MALAYSIA

:
Taking Stock of
HIV Prevention

Dr. Christopher KC Lee
Infectious Disease Unit
Department of Medicine
Hospital Sungai Buloh

HIV / AIDS:
The Global Burden

Global estimates for adults and children, 2005

• People living with HIV

38.6 million [33.4 – 46.0 million]

• New HIV infections in 2005

4.1 million [3.4 – 6.2 million]

• Deaths due to AIDS in 2005

2.8 million [2.4 – 3.3 million]

Global summary of the HIV and AIDS epidemic,
2005
Number of
people living
with HIV in 2005
People newly
infected
with HIV in 2005
AIDS deaths
in 2005

Total
million] Adults
million] Women
million] Children under

38.6 million [33.4 – 46.0
36.3 million [31.4 – 43.4
17.3 million [14.8 – 20.6
15 years
2.3 million [1.7 – 3.5 million]

Total
4.1 million [3.4 – 6.2 million]
Adults
3.6 million [3.0 – 5.4 million]
Children under 15 years 540 000 [420 000 – 670 000]
Total
2.8 million [2.4 – 3.3 million]
Adults
2.4 million [2.0 – 2.8 million]
Children under 15 years 380 000 [290 000 – 500 000]

3 million East Asia 680.5 million Oceania 1.6 million Sub-Saharan Africa Latin America 24.Adults and Children Estimated to Be Living With HIV.000 Western/ Central Europe UNAIDS.org. Available at: http://www.6 million 78.000 Caribbean Southern and 330.4 million 720.000 North Africa and Middle East 440. . 2006. 2005 Eastern Europe and Central Asia North America 1.000 1.000 Southest Asia 7.unaids.

Estimated number of adults and children newly infected with HIV.3 – 3. 2005 Western & Eastern Europe Central Europe & Central Asia 22 000 North America 43 000 [34 000 – 65 000] Caribbean 37 000 [18 000 – 33 000] 000] 220 000 [150 000– 650 000] East Asia North Africa & Middle East [26 000 – 54 000] 64 000 97 000 [55 000 – 290 000] South & South-East Asia [38 000 – 210 000] Latin America Sub-Saharan Africa [100 000 – 420 000] [2.7 million 830 000 [530 000 – 2.1 (3.2) million .4 – 6.1 million] 140 000 2.3 million] Oceania 7200 [3500 – 55 000] Total: 4.

3) million .Estimated adult and child deaths from AIDS.4 – 3.0 million 560 000 [370 000 – 810 000] Oceania 3400 [1900 – 5500] Total: 2. 2005 Western & Eastern Europe Central Europe & Central Asia 12 000 North America 18 000 [11 000 – 26 000] Caribbean 27 000 [<15 000] 53 000 [36 000 – 75 000] East Asia North Africa & Middle East [19 000 – 36 000] 37 000 33 000 [20 000 – 49 000] South & South-East Asia [20 000 – 62 000] Latin America Sub-Saharan Africa [47 000 – 76 000] [1.7 – 2.3 million] 59 000 2.8 (2.

2005 Western & Eastern Europe Central Europe & Central Asia 200 North America 500 [<1000] Caribbean 3700 [<400] 2300 [1400 – 3900] North Africa & Middle East [2100 – 5800] 6900 [3200 – 12 000] Latin America Sub-Saharan Africa [3500 – 8000] [370 000 – 590 000] 5000 470 000 East Asia 2300 [1000 – 4100] South & South-East Asia 44 000 [23 000 – 75 000] Oceania 1100 [400 – 2800] Total: 540 000 (420 000 – 670 000) 000 .Estimated number of children (<15 years) newly infected with HIV.

Over 11 000 new HIV infections a day in 2005 • More than 95% are in low and middle income countries • About 1500 are in children under 15 years of age • About 10 000 are in adults aged 15 years and older of whom: — almost 50% are among women — over 40% are among young people (15-24) .

something is more important to you than saving lives.Bill Clinton . and yet when I hear people pontificating against AIDS and acting as if we can do everything through abstinence. and saving lives is the highest ethical act. we are falling behind. about 10 people became infected. Even during our greatest advance.” . for each new person who got treatment for HIV. I think they don't know what most women are up against in too many parts of the world today.Bill Gates “If you oppose the distribution of condoms.” . .Melinda Gates “Empowering women to protect themselves seems so elemental. .2006 International AIDS Conference: Time to Deliver “Between 2003 and 2005 .” “Let’s agree that every life has equal worth.” .

MD “Indeed.Helene Gayle.Mark Wainberg.” . yet still the epidemic continues to outpace us . . We must demand action over rhetoric and research over ideology” . . we have a real opportunity to deliver like never before . I’m of the opinion they can never attain redemption. . PhD .2006 International AIDS Conference: Time to Deliver “The (South African) government has a lot to atone for.” Stephen Lewis “Today. we will have failed unless we dramatically and rapidly expand by millions the numbers of people around the world with access to antiretroviral drugs and simultaneously scale up prevention.

