Emerging DiseasesEpidemiology of HIV/AIDSShahid Beheshti University of medical sciences, 2005By: Hatami H. MD. MPH

Definition of AIDSAcquired immune deficiency syndrome (AIDS)Caused by HIV (Human Immunodeficiency Virus)

Definition of HIVHuman Immunodeficiency Virus :HTLV-I and HLTV-II , HTLV-IIIRNA virus Retrovirus (Oncovirus vs. Lentivirus)Target cell T4 cell and Lymphocyte/Monocyte

HIVI & HIVII Are serologically and geographically relatively distinct Have similar epidemiologic and pathologic characteristic HIVI is found in the Americas, Europe Africa and most other countries HIVII is found in Africa

HIV-Infected T-CellHIVT-CellHIV InfectedT-CellNew HIV

Incubation period Serologic incubation period Clinical incubation period

Window PeriodThis is the period of time after becoming infected when an HIV test is negative

90% of cases test positive within 3 months of exposure

10% of cases test positive within 3-6 months of exposure

HIV Infection and Antibody Response InfectionOccursAIDS Symptoms---Initial Stage-------------------Intermediate or Latent Stage-----------------Illness Stage---Flu-like SymptomsOrNo SymptomsSymptom-free

HIV/AIDS Factors affecting Incubation periodAccelerated ProgressionExtremes of agePoor immune responseSlowed ProgressionViral mutantsChemokine receptor mutationsAnti-HIV therapy

Clinical Stages of HIV InfectionPrimary infectionAcute HIV syndromeImmune response to HIVClinical latency3-6 weeks1 week 3 months1-2 weeks

Clinical findings in acute HIV syndromeGeneralFeverPharyngitis LymphadenopathyHeadache/retroorbital painArthralgia/myalgiaLethargy/malaiseAnorexia/weight lossNausea/vomiting/diarrhea

Clinical findings in acute HIV syndromeNeurologic Meningitis Encephalitis Peripheral neuropathy Myelopathy DermatologicErythematous maculopapular rashMucocutaneous ulceration

Clinical findings in acute HIV syndromeMost patients recover spontaneouslyMany are left with a mildly depressed CD4+ T cellIn most patients followed by prolonged period of clinical latency

Clinical Stages of HIV InfectionClinical latencySymptomatic diseaseCD4 Tcell < 200 L Opportunistic infections Neoplasms

Opportunistic InfectionsBacterialStrep pneumoniaTB MAIViralHerpesVaricella ZosterCMV / EBVInfluenzaParasitesPneumocystis cariniiToxoplasmosisCryptosporidumFungusCandidaAspergillusCryptococcus

MALIGNANCIES IN AIDSAIDS definingKaposis sarcomaPrimary brain lymphomaHigh grade non-Hodgkins lymphomaInvasive carcinoma of the cervixOtherAnorectal squamous carcinomaHodgkins disease

Once persons are infected they are always infected

Medications are available to prolong life but they do not cure the disease

Are capable of infecting others without having symptoms or knowing of the infection

HIV AIDS

HIV: The 4th DecadePre - 1970Silent

1971 - 1980Sporadic Cases

1981 - 1990Epidemic

1991 - Current Pandemic

AIDS is Present in Virtually Every Country in the World

People living with HIVNew HIV infections in 2004Deaths due to AIDS in 2004Total number of AIDS deaths

39.4 million [35.9 44.3 ]4.9 million [4.3 6.4 ]3.1 million [2.8 3.5 ]28 million

Global estimates for adults and children end 2004

Adults and children estimated to be living with HIV as of end 2004Total: 39.4 (35.9 44.3) million Western & Central Europe610 000[480 000 760 000]North Africa & Middle East540 000[230 000 1.5 million]Sub-Saharan Africa25.4 million[23.4 28.4 million]Eastern Europe & Central Asia1.4 million [920 000 2.1 million]South & South-East Asia7.1 million[4.4 10.6 million]Oceania35 000[25 000 48 000]North America1.0 million[540 000 1.6 million]Caribbean440 000[270 000 780 000]Latin America1.7 million[1.3 2.2 million]East Asia1.1 million[560 000 1.8 million]

