in HIVprevalence and incidence

Senegals sustained success in minimizing HIVincidence

Zimbabwes declining prevalencedue to behavior change

Declining risk and prevalence in Caribbeancountries


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Successful National HIVPrevention Strategies

Common Threads: High-level political leadership, civil society and

religious leaders

Environmental and contextual factors e.g. sociocultural, economic and legal factors thatcondition risk behavior

Open communication regarding sex: combat stigma and discrimination

Interventions based on epidemic profile Target key (e.g: IDUs, MSMs, SW and clients)

populations as appropriate


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Epidemic ProfilesExtent of HIVInfection

Highestprevalence

in a keypopulation

Prevalencein generalpopulation

WHO region

Low level


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Unified Prevention Theory

Prevention

Inter

ventions

Low Level ConcentratedGeneralized

Low

Generalized

High

Key Populations

Low HIV PREVALENCE High

General Population


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Interventions differ acrossepidemic profiles: Condom promotion

Condom PromotionLow-level Epidemic Address market inefficiencies in

condom procurement and focusdistribution on key populations

Concentrated Epidemic Intensify distribution andpromotion to key populations andlink to VCT and STI care

Generalized Low-Level Epidemic Subsidize social marketing ofcondoms: strengthen distributionto ensure universal access

Generalized High-Level Epidemic Promote condom use anddistribute condoms free in allpossible venues


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Circumcision + ++Surveillance None NoneIEC None NoneSchool-based

education

Abstinence education VCT ++ ++Peer-based programs ++ ++Condom promotion,

distribution & IEC++ +

Condom socialmarketing

? ?

STI Treatment ++ ++

Effectiveness Cost-Effectiveness

What Works? Evidence for Effectivenessand Cost-Effectiveness


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ART to reduce MTCT ++ ++MTCT, feeding

substitution+ None

Harm reduction, IDUs ++ ++

IDU Drug substitution ? None

Blood Safety ++ ++

Universal Precautions ++ None

ART for PEP + -

ART for PREP + None

Vaccines ? None

Behavior for HIV+s + None

Effectiveness Cost-Effectiveness

What Works? Evidence for Effectivenessand Cost-Effectiveness (cont)


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Levels of evidence:What works for prevention?

In 2005 there were more new infections than anyyear to date

Good evidence that targeted prevention works inconcentrated and generalized low-level epidemics

Less clear for low-level and generalized highepidemics

Deficit of cost-effectiveness data for all epidemicprofiles

Little evidence about the impact of combinationinterventions

Little evidence for contextual or structuralinterventions


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Interventions in the Pipeline or

in Trial Microbicides

Diaphragms

Community-based VCT HSV-2 treatment

ART to prevent sexual transmission

Vaccines Behavior change programs for people with HIV


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Care and Treatment


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Priniciple Care Interventions

Palliative Care

Antiretroviral (ART) therapy Laboratory testing and monitoring

Tx and Prophylaxis for OIs


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Palliative Care

Strategies for end of life care: Community home based care

most cost-effective

Pain management: Inexpensive options available, butsignificant barriers to access

Psychosocial support provides coping skills thatcan bolster adherence

Nutritional support: also a prerequsisite foreffective ART


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Antiretroviral Therapy

Significant reductions in ART drug prices Commitment to scaling up of ART among

international agencies and nationalgovernments, Outstanding concerns regarding quality of

scale up

Insufficient investment in health care infrastructure,in provider education and inregulation/monitoring/evaluation


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ART Level of Coverage

In 2006, 3 million people will likely becovered by ART meeting 41% of totalneed

By 2008, it is projected that 6.6 million

will be reached (63% of total need)

Source: UNAIDS. Resource needs for an expandedresponse to AIDS in low and middle-income countries. 2005


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Adherence to ART

Major problem worldwide

Effective treatment response

requires very high adherence Haiti and Uganda successesusing modified DOT

Research needed on how to maintainhigh levels of adherence in differentsocio/cultural/economic settings


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Laboratory Monitoring

Informs: When to initiate ART

Primary resistance

Patient response to therapy Toxicity due to therapy

Significant proportion of care costs

Additional research needed for optimalfrequency and types of tests used


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Role of ART in Relation to

Opportunistic InfectionsAntiretroviral therapy reduces viral load

and enables immune restoration

Prevents the onset and recurrenceof opportunistic infections.

Benefit of OI treatment is enhanced

when combined with ART Increased efficacy and cost effectiveness


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Research Agenda :

Rigorous evaluations for all interventions of effectiveness and cost

Best combination of prevention and treatmentfor each epidemic profile

How best to scale-up successful strategies coverage of interventions known to be effective

Simplified treatment regimens and low-cost, low-

tech methods for ensuring adherence,monitoring toxicity, and treatment response


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Conclusions

Magnitude and seriousness of the globalpandemic calls for action, even in theabsence of definitive data.

Interventions (care and prevention) mustbe tailored to the epidemic profile andlocal context.

Absence of firm data results in inefficient

investments.


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Many thanks to the DCPP editors,to the authors of the background

papers and especially to ourchapter coauthors

Documents

HIV - A tutorial