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The Most Probable

Past, Present, and


Future of the AIDS
Pandemic

JAMES (Jim) CHIN MD, MPH


Clinical Professor of Epidemiology
School of Public Health
University of California at
Probable Routes of Initial
Global Spread of HIV-1 in the
1960s and 1970s

?
?
AIDS
Who is at Risk of Acquiring or
Transmitting HIV Infection?
Factors that can Facilitate or
Limit Epidemic Sexual HIV
Transmission
Facilitating factors* Protective factors
Other STD, especially Male circumcision – lack
ulcerative STD of penile foreskin
Traumatic sex, “dry” sex Condom use
Acute phase of HIV Potential future factors –
infection (high viral load) Microbicides, vaccines
*Facilitating factors are not co-factors since they are not required for HIV
transmission but can “facilitate” or increase the risk of transmission
The Reproductive
Number (R0) of HIV

R0 for HIV via sexual transmission is dependent on:


• probability a sex partner is infected with HIV [p];
• probability of HIV transmission per coital act [r];
• number of unprotected coital acts with different sex
partners [n1, n2…]
R0 = (p x r x n1) + (p x r x n2)…
Risk of Sexual HIV Transmission Based on
Pattern of Sex Partner Exchange
Annual number
(Frequency of Pattern of Risk of HIV Examples
Exchange) Exchange Transmission
1 or none Zero or Majority of
(No partner Monogamous close to heterosexuals and
exchange) or abstinent zero (R0 <1) many MSM
Up to dozens Low Up to 20% of adults in
(Months to years) Mostly serial (R0 <1) Western countries
Moderate to 20-40% of adults in
Up to dozens Mostly high SSA countries and
(weekly to monthly) concurrent (R0 >1) most MSM
Up to several Direct/ indirect FSW
hundreds Concurrent High and MSM in small sex
(Daily to weekly) (R0 >1) networks
Large brothel based
Up to 1000 or more Concurrent Highest FSW, MSM in
(Daily) (R0 >1) bathhouses
Question
Why is epidemic (R0 >1) heterosexual
HIV transmission almost non-existent
in most countries in the world but is so
prevalent in sub-Saharan African
countries and to a lesser extent in
several Caribbean countries and in
only a few countries in South and
Southeast Asia?
HIV Prevalence by Wealth
Quintiles – Kenya
Understanding
HIV/AIDS Numbers
• Reported
• Official
• Estimated
• Actual
• HIV incidence
• HIV prevalence
• AIDS incidence
How Accurate are HIV
Prevalence Estimates?
• Estimation of HIV prevalence is more of
an art than a science. With the many
uncertainties in HIV serologic data and
the limitations of the data, methods, and
assumptions used, estimation of HIV
numbers cannot be precise.
• Current HIV prevalence estimates tend
to be high because of insufficient data on
urban/rural differentials.
HIV Prevalence Rates in
Selected sub-Saharan African Countries
0.1 Number overestimated in millions 2001-2003 national estimates based
39 mostly on sentinel ANC data
0.03 0.9
34 34
2002-2006 national estimates based
mostly on population based data

25 24 0.3 Total overestimation for these


22 1.2 SSA countries about 5 million
20
18 1.2
16 16 0.5
15
12 0.4 0.3
10
9
7
6 5
3

Swaziland Botswana Zimbabwe Zambia South Kenya Cameroon Cote Rwanda


Africa d'Ivoire

Percent HIV positive among population age 15-49


7/25/07
HIV Prevalence Rates
in Selected African,
0.15
Caribbean and Asian Countries
Number overestimated in millions
7
1.4 0.15 2001-2003 national estimates based
6 6 mostly on sentinel ANC data

2002-2006 national estimates


based mostly on population
based data
0.05 0.05
3 3
2.2
2
3
1 1 0.8 0.9
0.36

Burkina Faso Ethiopia Haiti Dominican Cambodia India


Republic

Percent HIV positive among population age 15-49


7/25/07
The “Glorious” Myth of
“Generalized” HIV Epidemics
Percent of Global Population Infected
with HIV - 2007
Infected Not Infected
Sub-Saharan Africa 3.0% 97.0%
Rest of World 0.2% 99.8%
Total Global 0.5% 99.5%
Influenza pandemics >50% <50%
Estimated HIV Prevalence in
Global Regions: 2001- 2006
HIV+ (%) HIV+ (%) HIV Risk
Region 2001 2006 Behaviors
Sub-Saharan Africa 6.5 [9.0] 5.9 Heterosexual
Caribbean 1.5 [2.3] 1.2 Heterosexual
South & SE Asia 0.6 [0.4] 0.6 [0.35]* FSW & IDU
Latin America 0.5 0.5 MSM & IDU
E Europe & Cent Asia 0.5 [0.2] 0.9 [0.4] IDU
Western Countries 0.4 0.4 MSM & IDU
N Africa & Mid-East 0.2 0.2 --
East Asia & Pacific 0.1 0.1 [0.08] Plasma & IDU
GLOBAL 1.0 1.0 [<1.0]
* In early July, 2007 estimated HIV prevalence in India was reduced
from close to 6 million (0.9%) to less than 2.5 million (0.36%).
Highest Estimated HIV Prevalence Countries - 2006