Adults and children estimated to be living with HIV as of end 2004

Estimated number of newly infected with HIV during 2004Total: 4.9 (4.3 6.4) million Western & Central Europe21 000[14 000 38 000]North Africa & Middle East92 000[34 000 350 000]Sub-Saharan Africa3.1 million[2.7 3.8 million]Eastern Europe & Central Asia210 000[110 000 480 000]East Asia290 000[84 000 830 000]South & South-East Asia890 000[480 000 2.0 million]Oceania5 000[2 100 13 000]North America44 000[16 000 120 000]Caribbean53 000[27 000 140 000]Latin America240 000[170 000 430 000]

Estimated deaths from AIDS during 2004Total: 3.1 (2.8 3.5) million Western & Central Europe6 500[

Children (

Estimated deaths in children (

Estimated number of children (

About 14 000 new HIV infections a day in 2004More than 95% are in low and middle income countriesAlmost 2000 are in children under 15 years of ageAbout 12 000 are in persons aged 15 to 49 years, of whom: almost 50% are women about 50% are 1524 year olds

Situation of HIV/AIDS in High-income countriesEnd 2004, prevalence = 0.4%

Situation of HIV/AIDS in High-income countriesApproximately 64000 people become infected in 2004A total of 1.6 million are now living with HIV/AIDSDramatic reduction in deaths due to antiretroviral therapy About 500000 people were receiving these drugs

19971998199920002001*02,0004,0006,0008,00010,00012,000Number of deathsNumber of deaths reported among AIDS cases in Western Europe: 1997-2001* January June 2001 data multiplied by 2.

Care Prolongs Productive Life The widening gap between North and South

Situation of HIV/AIDS in High-income countries (2)59% of new HIV diagnoses in several countries is occurring through heterosexual intercourse14% OF IDUs in USA are infected win HIV (Spain = 23% , France = 10-23% , Portugal => 50%The epidemics shift into poorer and marginalized sections of society is continuing

Percentage of probable route of HIV infection in the United Kingdom: 1990-2000Sex between men and womenInjecting drug use

HIV incidence among men who have sex with men in Vancouver, Madrid and San Francisco, 199520000.01.02.03.04.05.01995-9920001996200019961999Annual HIV incidence (%)VancouverMadridSan Francisco

Situation of HIV/AIDS in SUB-SAHARAN AFRICAEnd 2004, prevalence = 7.4%

Situation of HIV/AIDS in SUB-SAHARAN AFRICAThe worst-affected region29.4 million people living win HIV/AIDSApproximately 3.1 million new infections occurred in 200410 million young people (15-24) and 3 million (< 15 years old) live with HIV/AIDS

Number of people living with HIV/AIDS in sub-Saharan Africa, 1980-200105101520253019801983198619891992199519982001Millions

Number of people who died from HIV/AIDS in sub-Saharan Africa, 1980-200105001,0001,5002,0002,50019801983198619891992199519982001Thousands

Situation of HIV/AIDS in SUB-SAHARAN AFRICAA tiny fraction of the millions are receiving antiretroviral drugsMany millions are not receiving medicines to treat opportunistic infections

Adult HIV PREVALENCE

Situation of HIV/AIDS in SUB-SAHARAN AFRICA

Adult HIV PREVALENCE%Botswana38.8Lesotho31Swaziland33Zimbabwe33.7

HIV prevalence in adults in sub-Saharan Africa, end 200120 39%10 20% 5 10% 1 5% 0 1%trend data unavailableoutside region2001End 2004, prevalence = 7.4%

HIV prevalence among people consuming alcohol and among non-drinkers, Carletonville, South Africa, 1998010203040506070menwomenwomen in commercial sex areasdrinkersnon-drinkersHIV prevalence (%)