Burden of HIV in Malaysia .

559 cases notified to • as Ministry of Health numbers st Malaysia 31/12//05 1992 to 2005. 2005 : 70. December. years .MALAYSIA • First HIV case detected in 1986 of 31 .

Cummulative HIV infections Malaysia 1993-2005 Year .

Cummulative AIDS cases Malaysia 1993 .2005 Year .

Yearly AIDS Deaths Malaysia 1993 . . Dec.2005 Cummulative AIDS deaths: 2005) Year 8179 (31st.

6%) Female 5.345 (92.559 (100%) Malaysia 31/12/05 .Gender Male 65.214 (7.4%) TOTAL 70.

percentage HIV in Malaysia Proportion of Men / Women by Year .

39 yrs.5% : ages 20 .Age Distribution numbers 78. Age groups in years Malaysia 31/12/05 .

3% 10124 14.1% Malaysia 31/12/05 .5% 52407 74.04% 541 0.3% 28 0. % 1025 1.HIV : Routes of transmission •Homo / bisexuals •IV drug users •Heterosexuals •Blood / blood products •Mother-to-child •Unknown No.8% 6431 9.

percentag e HIV Proportion by route of transmission .

Percentages of IDUs reactive for HIV by year % Year .

remain at steady state. rate of decline dependant on viral load • CD4 cell count : production almost = destruction for sustained period of time . Average period from infection to AIDS 8-10 years • Viral load.Medically: What happens to those infected? • 50% will have flu-like illness for about 2-6 weeks after exposure (Primary HIV illness) • Will recover & enter a long asymptomatic phase (the latent period) • Prolong asymptomatic period. plasma HIV RNA. • CD4 T-lymphocyte count fairly stable.

CD4 counts & Opportunistic Infections CD4 counts Asymptomati c Mildly symptomatic AIDS-defining illness Years : mean survival ~ 10 yrs. .

recurrent • Toxoplasmosis. extrapulmonary • Cryptosporidiosis: diarrhoea > 1 month • CMV: except liver. lungs • Cervical ca. Salmonella septicaemis. disseminated My. invasive • Cryptococcosis. spleen & lymph nodes • Herpes simplex: ulcer > 1 month. lung.Examples of AIDS. recurrent.defining Illness (ADI) • Candidiasis: oesophagus. internal organ . loss> 10 %) Kaposi’s sarcoma Lymphoma.. trachea. tuberculosis PCP Pneumonia. non-Hodgkins My. avium . oesophagus • HIV dementia • • • • • • • • HIV wasting (wt.

hospital based services .human resource .finances • Social & developmental implications: . countries .political uncertainty / national threat .Implications of growing AIDS population • Increasing strain on health sector esp. communities.impact on families.hospital beds .

3% Kaposi's sarcoma 0.4% Isosporiasis 0.Prevalence of Opportunistic Infections among AIDS S. Singh.101-106. 1997 patients in India Infection PrevalenceRate Tuberculosis 40%-68% Toxoplasmosis 10%-66% Oropharyngeal candidiasis 58%-60% Cryptosporidiosis 4%-11% Cryptococcosis 5%-8% Systemic candidiasis 4%-8% Pneumocystis carinii pneumonia 0.27% . AIDS Reader 7(3).

Hospital Kenyatta. 1990s – treatment consumed 66% of public health spending. Bujumbura. Care & treatment for PLWHAs heavily taxing public health services in developing countries. o Rwanda. Chiang Mai. Burundi . 39% . o 1997 – Public health spending for AIDS > 2% of GDP in 7/19 African countries (total health spending 3-5% GDP) o AIDS take up 50% beds in Provincial Hospital.Health Sector Under Stress UNAIDS Photo Library A. & 70% in Prince Regent Hospital. Nairobi.

kills 1/3 PLWHAs. TB – rapidly increasing. increases TB risk in community at large o World Bank – 25% of HIV-negative people who die of TB in the future would not have been infected with the bacillus in the absence of AIDS. Other patients do not get beds in hospitals & die due to late treatment. . training and personnel. drugs.Health Sector Under Stress B. C. o New AIDS therapies – increases health sector expenditure in infrastructure.

2000 2000 . Zimbabwe 1990 AIDS beds beds Non -AIDS beds Non-AIDS Source : UNAIDS.Bed occupancy required for AIDS patients.

industry • Weakening of institutions – Governance.From “Health Issue” to “Development Crisis” • Destruction of social capital – Knowledge base of society – Production sectors: agriculture. health – Inhibition of private sector growth • Wider. civil service. education. armed forces. judiciary. deeper poverty .

