Treatment of Genital Herpes

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HIV/AIDS in Africa Is Hope on the Way?

• Social, cultural, and economic background
• Progression/natural history
• Knowledge gaps and interventions
• Images of hope

Nathan Thielman, MD, MPH Division of Infectious
Diseases and International Health Duke University
Medical Center n.thielman_at_duke.edu
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Estimated percentage of adults (1549) infected
with HIV
20.0 36.0 10.0 20.0 5.0 10.0 1.0
5.0 0.0 1.0 trend data
unavailable outside region
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6.23 Billion People
Sub-Saharan Africa 687 million
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Data from International Data Base, US Census
Bureau, released March 2004
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Adults and children estimated to be living with
HIV as of end 2004
Eastern Europe Central Asia 1.4 million 920
000 2.1 million
Western Central Europe 610 000 480 000 760
000
North America 1.0 million 540 000 1.6 million
East Asia 1.1 million 560 000 1.8 million
North Africa Middle East 540 000 230 000 1.5
million
Caribbean 440 000 270 000 780 000
South South-East Asia 7.1 million 4.4 10.6
million
Sub-Saharan Africa 25.4 million 23.4 28.4
million
Latin America 1.7 million 1.3 2.2 million
Oceania 35 000 25 000 48 000
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Total 39.4 (35.9 44.3) million
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Estimated number of adults and childrennewly
infected with HIV during 2004
Eastern Europe Central Asia 210 000 110 000
480 000
Western Central Europe 21 000 14 000 38 000
North America 44 000 16 000 120 000
East Asia 290 000 84 000 830 000
North Africa Middle East 92 000 34 000 350
000
Caribbean 53 000 27 000 140 000
South South-East Asia 890 000 480 000 2.0
million
Sub-Saharan Africa 3.1 million 2.7 3.8 million
Latin America 240 000 170 000 430 000
Oceania 5 000 2 100 13 000
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Total 4.9 (4.3 6.4) million
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Estimated adult and child deaths from AIDS
during 2004
Western Central Europe 6 500 lt8 500
Eastern Europe Central Asia 60 000 39 000
87 000
North America 16 000 8 400 25 000
East Asia 51 000 25 000 86 000
North Africa Middle East 28 000 12 000 72
000
Caribbean 36 000 24 000 61 000
South South-East Asia 490 000 300 000 750
000
Sub-Saharan Africa 2.3 million 2.1 2.6 million
Latin America 95 000 73 000 120 000
Oceania 700 lt1 700
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Total 3.1 (2.8 3.5) million
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HIV in Tanzania and the Kilimanjaro Region
Kilimanjaro Region
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Partners in the Kilimanjaro Region
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Kilimanjaro Christian Medical Centre (KCMC)

• One of four medical schools
• One of four consultant hospitals
• 16 schools of allied health sciences

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Kibongoto National Tuberculosis Hospital
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KIWAKKUKI
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KCMC-Duke University Kilimanjaro AIDS Program A
Collaborative Program between Duke University
and Kilimanjaro Christian Medical Centre
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63-74 of the worlds HIV burden
11 of the worlds population
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Health Inequalities and the Biopsychosocial Model

• In the treatment of pulmonary edema, it is
  scientifically incompetent to miss a pertinent
  ECG finding, but it is no less egregious a
  scientific error to ignore the sodium intake of a
  derelict, forced by poverty and absent dentures
  to subsist on canned soups loaded with salt.

Shimon Glick in Empathy and the Practice of
Medicine (Ed. H Spiro), 1993
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When AIDS came, bushes were dry they just
needed this spark to take fire.
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Sexual Practices Cultures
Poverty
Gender Inequality
Interactions with Other Infections
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Gross Domestic Product per Capita (2001)
Source Globalis/UNEP/Global Virtual University
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Ratio of Girls to Boys in Tertiary Education
(2000)
Source Globalis/UNEP/Global Virtual University
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Social and Economic Variables in Relation to
Variations in HIV Prevalence 72 Countries
Poverty
Gender Inequality
Eight epidemiological, social, and economic
variables accounted for 2/3 of the variation in
cross-country HIV infections rates.
World Bank. Confronting AIDS. Oxford Univ Press,
1997.
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HIV/AIDS Demographics, Africa
Composition of the Infected Population, 2001
Sub-Saharan Africa
Rest of the World
Total does not equal 100 percent due to
rounding. Source UNAIDS, Report on the Global
HIV/AIDS Epidemic, July 2002.
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Women- Biological Vulnerabilities