19902000HIV prevalence among pregnant women in South Africa, 1990 to 2001HIV prevalence (%)

Situation of HIV/AIDS in SUB-SAHARAN AFRICA

Projected population structure with and without the AIDS epidemic, Botswana, 202080757065605550454035302520151050020406080100120140020406080100120140MalesFemalesDeficits due to AIDSProjected population structure in 2020Population (thousands)Age in years

Leading causes of death in Africa, 200022.610.19.16.75.54.33.63.12.92.30.05.010.015.020.025.0HIV/AIDSMalariaPerinatalconditionsTuberculosisCerebrovascular diseaseDiarrhoeal diseaseLowerrespiratory infectionsMeaslesIschaemic Heartdisease Maternalconditions% ofTotal

Estimated and projected deaths at ages 15-34, with and without AIDS in South Africa: 1980-202504008001,2001,6002,000Deaths (Thousands)1980-19851985-19901990-19951995-20002000-20052005-20102010-20152015-20202020-2025Without AIDSWith AIDS

Estimated impact of AIDS on under-5 child mortality rates, selected African countries, 2010BotswanaKenyaMalawiTanzaniaZambiaZimbabwe050100150200250Deaths per 1,000 live birthsWithout AIDSWith AIDS

Changes in life expectancy in selected African countries with high and low HIV prevalence: 1950 - 2005with high HIV prevalence:ZimbabweSouth AfricaBotswanawith low HIV prevalence:MadagascarMali1950 19551955- 19601960-19651965-19701970-19751975-19801980-19851985-19901990-19951995-20002000-2005

010203040506070CambodiaHaitiMozambiqueRwandaCte d'IvoireZambiaKenyaSouth AfricaZimbabweBotswanaLife expectancy at birth (years)Predicted life expectancyLoss in life expectancy due to HIV/AIDSPredicted loss in life expectancy due to HIV/AIDS in children born in 2000Source: U.S. Census Bureau, 2000

Situation of HIV/AIDS in Eastern Europe and Central AsiaEnd 2004, prevalence = 0.8%

Situation of HIV/AIDS in Eastern Europe and Central AsiaHaving the worlds fastest-growing HIV/AIDS epidemic210000 new infections in 20041.4 million people living win HIV/AIDSEpidemics in Russian Federation in less than 8 years have been discovered in more than 30 cities and 86 of 89 region

Situation of HIV/AIDS in Eastern Europe and Central AsiaUp to 90% of the registered infections have been attributed to infecting drug useThe total number of reported cases were 200000 by mid-20024 years ago it has been 10993

Cumulative reported HIV infections per million population in Eastern European countries: 1993-2001BelarusEstonia*KazakhstanLatviaLithuaniaMoldova, Republic ofRussian FederationUkraine199319941995199619971998199920002001ProjectedCases per million population* actual 2001 year-end data

Young Women, Ukraine 1999

Situation of HIV/AIDS in Asia and the Pacific

Situation of HIV/AIDS in Asia and the PacificAlmost 1 million people in Asia and the Pacific acquired HIV in 20048.2 million of people now living with HIV/AIDS12% increase since 2002540000 have died of AIDS in 2004

Number of people living with HIV/AIDS in Asia: 1980-2001Millions0.01.02.03.04.05.06.07.019801983198619891992199519982001

Number of people who died from HIV/AIDS in Asia: 1980-2001Thousands010020030040050019801983198619891992199519982001

HIV prevalence in adults in Asia: end 20012 5%1 2%0.5 1%0.1 0.5%0 0.1%trend data unavailableoutside region2001End 2004 = 0.4%

HIV infection in Thailand: 1985-2000 0200400600800100012001400Thousands of HIV infectionsLiving with HIV and AIDSCumulative HIVNew HIV19851990199520002005201020202015

Annual number of persons diagnosed with HIV and AIDS in Myanmar : 1988 - end Sept 2001

