the global epidemic of hiv infection ford von reyn infectious disease section dartmouth-hitchcock...

The global epidemic of HIV The global epidemic of HIV infectioninfection

Ford von Reyn

Infectious Disease Section

Dartmouth-Hitchcock Medical Center

AIDS at DHMCAIDS at DHMC

7/15/81

33 yo gay man, IDU

Admitted with bilateral pulmonary infiltrates

Dx: Pneumocystis carinii pneumonia (PCP)

Rx: Died after 16 days

CDC: 30-35 cases reported

Rock Hudson reported with AIDS-1985

Global estimates for adults and childrenGlobal estimates for adults and childrenend 2003end 2003

People living with HIV/AIDS

New HIV infections

Deaths due to HIV/AIDS

46 million

5 million

3 million

Adults and children estimated to be living Adults and children estimated to be living

with HIV/AIDS as of end 2001with HIV/AIDS as of end 2001

Western Europe

550 000550 000North Africa & Middle East

500 000500 000Sub-Saharan

Africa

28.5 28.5 millionmillion

Eastern Europe & Central Asia

1 million1 million

South & South-East Asia

5.6 million5.6 million

Australia & New Zealand

15 00015 000

North America

950 000950 000Caribbean

420 000420 000

Latin America

1.5 1.5 millionmillion

Total: 40 million

East Asia & Pacific

1 million1 million

Modes of transmission of HIVModes of transmission of HIV

SexualSexual

ParenteralParenteral

PerinatalPerinatal

Global transmission patternsGlobal transmission patterns

Pattern I: developed countries Pattern I: developed countries (e.g. US, (e.g. US, Australia, W Europe)Australia, W Europe)

Sexual:Sexual: homosexual>heterosexual homosexual>heterosexual

Parenteral:Parenteral: injecting drug use injecting drug use

Perinatal:Perinatal: perinatal/postnatal>prenatal perinatal/postnatal>prenatal

Seroprevalence: <1% (M>>F)Seroprevalence: <1% (M>>F)

Global transmission patternsGlobal transmission patterns

Pattern II: developing countries Pattern II: developing countries (e.g. sub-(e.g. sub-Saharan Africa)Saharan Africa)

Sexual:Sexual: heterosexual (M=F) heterosexual (M=F)

Parenteral:Parenteral: unsterile needles, transfusion unsterile needles, transfusion

Perinatal:Perinatal: perinatal/postnatal>prenatal perinatal/postnatal>prenatal

Seroprevalence: 1-25%(M=F)Seroprevalence: 1-25%(M=F)

*Adjusted for reporting delaysQuarter-Year of Diagnosis/Death

Estimated Incidence of AIDS and Deaths of Adultswith AIDS*, January 1985 - June 2000, United States

0

5,000

10,000

15,000

20,000

25,000

19851986198719881989 199019911992199319941995199619971998 19992000

Deaths

AIDS 1993 definitionimplementation

1986 1988 1990 1992 1994 1996 1998 20000

10

20

30

40

50

60

70

Year of Report

American Indian/Alaska Native

Black, not Hispanic

Hispanic

Asian/Pacific Islander

White, not Hispanic

Proportion of AIDS Cases, by Race/Ethnicity and Year of Report,1985 - 2000, United States

0

10

20

30

40

50

60

70

1986 1988 1990 1992 1994 1996Year of Diagnosis

Proportion of Estimated* Adult/Adolescent AIDS Cases by Exposure Category and Year of Diagnosis,

1985 - 2000, United States

*Data adjusted for reporting delays and proportional redistribution of cases reported without a risk.

1998 2000

MSM & IDU

Men who have sex with men (MSM)

Injection drug use (IDU)

Heterosexual contact


SexualSexual


PerinatalPerinatal

Heterosexual Transmission: UgandaHeterosexual Transmission: Uganda

415 couples with HIV pos and HIV neg partner415 couples with HIV pos and HIV neg partner Up to 30 month follow with counselingUp to 30 month follow with counseling Seroconversion in 90 couples (12/100 py)Seroconversion in 90 couples (12/100 py) No difference in M to F vs F to M transmissionNo difference in M to F vs F to M transmission Role of circumcisionRole of circumcision

seroconversion 16.7/100 py in uncircumcised malesseroconversion 16.7/100 py in uncircumcised males seroconversion 0/100 py in circumcised malesseroconversion 0/100 py in circumcised males

Role of viral load: seroconversion 0/100 py in 51 Role of viral load: seroconversion 0/100 py in 51 patients with viral load <1500patients with viral load <1500