• Larger mucosal surface area
• Microlesions during intercourse
• Very young women most vulnerable
• Coerced sex increases risk of microlesions
• More virus in sperm than in vaginal secretions
• At least 4x more vulnerable to STIs STIs are a
  risk factor for HIV

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KIWAKKUKI HIV-VCT May 2003 - Aug 2004
Moshi AIDS Information Centre (N2,684)
1,185 Men
1,499 Women
24 HIV
9.1 HIV
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Women - Sociocultural Vulnerabilities
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Frequency of Concurrent and Suspected Concurrent
Sexual Relationships
of 15-49 year-olds reporting gt1 regular partner
or spouse
of those who believe that their partner has
other regular partners
Halperin, D. and Epstein, H. Lancet 3645, 2004
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Do you have a sexual partner who has other
partners?
HIV-seronegative (n1687)
HIV-seropositive (n327)
Yes
Yes
No
No
Dont Know
Dont Know
KIWAKKUKI VCT Clients, 11/03 9/04
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Sexual Concurrency and HIV Transmission
Garnett, GP and Johnson, AM AIDS 116811997
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Women-Sociocultural Vulnerabilities
Source Report from the Durban Monitoring the
AIDS Pandemic (MAP) Network Symposium, The Status
and Trends of the HIV/AIDS in the World, 2000
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Women - Economic Vulnerabilities
Proportion of women who reported non-spousal
sexual partnerships in the previous year in
exchange for money or gifts.
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Buve, A AIDS 15 suppl 4 (2001), S5-14
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Women - Economic Vulnerabilities
Moshi
Proportion of women who reported ever exchanging
sex for money or gifts.
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Chu, H.Y. et al, Int J. STDs AIDS, In press.
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Interactions Between HIV, OIs, and Other
Infections
? OIs
? Plasma HIV RNA
TB, Malaria
? CD4
? HIV RNA in genital secretions
STDs
? Sexual Transmission
Ulcerations
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Tuberculosis Cases per 100,000 People (2001)
Source Globalis/UNEP/Global Virtual University
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Malaria Cases Per 100,000 (2000)
Source Globalis/UNEP/Global Virtual University
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Diagnoses assigned to 1,242 HIV-infected
inpatients 1997-2001
Most lethal meningitis (52, RR death, 2.3),
septicemia (47, RR 2.0), renal disease (44, RR
1.9), and non-TB pulmonary infection (RR 1.6)
Ole-Nguyaine, S. et al. Ann Trop Med Parasitol.
2004 Mar98(2)171-9.
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Does TB Increase Plasma HIV Viral Load?
JH Day et al, JID 1901677, 2004
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Does TB Increase Plasma HIV Viral Load?
JH Day et al, JID 1901677, 2004
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plt0.0001
p0.086


N47
N27
N21
N42
log10 plasma HIV-1 RNA
Blood Donors
Blood Donors
Malaria patients
Malaria patients
Anti-malaria Rx
Hoffman, I. et al. AIDS 13487, 1999
Baseline
Week 4
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Cumulative Probability of Death Following
Seroconversion among 168 Rural Ugandans
Median time from seroconversion to death, 9.8
years
Morgan, D. et al. AIDS 16597, 2002
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Ugandan Cohort Cumulative Probability of
Remaining Symptom-free from Time of Seroconversion
Morgan, D. et al. BMJ 324193, 2002
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HIV Progression in Ugandan Cohort
CD4Cells

1
2
3
4
5
6
7
8
9
10
11
12
13
14
Infection
Time in Years
Morgan, D. et al. BMJ 324193, 2002
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Concept for ISAAC COMMUNITY-BASED COHORT
KIWAKKUKI VCT
Incident cases and neg. controls
Prevalent cases
Simple Symptom Diary



Quarterly visits by HBC-FW to assess For
syndromic outcomes, hospitalizations, deaths

Month 0 Hx Staging exam BMI CBC/diff CD4 Archive
plasma/serum PPD
Month 12 Hx Staging exam BMI CBC/diff CD4 Archive
plasma/serum PPD
Outcomes investigated through integration with
other scientific programs accessing
diagnostic/treatment facilities at
KCMC PROLONGED FEVER (eg) PROLONGED
DIARRHEA PULMONARY SYMPTOMS
Notes BMIbody mass index HBC-FW Home-based
care field worker Patients will be instructed
to present to KCMC HIV Clinic for medical care
close integration/communication of HBC-FW and
clinic required.
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HIV/AIDS Prevention and Care Continuum

When to Start HAART
VCT
Living with AIDS
Endstage
Living
Uninfected
Sexual Cultures Practices
Poverty
Interactions with Other Infections
Gender Inequality
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