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Overview of HIV epidemic, morbidity, mortality and modes of transmission Natural history of HIV infection, progression to AIDS Anti Retroviral Therapy (ART), applications and impact on HIV/AIDS Response to HIV: global steps and achievements in treatment and care Challenges and future directions
1.5 million
[720 000 910 [1.3 million 1.6 million] 000] East Asia Middle East & North Africa [560 000 1.0 million] South & South-East Asia [3.7 million 4.6 million] Oceania [50 000 64 000]
820 000
1.4 million
770 000
[400 000 530 000] [220 000 270 000] Central & South America [1.2 million 1.6 million] Sub-Saharan Africa [20.9 million 24.2 million]
240 000
460 000
4.1 million
22.5 million
1.4 million
57 000
Estimated number of adults and children newly infected with HIV 2009
Eastern Europe Western & Central Europe & Central Asia North America [44 000 130 000] Caribbean
70 000
[110 000 160 [23 000 40 000] 000] East Asia 82 000 [48 000 140 000] Middle East & North Africa [61 000 92 000] Sub-Saharan Africa [1.6 million 2.0 million]
31 000
130 000
17 000
75 000
South & South-East Asia [240 000 320 000] Oceania [3400 6000]
270 000
1.8 million
92 000
4500
Routes of Exposure and HIV INFECTION ROUTE RISK OF INFECTION Sexual Transmission a. Female-to-male transmission..1 in 700 to 1 in 3,000 b. Male-to-female transmission....1 in 200 to 1 in 2,000 c. Male-to-male transmission....1 in 10 to 1 in 1,600 d. Fellatio??.. 0 (CDC) or 6% (SF) Parenteral transmission a. Transfusion of infected blood.95 in 100 b. Needle sharing.1 in 150 c. Needle stick..1 in 200 d. Needle stick /AZT PEP1 in 10,000 Transmission from mother to infant a. Without AZT treatment....1 in 4 b. With AZT treatment.Less than 1 in 10 Royce, Sena, Cates and Cohen, NEJM 336:1072-1078, 1997
Towards Universal Access
SQV
LPV/r APV
Protease Inhibitor Atazanavir Darunavir Fosamprenavir Indinavir Lopinavir/rtv Nelfinavir Ritonavir Saquinavir Tipranavir Fusion Inhibitor Enfuvirtide CCR 5 antagonist Maraviroc
ATV DRV FPV IDV LPV/rtv NFV RTV SQV TPV T-20 MVC
ETR
Disease Care Acute Reactive Focus on dx/rx Customized care Spiritual MD role central
Health Care Chronic Proactive Focus on behavior Standardized care Practical Pt role central
16
Slide 17
6 19 97 19 98 19 99 20 00 20 01 20 02 20 03
Year
Patients on HAART
Slide 18
Pulmonary TB Disseminated TB
0.05
0.00 1985
1990 Mono
Dual
1995
www.aids.gov.br/boletim/bol_htm/boletim.htm
20066: TDF-FTC-EFV
NIGHT
ART Applications
Treatment of HIV disease (HAART) Prevention of Mother-to-Child-Transmission (PMTCT) Post-exposure Prophylaxis (PEP) Pre-exposure Prophylaxis (PrEP, iPrEP) Prevention ART-population based ART
Promising results for the prevention of mother-to-child transmission of HIV since 1994
Pre-Exposure Prophylaxis
Daily anti-HIV medication taken by HIV-negatives
Started prior to potential exposure Continued throughout periods of risk Added to existing prevention efforts
Use of TDF-FTC was associated with a 44% risk of HIV acquisition (MITT analysis) In adherent individuals protection was close to 90%
Grant, N Engl J Med 2010; 363:2587-259
USA Thailand
Launching PEPFAR
AIDS can be prevented. Anti-retroviral drugs can extend life for many years. And the cost of those drugs has dropped from $12,000 a year to under $300 a year -- which places a tremendous possibility within our grasp. Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many January 28, 2003
"
Universal Access
2005 G8 Summit at Gleneagles, Final Communiqu: working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010.
Number of people receiving antiretroviral therapy in low- and middle-income countries, by region, 20022009
Estimated percentage coverage with antiretroviral therapy in low- and middle-income countries by region, based on WHO 2010 and 2006 guidelines, 2008 and 2009
Percentage of pregnant women living with HIV receiving antiretrovirals for preventing mother-to-child transmission of HIV in low- and middle-income countries by region, 2005, 2008 and 2009
Before
After
Challenges
Long term toxicity, early initiation of ART Burden of NCD in HIV Ensure retention and adherence and development of drug resistance Sustainability
Hepatotoxicity
Earlier Initiation
clinicaloptions.com/hiv
Moore RD, et al. CROI 2008. Abstract 805. Graphic reproduced with permission.
Earlier Initiation
clinicaloptions.com/hiv
187 100
200 120
180 85 100
160 55
Cases (n)
14 12 10 8 6 4 2 0 <30 30-34 35-39 Age Group 40-44 45-49 50-54 55-59 60-64 65-69
ADM, AIDS-defining malignancies; nADM, non-AIDS defining malignancies; PFYU, person-years of follow-up
Approximately only 1/3 of elegible patients initiate ARV timely. Kranzer et al (2010)
60 40 20
67% 55%
71%
22%
0 > 94% 90-94% 80-89% 70-79% < 70% Level of Adherence
Resistance
Adherence
Age-specific factors (eg, visual or cognitive impairment) Difficulty taking meds (eg, problems swallowing pills, erratic schedule)
UNAIDS
PAHO/WHO