-Quinn 2000-Quinn 2000

Sexual transmission of HIVSexual transmission of HIVTransmission is bidirectional

M F = F M

Rate of transmissionper episode intercourse: 1/1000long term partner: 15-25%

Risk factors: viral load lack of circumcision genital ulcers


SexualSexual


PerinatalPerinatal

Perinatal Transmission of Human Perinatal Transmission of Human Immunodeficiency Virus (HIV)Immunodeficiency Virus (HIV)

Prenatal(7%) -Transplacental

Intrapartum(13%) -During delivery

Postpartum (14%) -Breast feeding

Mofenson 2001Mofenson 2001

AIDS as a zoonosis

Simian immunodeficiency viruses

Pan troglodytes SIVcpz (chimpanzee)

Sooty mangabeys SIVsm

-Hahn 2000, Science

TuberculosisTuberculosis

Risk:Risk: active TB = 5% in reported AIDS casesactive TB = 5% in reported AIDS casesreactivation 7%/yrreactivation 7%/yr

Mortality:Mortality: low low (unless MDR)(unless MDR)

CD4 range:CD4 range: all, median = 354 all, median = 354 (US, Theuer)(US, Theuer)

SurveillanceSurveillance:: annual PPD skin testing annual PPD skin testing (read by provider)(read by provider)

Prevention:Prevention: childhood BCG (developing countries)childhood BCG (developing countries)INH 300 mg+pyr 50 mg x 12 mos forINH 300 mg+pyr 50 mg x 12 mos for

PPD PPD >> 5mm 5mmanergic patients at high risk (e.g. IDU)anergic patients at high risk (e.g. IDU)

Pneumocystis cariniiPneumocystis carinii Pneumonia Pneumonia

Risk:Risk: 80% cumulative risk80% cumulative risk

Mortality:Mortality: 15% per episode 15% per episode

CD4 range:CD4 range: usually <200, usually <200, (10% higher, most <50)(10% higher, most <50)

Prevention:Prevention: for CD4<200 or any OI for CD4<200 or any OI (e.g. thrush)(e.g. thrush), give, give

TMP/SMZ DS (160/800) 3x/wkTMP/SMZ DS (160/800) 3x/wkoror

Dapsone 100 qd or 50 bidDapsone 100 qd or 50 bidoror

Aerosol pentamidine 300/moAerosol pentamidine 300/mo

Malignancies in HIVMalignancies in HIV

1. Kaposi’s Sarcoma1. Kaposi’s SarcomaTumor due to sexually acquired HHV-6. Cutaneous or Tumor due to sexually acquired HHV-6. Cutaneous or mucous membrane involvement most common but may mucous membrane involvement most common but may have primary lesion in GI tract.have primary lesion in GI tract.

2. Lymphoma2. LymphomaMost are B cell and extranodal, esp brain and abdominal Most are B cell and extranodal, esp brain and abdominal mesentarymesentary

3. Anorectal Tumors3. Anorectal TumorsSquamous cell tumors of the anus and rectum in gay menSquamous cell tumors of the anus and rectum in gay men

Treatment of HIVTreatment of HIV

Highly active antiretroviral therapy Highly active antiretroviral therapy (HAART)(HAART)

Reduces viral load, increases CD4 and Reduces viral load, increases CD4 and prolongs survivalprolongs survival

Side effects are significantSide effects are significant

PseudoobesityPseudoobesity

Abdominal visceral fat accumulation appearing within 7 months of treatment

N Engl J MED 1998;339:1296N Engl J MED 1998;339:1296

Peripheral Lipoatrophy, LegPeripheral Lipoatrophy, Leg

Loss of subcutaneous fat in the legs, leading to abnormally visible veins and muscles.

Btrtish J Derm 2000;142:496-500Btrtish J Derm 2000;142:496-500

Peripheral Lipoatrophy, FacePeripheral Lipoatrophy, Face

Wasting of the buccal fat, giving a pseudocachectic appearance.

Btrtish J Derm 2000;142:496-500Btrtish J Derm 2000;142:496-500

Prevention of HIV infectionPrevention of HIV infection

Sexual: counselling and testing, Sexual: counselling and testing, education, condom distributioneducation, condom distribution

Parenteral: blood screening, needle Parenteral: blood screening, needle safety, needle exchange treatment for safety, needle exchange treatment for drug abusedrug abuse

Perinatal: screening, antiviral Perinatal: screening, antiviral prophylaxisprophylaxis

Vaccine: challengingVaccine: challenging

-Furtado 1999 NEJM

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