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Pediatric HIV Infection in Developing Countries

Pediatric HIV Infection in Developing Countries. Chokechai Rongkavilit Pediatric Infectious Diseases. Objectives:. Scope and basic information of pediatric HIV epidemic International efforts and research interest to deal with the epidemic. BASIC INFORMATION. Pediatric HIV Epidemic.

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Pediatric HIV Infection in Developing Countries

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  1. Pediatric HIV Infection in Developing Countries Chokechai Rongkavilit Pediatric Infectious Diseases

  2. Objectives: • Scope and basic information of pediatric HIV epidemic • International efforts and research interest to deal with the epidemic

  3. BASIC INFORMATION Pediatric HIV Epidemic

  4. Estimated number living with HIV/AIDS by end 2003

  5. GlobalAIDS epidemic 1990−2003 50 5.0 Number of people living with HIV and AIDS Millions % HIV prevalence, adult (15-49) 40 4.0 Number of people living with HIV and AIDS 30 3.0 % HIV prevalence adult (15-49) 20 2.0 10 1.0 0 0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year Source: UNAIDS/WHO, 2004 2004 Report on the Global AIDS Epidemic (Fig 1)

  6. Median HIV prevalence in antenatal clinic population in Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu, India, 1998−2003* Andhra Pradesh Karnataka Maharashtra Tamil Nadu 5 4 3 % HIV prevalence 2 1 0 1998 1999 2000 2001 2002 2003 Year * Data from consistent sites Source: National AIDS Control Organization 2004 Report on the Global AIDS Epidemic (Fig 2)

  7. Estimated number of new HIV infections in Thailand by year and changing mode of transmission 160 140 Spouse 50% IDU 20% SW 15% MTCT 15% SW 90% Spouse 5% IDU 5% 120 New HIV infections (number of people, in thousands) 100 80 60 40 20 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year Spouse: heterosexual transmission of HIV in cohabiting partnerships; SW: HIV transmission through sex work IDU: HIV transmission through injecting drug use; MTCT: mother to child transmission of HIV Source: Thai Working Group on HIV/AIDS Projections, 2001 2004 Report on the Global AIDS Epidemic (Fig 4)

  8. 30 30 25 25 20 20 15 15 10 10 5 5 0 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Epidemic in sub-Saharan Africa 1985−2003 Millions Number of people living with HIV and AIDS % HIV prevalence, adult (15-49) Number of people living with HIV and AIDS % HIV prevalence adult (15-49) Year Source: UNAIDS/WHO, 2004 2004 Report on the Global AIDS Epidemic (Fig 5)

  9. Botswana South Africa 70 Swaziland Zambia Zimbabwe 60 50 40 Years 30 20 1980-1985 1985-1990 1990-1995 1995-2000 2000-2005 2005-2010 Life expectancy at birth in selected most affected countries, 1980−1985 to 2005−2010 Source: UN Population Division, World Population Prospects: the 2002 Revision 2004 Report on the Global AIDS Epidemic (Fig 12)

  10. %

  11. Orphans per region within sub-Saharan Africa, end 2003 5 4 3 Number of orphans (millions) 2 1 0 Central Africa Eastern Africa Southern Africa Western Africa REGIONS Source: UNAIDS, 2004 2004 Report on the Global AIDS Epidemic (Fig 15)

  12. Problems among children and families affected by HIV/AIDS HIV infection Increasingly serious illness Children may become caregivers Psychosocial distress Economic problems Deaths of parents and young children Problems with inheritance Children withdraw from school Children without adequate adult care Inadequate food Discrimination Problems with shelter and material needs Exploitative child labour Sexual exploitation Reduced access to health-care services Life on the street Increased vulnerability to HIV infection Source: Williamson, Jan (2004) A Family is for Life (draft), USAID and the Synergy Project. Washington. 2004 Report on the Global AIDS Epidemic (Fig 15a)

  13. International efforts to deal with the epidemic

  14. Prevention/Education Comprehensive prevention & education programs Prevention of mother-to-child transmission (PMTCT Plus) Microbicide (chemical condom) research programs Bill and Melinda Gates Foundation International Working Group on Microbicides HIV Vaccine US NIH, CDC, ANRS International AIDS Vaccine Initiative Bridging the gap between the rich and the poor

  15. Prevention of Mother-to-Child TransmissionInternational perinatal HIV studies Transmission rate delivery 1 wk 36 wk labor 6 wk 14 wk 7.6 % 9.5 % 15 % 17 % 8 % 12 % 19 % 12 % 10 % 7.7% ACTG 076 FF Thailand Retro-CI DITRAME PETRA-A PETRA-B BF PETRA-C HIVNET 012 SAINT NVAZ AZT AZT+3TC NVP