Indonesia HIV infection rates: 1999-2000SW 6.4%SW 8.0%SW 6.0%SW 26.5%IDUs 40%SW 1.5%IDUs 24.5%IDUs 53%0 %< 1%> 5 %1 - 5 %SW - Sex Workers IDUs Injecting Drug Users

Situation of HIV/AIDS in Asia and the PacificInjecting drug use offers the epidemic huge scope for growth.Very high rates of needle-sharing have been documented in Bangladesh and Viet NamMale-to-male sex occurs in all countries of the region

HIV prevalence among injecting drug users in Nepal: 1991-1999

HIV prevalence among men who have sex with men, in selected Asian countries: 1986-2000

Situation of HIV/AIDS in Asia and the PacificChina and India are experiencing serious, localized epidemics that are affecting many millions of people.5.1 million people were living with HIV in India at the end of 2003The second higher figure in the world (India) after Africa

HIV prevalence among sex workers in selected provinces in China: 1993-200003691219931994199519961997199819992000% HIV-positiveGuangxiGuangzhouYunnan

Situation of HIV/AIDS in Middle East and North AfricaPrevalence End 2004 = 0.3%

Situation of HIV/AIDS in Middle East and North Africa92000 people having acquired the virus in 2004540000 people living with HIV/AIDS in 2004Systematic surveillance remains inadequateIt is very difficult to deduce accurate trends

Situation of HIV/AIDS in Middle East and North AfricaIt is possible that hidden epidemics could be spreading in this region.Better surveillance system such as those introduced in Iran will enable more countries Significant outbreaks of HIV infections among IDUs have occurred in about 50% of countries in the region notably in North Africa and IRAN

Situation of HIV/AIDS in Middle East and North AfricaIn IRAN most HIV transmission is occurring among the 200000-300000 IDUs 10% of IDUs living with HIVHigh-risk behavior is widespread in this largely male population50% of them share injecting equipment

Situation of HIV/AIDS in IRAN33% have extramarital sexual relationsMore than 50% of them are marriedCondom use is very rareAbout 10% of prisoners inject drugs and more than 95% of them share needles HIV prevalence among them was 12% in 2001

Situation of HIV/AIDS in Middle East and North AfricaUnless countries promptly introduce harm reduction and other prevention services for injecting drug users, the epidemic could grow dramatically and spread into the wider population 0

Situation of HIV/AIDS in IRANThe HIV epidemic in the IRAN appears to be accelerating at an alarming termAbout 15% of all HIV infections since the start of the epidemic in Iran were reported in 2003

Situation of HIV/AIDS in IRANThe 64% of all cases were injecting drug users (51% in 1383 ??)HIV rate among prisoners rose up to six times higher in 1999 compared to 1996

Estimated number of adults and children living with HIV/AIDS in IRAN

Adults (15-49)20000Women (15-49)5000Children (0-15)< 200Deaths in 2001290

Source = Epidemiological fact sheet on HIV/AIDS, WHO, 2002 update

Situation of HIV/AIDS in IRAN1/10/83 = 980095%5%1038373

HIV/AIDS 1/10/1383

Chart1

21

43

536

2666

1992

1231

205

36

3070

Sheet1

4021

14543

2415536

34252666

44351992

54451231

6455205

65+36

3070

Sheet1

Sheet2

Sheet3

HIV/AIDS 1/10/1383

Chart2

5

14

20

47

48

69

48

57

28

29

253

818

402

449

494

1499

1567

2151

1802

Sheet1

13655

14

20

47

136948

69

137148

57

137328

29

1375253

818

1377402

449

1379494

1499

13811567

2151

13831802

Sheet1

Sheet2

Sheet3

HIV/AIDS 1/10/138351%

Chart3

578

214

5032

35

3941

Sheet1

578

214

5032

35

3941

Sheet1

Sheet2

Sheet3

HIV/AIDS 1/10/1383 ( )