Bonnel (2000) Economic Analysis ofHIV/AIDS. ADF2000 Background paper.8 -1 -1. World Bank 30 35 .4 -0.Economic Growth Impact of HIV (1990-97) Growth Impact of HIV (1990-97) (80 developing countries) Reduction in growth rate GDP per capita (%.2 -0.2 -1.6 -0.4 -1.6 0 5 10 15 20 25 HIV Prevalence Rate (%) Source: R. per year) 0 -0.

2000 2000 . Source: UNDP Source: HIV/AIDS HIV/AIDS & & Human Human Development Development South South Africa. UNDP. Africa. UNAIDS UNAIDS & & UNDP..HIV/AIDS changes the welfare of countries In 1998 UNDP estimated that the Human Development Index (HDI) of South Africa would be 15% lower due to AIDS in 2010.

AIDS .Developmental Crisis Demographic Impact of AIDS Botswana 2020 – More adults aged 60 – 70 yrs than 40 – 50 yrs  Small number of young adults support large number of young & old people Projected population structure with & without the AIDS epidemic. World Population Profile 2000 . Botswana 2020 Source: US Census Bureau.

Leads to fewer purchases & savings Thailand 1/3 family affected by AIDS 50% in agricultural output – threatens food security  15% forced to take children out of school. .Household Impact Survey: Impact of family member with AIDS – households suffer in income.

1997 Monthly Monthly income income per per capita capita Monthly Monthly consumption per per capita capita Savings/Disavings Savings/Disavings . Côte d’Ivoire General population Families living with AIDS 30 30 000 000 Francs Francs CFA CFA 25 25 000 000 20 20 000 000 15 15 000 000 10 10 000 000 55 000 000 00 – 55 000 Source: SimulationSimulation-based on data from Bechu.Impact of HIV/AIDS in urban households. Delcroix and Guillaume.

abuse. 1997. 95% in developing countries Before AIDS .AIDS Orphans Children who lose their mothers or both parents to AIDS < age of 15 yrs 13.high risk of malnutrition. 7 – 11% of children were orphans AIDS orphans – raised by elderly or left on their own. UNICEF/UNAIDS. sexual exploitation by others. illness.2% of children in developing countries were orphans. 1999 – AIDS orphans . Also face stigma and .2 mil AIDS orphans.

HIV is hurting business  Impact of AIDS in sugar estate.000 days of labour lost due to sickness between ’95-97) b) Lower productivity (50%  in the ratio of processed sugar from raw cane from ’93-97) c) Higher overtime costs when healthy workers fill in for sick colleagues d) Spending on funerals  5 times between ’8997 e) Health costs  > 10 times (3/4 HIV-related illness)  HIV-related illness & death – main reason people leaving company . Kenya a) Absenteeism (8.

Current Status: the HKL cohort > 2800 patients registered since `92 • New patients per year: ~ from 150 (1993) to about 565 (2005) patients • 82% Malays IV drug users • 78% Chinese infected through sex • 70% education level : < Form 3 • Employment: 79% blue-collared workers CLee.HKL .IDclinic.

Is there any Good News ? .

Cambodia 1997-2000 (%) 3.2 1997 1998 1999 2000 Source : MOH Cambodia .2 3.4 2.0 2.6 2.8 2.HIV Prevalence among antenatal women.

Trend in HIV prevalence in 21 year old military conscripts in Thailand HIV prevalence (%) 5 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 Source: Armed Forces Research Institute of Medical Sciences. Thailand 1998 1999 .

communities. districts. etc.Prevention Strategies Has to be individualised for countries. Targetted vs Generalised Objective: Behavioural Change Community sensitive Gender sensitive Obstructive policies need to be addressed Multisectoral involvement often required .

methadone maintenance treatment .needle exchange programs Targeted Condom promotion Women specific & sensitive programs Involvement of civil society – religious. corporate sector . community leaders.What has worked …? HIV Education programs for schoolchildren – various models Harm Reduction programs: .

R. H.T.A.A. Highly Active AntiRetroviral Therapy .

338:853-860 ARV therapy including protease inhibitors 100 . HIV Outpatient Study Investigations. N Engl J Med 1998.Declining morbidity & mortality among patients with advanced HIV infection Deaths per 100 person yrs 75 50 25 0 ‘94 ’95 ‘96 ‘97 Pallella FJ et al.

HIV and and AIDS AIDS in in Canada. 1990 to 1999 1600 Number of AIDS deaths 1400 1200 1000 800 600 400 200 0 00001-E-42– 00001-E-42– 27 27 June June 2000 2000 90 91 92 93 94 95 96 97 98 Source: Source: Health Health Canada. 31. Surveillance Surveillance Report Report to to December December 31. Canada. 1999 1999 99 . Canada. Canada.Annual number of deaths due to AIDS.

Ringgit per month ARV drug Prices in Malaysia * Expected new .

Thank You “Do What you Can with what you Have Where you Are !” Theodore Roosevelt .