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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