  16. Percentage of young women (15−24 years old) with comprehensive HIV and AIDS knowledge, by region, by 2003 60 52 50 40 40 37 30 30 % 23 20 19 18 14 10 7 5 2 0 0 Sub-Saharan Africa South & South- East Asia Latin America & the Caribbean Eastern Europe & Central Asia Note: For each region, the percentage is shown for countries with low, median and high values Source: United Nations Development Programme (2002), Botswana AIDS Impact Survey (BAIS 2001): Survey Results and Indicators Summary Report. Gaborone; UNICEF, Multiple Indicator Survey (2000); FHI, Behavioural Surveillance Survey (2001) and; Measure DHS+, Demographic and Health Surveys, (1998-2002) 2004 Report on the Global AIDS Epidemic (Fig 32)

  17. Pregnant women attending antenatal clinics, served by 'Call to Action' programme in Africa*, 2000−2003** (N = 416,498) 100 80 60 % 40 20 0 Voluntarily counselled Tested (of those voluntarily counselled) Received results (of tested) HIV+ women (of tested) Mothers on Nevirapine (of HIV+ women) Babies on Nevirapine (of those born to HIV+ women) * Cameroon, Democratic Republic of Congo, Kenya, Malawi, Rwanda, South Africa, Uganda, Zambia and Zimbabwe ** Cumulative through June 2003 Source: Elizabeth Glaser Pediatric AIDS Foundation 2004 Report on the Global AIDS Epidemic (Fig 28)

  18. Pregnant women attending antenatal clinics, served by 'Call to Action' programme outside Africa*, 2000−2003** (N = 243,103) 100 80 60 % 40 20 0 Voluntarily counselled Tested (of those voluntarily counselled) Received results (of tested) HIV+ women (of tested) Mothers on Nevirapine (of HIV+ women) Babies on Nevirapine (of those born to HIV+ women) * Dominican Republic, Georgia, India and Thailand ** Cumulative through June 2003 Source: Elizabeth Glaser Pediatric AIDS Foundation 2004 Report on the Global AIDS Epidemic (Fig 29)

  19. MTCT-Plus InitiativeMTCT = mother-to-child transmission • A new major program to combine prevention and treatment for HIV-infected women and their families • Coalition of private foundations, UN and Columbia University • $100 million funding for 5 years • Targets: MTCT centers or programs worldwide • Family-centered care and treatment • Service package: education, counseling, psychosocial support, antiretroviral therapy, prophylaxis and treatment of HIV complications • Community outreach

  20. Bridging the gap between the rich and the poor • Treatment • Anti-HIV therapy • Improves rates of morbidity & mortality • Prolongs lives • Improves quality of life • Revitalises communities • Transforms perception of AIDS from a deadly disease to a manageable, chronic illness • However, less than 7% of those in developing world have access to the drugs (half of these live in one country, Brazil)

  21. Antiretroviral therapy coverage for adults, end 2003 400,000 people on treatment: 7% coverage 60 50 40 30 % 20 10 0 Africa Asia Latin America and the Caribbean Eastern Europe and Central Asia North Africa and Middle East Source: UNAIDS/WHO, 2004 2004 Report on the Global AIDS Epidemic (Fig 33)

  22. TRIPS safeguards • TRIPS = WTO Agreement on Trade Related Aspects of Intellectual Property Rights • TRIPS gives patents on medicine for a certain period of time (monopoly to patent-holders)

  23. TRIPS safeguards • Countries can counter TRIPS by building TRIPS-compliant safeguards • Compulsory Licensing • Break patents and grant licensing for local production of drugs in case of national public health threat (Doha Declaration) • Parallel importation • Allows a country to shop around for the best price of a branded drug on the global market

  24. Global Effort in HIV Therapy • Global Fund to Fight HIV, TB and Malaria • President’s Emergency Plan for AIDS Relief • Clinton Foundation • WHO “3 by 5”

  25. Global Fund to Fight AIDS, TB and Malaria • Scale up antiretroviral therapy in resource-limited settings • Collaborative effort • United Nations: UNAIDS, UNICEF, UNESCO • WHO • Family Health International (FHI) • World Bank • Local governments • Non-government organizations (NGO) and private sectors • Philanthropic foundations

  26. Global Fund to Fight AIDS, TB and Malaria • Initiated by UN Secretary General Kofi Annan in 2001 • A financial instrument to complement existing programs addressing AIDS, TB and malaria • It concentrates on generating additional resources and making them available at the community and country levels. • 60% supports HIV/AIDS prevention and treatment programs (including purchasing HIV drugs).