Chart1

9.9

3.7

85.9

0.6

Sheet1

9.9

3.7

85.9

0.6

Sheet1

Sheet2

Sheet3

HIV TransmissionSexual ContactMother to InfantBlood ContactIV needle sharingBlood products including transfusionHealthcare worker exposure to blood and body fluid Are analogous to those of hepatitis B

HIV TransmissionFrom 25% to 35% of infants born to HIV-infected mothers are infected before, during or shortly after birthAfter injecting with needles

HIV 0.5% But Hepatitis B 25%

HIV TransmissionHIV enters the bloodstream through:Open CutsBreaks in the skinMucous membranesDirect injection

HIV TransmissionCommon fluids that are a means of transmission:

Blood

Semen

Vaginal Secretions

Breast Milk

HIV Transmission

HIV Transmission

HIV in Body Fluids

Semen11,000

Vaginal Fluid7,000Blood18,000Amniotic Fluid4,000Saliva1Average number of HIV particles in 1 ml of these body fluids

IRAN 5%

Risk CategoriesFrom greatest to least risk are as follows:Males having sex with malesInjecting drug usersMales having sex with males that also inject drugsHeterosexual transmissionBlood transfusionPerinatal transmissionNo reported risk category

HIV TransmissionTransmission after contact with saliva, tears, urine and bronchial secretions has not been reportedRoutine or community contact with an HIV-infected person carries no risk of transmissionInsect bite ?

Period of communicabilityUnknownEarly after onset of HIV infection and extend throughout lifeCommunicability increases with increasing immune deficiency

Susceptibility and resistanceSusceptibility presumed to be generalRace does not appear to affect susceptibility to HIV infection or AIDSPresence of other STIs may increase susceptibility No recovered cases have been documentedDegree of immunity is unknown

Preventive measures

Preventive measuresThe cornerstones of prevention :EducationCounseling Behavioral modification

Preventive measures Widespread voluntary testing of individuals with high-risk behaviors Counseling of infected individuals Information gathering

Testing Counseling Behavioral modificationInformation gathering Safe sex Stop the use of injection

Preventive measuresBehavioral modification : Safer sex Abstinence from sexual relationship Monogamous sexual relationship Use of condom

Preventive measuresPublic and school health educationAvoid sexual intercourse with persons known or suspected to be infected with HIVExpansion of treatment facilities for drug usersPhysicians should adhere strictly to medical indications for transfusions

Preventive measuresOnly clotting factor products that have been screened and treated to inactivate HIV should be usedCare should be taken in handling, using and disposing of needles or other sharp instrumentsWHO recommends immunization of asymptomatic HIV infected children with the EPI vaccines

Preventive measuresEfforts should be made to take advantage of the strong religious beliefs prevailing in order to promote healthy lifestyles and abstinence from unhealthy lifestyles

Preventive measuresAvoid sexual relations outside marriageKnowledge and virtue will protect you from HIV/AIDS

Public health educationGeneral public health education is neededThe public should be informed of the nature of the diseaseThey should be informed the dangers of promiscuous sexual relations

HIV Post Exposure Prophylaxis

HIV Occupational ExposureReview facility policy and report the incidentMedical follow-up is necessary to determine the exposure risk and course of treatmentBaseline and follow-up HIV testingFour week course of medication initiated one to two hours after exposure Liver function tests to monitor medication toleranceExposure precautions practiced

Sources :HIV/AIDS, North Dakota Department of Health HIV/AIDS ProgramHIV/AIDS: The Status of the Epidemic Today, Kristine Thyng, HHMI-MCB Workshop, Summer 2004Helene D. Gayle, MD, MPH Director, HIV/AIDS & TB Worldwide Epidemiology of HIV/AIDS HIV/AIDS in sub-Saharan Africa July 2002UNAIDS , Epicore2004_Dec04UNAIDS, AIDS epidemic update, December 2004Iranian Center for diseases management, HIV/AIDS, update, 1383/10/1

Harrison 2005, pp 1104 Harrison 2005, pp. 1137

Harrison 2005, pp. 1137

Harrison 2005, pp. 1137 Harrison 2005, pp. 1137