7/04/07
Estimated HIV Prevalence in
10,000 Females - 2006
Country Number HIV Transmission
Swaziland >3,000 Primarily heterosexual
Thailand 100 Primarily FSW/Clients & IDU
Russia 75 Primarily IDU
India 50 Focal FSW and IDU
USA 30 Mostly MSM & IDU
Mexico 20 Mostly MSM & IDU
Malaysia 15 Primarily IDU
China 3 IDU and paid plasma donors
Philippines 1 No epidemic HIV spread
Turkey <1 No epidemic HIV spread
Estimated HIV Prevalence and
Incidence – California - 2000
HIV Prevalence HIV Incidence
Population Number Number rate (%) Number rate (%)
MSM 720,000 85,000 12% 5,000 0.7%
IDU 220,000 9,900 4.5% 1,000 0.5%
MSM/IDU 80,000 8,000 10% 500 0.63%
Heterosexual*
Males 5,700,000 2,500 0.044% 150 0.0026%
Females 6,300,000 5,000 0.08% 300 0.0048%
Totals 13,020,000 110,400 0.85% 6,950 0.053%

* Populationage 20-44 - Estimates developed by a consensus meeting of


about 50 California HIV/AIDS experts in 2001
HIV Epidemics in IDU
Populations in Asia
HIV Prevalence In Female Sex
Workers and Truck Drivers in
Yunnan, China, 1999-2000
Number Percent
Group Number HIV+ HIV+
Truck Drivers 550 0 0.0
FSW denying
drug use* 213 0 0.0
FSW admitting
drug use** 292 52 17.8
Total FSW 505 52 10.3
* In a prior study, HIV prevalence in underground FSW not using drugs was 2.2%.
** HIV prevalence in IDU tested in detention camps in 2000 was about 25%.
95 Botswana
95
94/95

94
97
87

88
93

Uganda
87

Kenya
93
UNAIDS Report to UNGASS –
May 30, 2006 OVERVIEW OF
THE GLOBAL A I D S EPIDEMIC
“Overall globally, the HIV incidence rate (the
annual number of new HIV infections as a
proportion of previously uninfected persons) is
believed to have peaked in the late 1990s
and to have stabilized subsequently…
…Changes in incidence along with rising AIDS
mortality have caused global HIV prevalence
(the proportion of people living with HIV) to
level off….”
UNAIDS 2006 Estimates of Annual
HIV Incidence and Annual AIDS
Deaths in Selected Regions
Region *HIV *AIDS HIV:Death
Incidence Death Ratio**
Sub-Saharan Africa 2.8 2.1 1.3:1
N Africa & Middle East 0.068 0.036 1.9:1
South & SE Asia 0.86 0.59 1.5:1
East Asia 0.1 0.043 2.3:1
Latin Amer & Caribbean 0.17 0.084 2.0:1
Totals 4 2.85 1.4:1
*Numbers are in millions **When HIV incidence peaks, the ratio of new HIV infections
to AIDS deaths is about 2:1; after 5 years it is 1.5:1; and after 10 years close to 1:1
UN Millennium target
“Have halted by 2015
and begun to reverse
the spread of
HIV/AIDS”
What are the Major Factors
Responsible for Peaking of
Sexual HIV Epidemics?
• Increase of responsible sexual behaviors,
i.e., sexual Abstinence and/or Being faithful
• Increase of consistent Condom use for
risky sex behaviors
• Saturation of infection in those with the
highest sexual risk behaviors
All of the above, but perhaps saturation of
infection may be the most important factor!
Modeling HIV/AIDS in Cambodia

Start of national 100%


condom program

“Riding to glory on the


down slope of the
epidemic curve!”

Peak annual HIV


incidence numbers
Peak annual numbers
of AIDS deaths
Estimated Annual TB Cases
Top Two Leading Causes of Death in Global “Regions” - 2001

HIV/AIDS # 10 - 2.5%

HIV/AIDS # 8 – 2%

Data source: Version 3 revisions of the Global Burden of Disease (GBD) study.
The Impact of AIDS on the San
Francisco Gay Men’s Chorus
Can You Believe This?

Source: WHO’s World Health Report 2004


Estimated and Projected Annual HIV
Incidence in sub-Saharan Africa

UNAIDS modeled
baseline scenario

Jim Chin’s more


logical scenario

UNAIDS’ comprehensive
prevention & treatment
scenario
Estimation and Projection of
HIV Prevalence to 2020

Overestimates and
projections by
UNAIDS & UN Most likely scenario
Population Division

SUB-SAHARAN
AFRICA

SOUTH &
SE ASIA Most likely scenario

ALL OTHER REGIONS


James (Jim) Chin, MD, MPH
Clinical Professor of Epidemiology, School of
Public Health University of California, Berkeley
Formerly, Chief of the Surveillance, Forecasting,
and Impact Assessment (SFI) unit of the Global
Programme on AIDS (GPA), World Health
Organization (WHO), Geneva, Switzerland

Forward by Jeffery Koplan, MD, MPH


Vice President, Academic Health Affairs, Emory
University, Atlanta
Formerly Director, Centers for Disease Control
and Prevention (CDC)

****
The AIDS Pandemic argues that
the story of HIV/AIDS has been
distorted by UNAIDS and AIDS
activists in order to support the
myth of the high potential risk of
HIV epidemics spreading into the
general population.
Radcliffe-Oxford, 2007
www.theaidspandemic.com