  27. The Global Fund to Fight AIDS, Tuberculosis and Malaria Pledges and contributions received, as of December 31, 2003 France 14% EC 11% France 6% EC 19% Italy 9% Italy 10% U.S. 33% U.S. 30% Germany 2% Germany 7% U.K. 6% Other Govt’s 10% Japan 8% Netherlands 2% U.K. 6% Canada 2% Other Govt’s 7% Japan 5% Corporate/Private* 5% Netherlands 3% Corporate/Private* 2% Canada 2% Total pledges: US$ 4,966 million Total contributions received: US$ 2,104 million *Foundations and Non-for-profit organizations, Corporations, and Individuals, Groups and Events Source: THE GLOBAL FUND ANNUAL REPORT 2003, January 1 - December 31, 2003. 2004 Report on the Global AIDS Epidemic (Fig 42)

  28. Global resources needed for prevention, orphan care, care and treatment and administration and research 2004−2007 (in US$ millions) Prevention Orphan care Care & treatment Admin & Research 20,000 US$ millions 15,000 10,000 5,000 0 2004 2005 2006 2007 2004 Report on the Global AIDS Epidemic (Fig 36)

  29. President Bush’s Emergency Plan for AIDS Relief • Focusing significant new resources in 15 countries ($9 billion) • Commitment to provide prevention and treatment services • ABC Model: Abstinence, Be faithful, Condoms • US Global AIDS Coordinator: coordinate all US government HIV/AIDS activities worldwide

  30. The Clinton HIV/AIDS Initiative (CHAI) • Developing "business plans" for bringing integrated care, treatment, and prevention programs to large numbers of people • Assisting in presenting the plan to donor governments, foundations, multilateral organizations, and private corporations to help mobilize the financial resources • Negotiating supplier agreements for low-priced drugs and medical equipment • Primary focus: Africa, Caribbean and China

  31. Reducing the price of HIV drugs • Encouraging generic competition • This is one of the most powerful tools that country policymakers have to lower prices. Brazil d4T + 3TC + NVP $712 $347 Galvão J. Lancet. http://image.thelancet.com/extras/01art9038web.pdf

  32. Prices (US$/year) of a first-line antiretroviral regimen in Uganda: 1998−2003 14 000 Launch of Accelerating Access Initiative (AAI) 12 000 10 000 Generic companies’ offer of price reduction to Uganda Negotiatiations with R & D Pharma within AAI 8 000 Price US$ Further price reductions by AAI companies Further discussion with generic companies Negotiations by William J. Clinton Foundation with 4 generic companies 6 000 4 000 2 000 0 Jun 98 Jul 98 Aug 98 Sep 98 Jun 00 Oct 00 Nov 00 Dec 00 Jan 01 Feb 01 Mar 10 Apr 01 May 01 Jun 01 Jul 01 Aug 01 Mar 03 Sep 03 Oct 03 1 200 1 100 1 000 900 800 700 Price US$ 600 500 400 300 200 100 0 Nov 00 Dec 00 Jan 01 Feb 01 Mar 01 Apr 01 May 01 Jun 01 Jul 01 Oct 03 Source: UNAIDS/WHO, 2004 2004 Report on the Global AIDS Epidemic (Fig 34)

  33. WHO 3 by 5 Initiative • Providing antiretroviral treatment to three million people living with AIDS in developing countries and by the end of 2005. • WHO and UNAIDS will focus on five critical areas: • Simplified, standardized tools to deliver antiretroviral therapy. • A new service to ensure an effective, reliable supply of medicines and diagnostics. • Rapid identification, dissemination and application of new knowledge and successful strategies. • Urgent, sustained support for countries. • Global leadership, strong partnership and advocacy.

  34. Khayelitsha: Availability of decentralized antiretroviral therapy (ART) access, advocacy, and multi-disciplinary support services dramatically increases demand for testing and counselling HIV tests Support groups 15,000 25 12,000 20 9,000 15 6,000 10 3,000 5 0 0 1998 2002 1998 2002 Before ART ART started Source: WHO, 2004 (courtesy of Dr. Fareed Abdullah) 2004 Report on the Global AIDS Epidemic (Fig 27)

  35. Pediatric treatment guidelines

  36. Many questions remain… • How will an HIV drug program affect or change stigmatization and perception of HIV in community levels? • What will the effect of HIV care be on community in regard to prevention practices? • What monitoring tools can be used in the resource-limited setting? • What are the determinants of adherence to ARV therapy and what is necessary to develop sustainable adherence practices? • What is an affordable household expenditure for HIV care with ARV therapy? • How will an HIV drug program affect drug resistance dynamics and other co-morbidity such as TB in community/country levels? • And many many more…

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