GLOBAL PUBLIC HEALTH Osher Lifelong Learning Institute at
GLOBAL PUBLIC HEALTH Osher Lifelong Learning Institute at Berkshire Community College Winter Session 2021, Katherine M. Kidd, Ph. D
Objectives for class • Focus on HIV/AIDS in Sub-Saharan Africa (SSA) • Consider some ways in which HIV/AIDS epidemiology in SSA differs and differed from the US and other HICs • Follow a timeline for the unfolding of the HIV/AIDS crisis in SSA including key breakthroughs • Consider critical innovations – medical, financial, organizational, administrative – to combat HIV/AIDS • Case study of Mother to Child (Mt. C) program in Botswana • Recognize gains made and challenges to come • Lessons learned
HIV/AIDS and Sub-Saharan Africa • HIV/AIDS spread more quickly in Anglophone countries • HIV/AIDS is a heterosexual disease in SSA • Women and girls have the highest prevalence rates • HIV/AIDS spread first among middle-income, well educated population first • HIV infected people in SSA comply with ART regimens better than HIV positive people in the US • Ideas from HICs about who got HIV and how it was spread made gathering social and political will more difficult
HIV/AIDS in Africa - 2007
HIV/AIDS and Sub-Saharan Africa • 1980 – 1987 HIV/AIDS was known to be a threat but no cure meant no action • 1985 – 85% of sex workers in Nairobi had HIV • 1987 – Uganda developed a national plan to address HIV • Pres. Kaunda of Zambia announces that he son died of AIDS reducing shaming and stigma of AIDS • WHO creates HIV/AIDS program and designates Africa a priority region
HIV/AIDS and Sub-Saharan Africa • 1990 - 1995 HIV/AIDS spreads rapidly with no scalable solutions in sight • 1993 - AIDS death toll is 14 million world wide, 9 million in SSA • Infection rates are rising everywhere except Uganda • 1994 – AZT developed • 1996 UNAIDS created • First medications for AIDS become available in HICs • Death rate in HICs declines 84% by 2000 • 1998 – Glaxo. Wellcome cuts price of AZT by 70% for SSA • 1999 – US backs down on full pricing of ARTs and makes lower cost drugs available for Mt. C treatment
HIV/AIDS and Sub-Saharan Africa • 2000 – Five big pharma companies agree to tiered pricing system • 2001 Global Fund to Fight AIDS, TB, and Malaria is created • 20 million people with AIDS in SSA, 8000 on medication • 2004 funding is up 300% to $6. 1 billion • 2008 funding up to $15. 6 billion • 2002 – Botswana announces MASA program • 2003 – PEPFAR announced by President Bush • 2003 -05 ARTs become available to 800, 000 people with HIV/AIDS in SSA
HIV/AIDS and Sub-Saharan Africa • 2006 – Namibia reaches 71% coverage • DOTs used to ensure drug regimen adherence • Nigeria at 15% • 2007 death toll in SSA reaches 15 million • 2008 42% of people with HIV get ARTs but death toll is still over 1 million annually
HIV/AIDS and Sub-Saharan Africa • 2010 – first single pill ART developed • WHO revises guidelines for who needs ARTs and coverage numbers decline • 2010 – 90 -90 -90 strategy announced • 90% of people who have HIV know their status • Opt out policy implemented • Rapid testing becomes available • Home test kits come on line (2018 -20) • 90% of people are in treatment • Single pill ART reduces needs for DOTS • Goal in 2020 is a single shot given quarterl. • 90% have suppressed viral loads • Low enough that HIV will not be transmitted during sexual relations
HIV/AIDS and Sub-Saharan Africa • 2014 - 90 -90 -90 strategy becomes 95 -95 -95 by 2030 tied to SDGs • 2015 - WHO new guidelines call for ARTs to be given upon diagnosis, regardless of CD 4 numbers • 2019 - Adolescent girls most at risk, two times the rate of infection of boys • 2020 - Global Fund gave $8. 54 billion in grants 70% in SSA • Prophylactic vaginal ring introduced – can cut HIV transmission by 50% in sexually active women and girls • 235, 000 women and girls infected with AIDS annually in SSA • 2021 - Education Plus Initiative begins focused on adolescent girls
HIV/AIDS and Sub-Saharan Africa
HIV/AIDS and Sub-Saharan Africa
HIV/AIDS Progress, Challenges and Opportunities 3 m AIDS-related deaths in GF-supported countries New HIV infections in GF supported countries 1. 8 m 2 m continuation of trend 1 m 0 2010 2020 Currently off track to meet 2030 targets, but mortality declining faster than incidence • Key populations & partners remain disproportionately affected (>60% of new HIV infections in 2019) • Significant scale-up of prevention needed, grounded in human rights principles, addressing structural drivers • Opportunity to focus on more catalytic approaches in countries with increased domestic financing for HIV • Regional share of global PLHIV gains (2019)and COVID-19 threatens to reverse undermine progress 1 m continuation of trend UNAIDS Fast. Track targets 2000 • 2030 UNAIDS Fast. UNAIDS Track targets Fast-Track targets 2010 2020 0 2000 2030 95 -95 -95 Treatment Cascade by Global Fund region (2018) Eastern & Southern Africa East. Europe & Central Asia & Pacific 54% Eastern & Southern Africa Western & Central Africa Lat. America & Caribbean Middle East & N. Africa 15% Asia & Pacific 6% Latin America & Caribbean 13% Wester n& Central Africa 4% Eastern Europe & Central Asia 1% Middle East & North Africa VLS=viral load suppression in all PLHIV Sources: UNAIDS, Global Fund analysis
