HIV in a low endemicity country;country response

Turkey

Serhat Ünal, M.D, FACP, FEFIMProfessor in Medicine

ChairHacettepe University, Faculty of Medicine

Department of Infectious Diseases

PresidentHacettepe University HIV/AIDS Treatment and Research Center

General Demographic Indicators Turkey

1990 2000 2010 2011

Total Population 56.473.035 67.803.927 73.722.988 74.724.269

Rural Population (%) 48,7 40,8 29,0 28,2

Urban Population (%) 51,3 59,2 71,0 71,8

0-14 y/o Population (%) 35,0 29,8 25,6 25,3

65 y/o and Over Population (%) 4,3 5,7 7,2 7,3

Population Growth Rate Per Year ( ‰) 17,0 13,8 13,0 12,8

Crude Birth Rate ( ‰) 24,1 20,3 17,5 17,3

Crude Mortality Rate ( ‰) 7,1 6,6 6,3 6,3

Total Fertility Rate (Number Of Children Per Woman) 2,9 2,4 2,1 2,1

Source: Turkish Statistical Institute

TURKEY - TÜRKİYE

Ministryof Health, Turkey

HIV/AIDS CASES ACCORDING TO YEARS

1 October 1985 – 31 December 2013n:6802

0

200

400

600

800

1000

1200

1400

85 87 89 91 93 95 97 99 2001 2003 2005 2007 2009 2011 2013

HIV (+) AIDS

7000/ 7000000 = 0.1 %

Ministry of Health, Turkey

0

50

100

150

200

250

300

350

0 '1-4 '5-9 '10-14 '15-19 '20-24 '25-29 '30-34 '35-39 '40-49 '50-59 '60+

Male Female

HIV/AIDS CASES ACCORDING TO AGE AND SEX

1 October 2013 – 31 December 2013n:1313

1985

Ministry of Health, Turkey

HIV/AIDS CASES BY MODE OF TRANSMISSION AND SEX

1 October 2013 – 31 December 2013n:1313

8.5%

0%

56%

4.5%

1,6%

32,60%

Homosexual intercourse

IDU

Heterosexual contact

Mother-to-child

Nosocomial infection

Undetermined

1985

CONDITION OF EPIDEMIC DISEASES AMONG THE GROUPS HAVING BEHAVIOURS OF RISK (TADOC – 2010)

Intravenous Drug Users

Number %

HIV/AIDS 1 1.5

Hepatitis B 2 2.9

Syphilis 1 1.5

Gonorea 1 1.5

Chlamydia 2 2.9

Main Factors That Lead To Increase The Number of HIV/AIDS Cases In Turkey

Turkey has a very young population (15-49 ages groups)

General knowledge of population regarding HIV/AIDS and sexual transmitted infections are limited

Increase in useage of intravenous drugs Growth of the Turkish tourism Large number of Turkish men working abroad Increase in number of commercial sex workers

Important Milestones in HIV/AIDS Turkey

1985 Detection of the first AIDS case1985 HIV/AIDS; mandatory notifiable disease1986 HIV testing1987 Serological testing for:

• Blood/tissue/organ donors• Registered sex workers• Before major surgical operations

1994 Medical treatment became free of charge1994 Coding system for notifications for HIV/AIDS cases

1996 Establishment of National AIDS Commission

2004 Gonorrhea and Chlamydia; mandatory notifiable diseases

2005 “HIV/AIDS Prevention and Support Programme” funded by the Global Fund

2007 Approval of 2007-2011 HIV/AIDS National Strategic Action Plan

2010 Establishment of Sexual Transmitted Diseases Scientific Committee

PMSocial Services

and Child Protection

ReligiousAffairs

Ministry ofFinance

Ministry ofDefence

Ministry ofJustice

PrimeMinistry

PMYouth andSport GD

State Instituteof Statistics

PMWomen’s Status and Issues GD

StatePlanning

OrganisationMinistry of Labour

and Social Security

Ministry of Health

Ministry ofNational

Education

Ministry ofInterior

Ministry of Culture and

Tourism

TGNA Legal Affairs Dep.