Mother to Child Transmission of HIV • 2000 • 90% of Mt. C transmissions were in SS Africa • 50% of HIV positive children died by age two
Mother to Child Transmission of HIV • How does transmission occur? • Transmission during pregnancy – approximately 33 - 45% of cases • Transmission during delivery – approximately 10% of cases. Giving ZDV immediately after birth for mothers and children can reduce this cause by nearly 100% • Transmission during breastfeeding – 33 -50% of cases • Children who are not breastfed have a 600% chance of dying from 1 -2 months, a 400% change of dying from 3 -4 months, a 250% chance of dying from 5 -6 months • Learning on the fly • From 1985 – 2010, WHO provided 16 different guidelines as knowledge of HIV and access to ARTs changed
Mother to Child Transmission of HIV • In 2010, 500, 000 children in Africa got HIV annually. 90% got it from their mothers • Use of ARTs during pregnancy only reduced infection to 20 -45% depending on location and approach to support • Before 2014 use of ART varied depending on the clinical stage of the illness or the level of virus load • Since 2015 WHO issued new guidelines recommending all mothers be treated with ARTs during the entire pregnancy and breastfeeding period • Since 2014, 66% + of pregnant women are on ARTs – highest level for all population groups
Partners and Impact on Mt. C Transmission • WHO • UNICEF • 28 organizations that work together on this issue • Interagency Task Force for the Elimination of Mother-to-Child Transmission (IATT) • Established a Global Plan in 1998 • From 2009 – 2014 new infections in children dropped 60%
Botswana and Mother to Child HIV • 1999 – Mother to Child Program started • Partners in project – National Ministry of Health, Gates Foundation, and Merck. CDC provides clinical back up. 2003 PEPFAR joined partnership. Harvard, UPenn and Baylor created labs, health care training programs, and pediatric care programs. • 33% of pregnant women had HIV • First program to give ART free during pregnancy and lactation • Outreach to all areas of the country after trial period in Gaborone and Francistown
Botswana and Mt. C HIV • Uptake initially very low • Fearful of knowing status – opt in testing • Conversations with MDs were difficult • Required individual counseling became a roadblock • Once mothers stopped breastfeeding, ART treatment ended • 2003 – changes in program • ART treatment continued after lactation • Peer to peer group counseling/education sessions enhanced coverage • Integrated care centers created • Opt-out model introduced. • Started ZDT at 28 weeks instead of 34 to guarantee adequate coverage
Impact of Mother to Child Program • 2006 only 4% of children born were infected with HIV • 2007 – Botswana begins offering ARTs to all HIV positive citizens • Lessons learned • Mothers need to continue on ARTs for life • Once lifetime coverage is assured, pregnant women follow regimens at high rates • Peer-to-peer and group counseling work best • Integrated care centers essential to continuity of care • Breastfeeding is still the best option
Botswana and HIV Today
Botswana and HIV Today
Lessons Learned • New organizations were needed to address HIV/AIDS • New funding programs provided vastly increased flows of aid • Pharmaceutical companies must be on board - new global pricing plans required to both protect intellectual property and provide treatment to all • Research, good data and communication are essential • Willingness to change practices and standards often is critical with a newer health challenge • Medical professionals are not always the best HIV communicators • Peer-to-peer counseling works • Group counseling works
Lessons Learned • Testing is essential • Opt-out works • Rapid testing increases chances of follow up • Without testing, contact tracing for prevention is difficult • Guarantee of access to ARTs increases willingness to test • Political will at all levels - international, national and local - is necessary • PEPFAR gave and is still giving an essential boost to HIV programs • Nigeria and Mt. C Transmission • 2016 Nigeria had one of highest rates of Mt. C HIV • Only 34% of pregnant women on ARTs • 2018 national Mt. C program launched
Questions and Answers
- Slides: 25