Turkish Radioand Television

HigherEducation Council

PM – FamilyResearchInstitute

Health Professional Associations

Turkish Red CrescentAssociation

Turkish FamilyPlanning Association

AIDS PreventionSociety

Association forCombat with AIDS

Human ResourceDevelopmentFoundation

Turkish ThirdSector Foundation

Artisans and Entrepreneurs Confederation

TurkishJournalistsAssociation

TGNAPopulation and

Development Group

Hacettepe AIDS Prev., Treat. andResearch Center

NATIONAL AIDS COMMISSION

PLA PODER

HIV/AIDS National Strategic Action Plan

Targets & Strategies

Prevention & Support VCT Diagnosis and Treatment Supportive Environment Monitoring & Evaluation Social support Intersectoral Collaboration

Vulnerable Populations

Commercial Sex Workers

Men Having Sex With Man

Intravenous Drug Users

Prisoners

HIV/AIDS (+)

Refugees and asylum seekers……….

HIV/AIDS Prevention and Support Programme of Turkey

Donor Organisation The Global FundGrant Number TUR-405-G01-H Principal Recipient Ministry of HealthProgram Duration 36 MonthsStart- End Dates August 2005 - 15 June 2008Budget USD 3,891,762

85% out of the total budget has been disbursed

Programme cities Ankara, Istanbul, Izmir, Gaziantep and Trabzon

Goal To prevent the further spread of HIV through active preventive interventions, especially among the most vulnerable populations, like IDUs, MSM, CSWs and detainees of penitentiary institutions and to support and empower vulnerable populations including PLWHA

Objectives To increase the access of CSWs, MSMs, IDUs to health

centers for preventive HIV/AIDS services To increase the access of general population to VCT

services and carry out their instituationalisation To improve the access of psychosocial support services

for PLHA and improve national legislative framework To improve preventive HIV services in prisons and

detention centers To improve national STIs/HIV/AIDS monitoring and

evaluation system

Activities

Awareness raising activities for NGOs Training of outreach workers Training of police officers 14 VCT centers, VCT Training for health staff Produce and distribution of outreach services and VCT materials

(brochures, posters, VCT guidelines, outreach guidelines) Procurement and distribution of rapid HIV tests, condoms, lubricants Monitoring and evaluation Behavioural Survey 13 NGOs; including PLA and PODER, 16 projects, 1,8 million US Dollar Workshop on IDU and HIV/AIDS Workshop on HIV/AIDS and Human Rights Workshop on the Evaluation of VCT Services VCT Media Campaign

Voluntary Councelling and Test CentersTurkey

Begin to provide service in 2007 to high risk and critical groups in terms of HIV/AIDS

• Information about transmission routes and protection from HIV/AIDS

• Free and confidential HIV testing,• Pre and post test councelling• Guidance to a healthcare center for treatment

HIV/AIDS Tests in Turkey

HIV test groups

a) Blood donors (mandatory)

b) Sex workers (mandatory)

c) Volentary Councelling & Test Centers

d) Pre-marital councelling

e) After risky behavior,

f) Pre surgery

HIV Test Number in Years (2002-2013*)

*Until Oct 2013

Diagnosis Time in Turkey

Şekil. Vakaların CD4+ Hücre Sayılarına Göre İki Döneme Göre Dağılımları

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

<2006 ≥2006

n=59

n=36n=33

n=55

n=15

n=39

<200

200-500

>500

CD4+Hücre/mm3

Barriers to Testing in Turkey

• Lack of awareness• Stigmatisation- social isolation• Cost• No quidelines• Low numbers of centers for testing• Social aspect – patient privacy• Hard ro reach groups Homosexual men

Sex workers Injecting drug users Prisoners Refugees , illegal immigrants

HIV/AIDS TANI TEDAVİ REHBERİ – TÜRKİYEHIV/AIDS Diagnose and Treatment Guideline

Turkey 2013

KLİNİK KATEGORİ CD4 T HÜCRESİ SAYISI ÖNERİLEN

Semptomatik hasta Herhangi bir değer Tedavi başlanmalı

Asemptomatik hasta <350 hücre/mm3 Tedavi başlanmalı

Asemptomatik hasta 350-500 hücre/mm3Tedavi başlanması yararlıdır. Hastanın özel koşullarına göre tedavi önerilir.

Asemptomatik hasta >500 hücre/mm3Tedavi başlanabilir. Hastanın özel koşulları değerlendirilerek, istekli ve hazırsa tedavi önerilebilir.

Turkish Ministry of Health 2013

TURKEY - TÜRKİYE

People newly infected with HIV

UNAIDS global AIDS epidemic report 2012 Slide 33