HIV/AIDS HIV/AIDS -- 20092009

Barbara RussellBarbara RussellRN, MPH, CICRN, MPH, CIC

Prevalence

Incidence (new infections)

Deaths (outflow)

Schematic of a Chronic Schematic of a Chronic Incurable InfectionIncurable Infection

Global summary of the AIDS epidemic, December 2007

Total 33 million [30 – 36 million] Adults 30.8 million [28.2 – 34.0 million]Women 15.5 million [14.2 – 16.9 million] Children under 15 years 2.0 million [1.9 – 2.3 million]

Total 2.7 million [1.6 – 3.9 million]Adults 2.3 million [1.3 – 3.4 million]Children under 15 years 370 000 [330 000 – 410 000]

Total 2.0 million [1.8 – 2.3 million]Adults 1.8 million [1.6 – 2.1 million]Children under 15 years 270 000 [250 000 – 290 000]

Number of people living with HIV in 2007

People newly infected with HIV in 2007

AIDS deaths in 2007

Estimated number of adults and children newly infected with HIV, 2007

Western & Central Europe

27 00027 000[3200 [3200 –– 69 000]69 000]

Middle East & North Africa40 00040 000

[18 000 [18 000 –– 69 000]69 000]Sub-Saharan Africa

1.9 million1.9 million[1.3 [1.3 –– 2.4 million]2.4 million]

Eastern Europe & Central Asia

110 000 110 000 [53 000 [53 000 –– 200 000]200 000]

South & South-East Asia

330 000330 000[76 000 [76 000 –– 680 000]680 000]Oceania

13 00013 000[12 000 [12 000 –– 15 000]15 000]

North America54 000

[7600 – 130 000]

Latin America110 000110 000

[37 000 [37 000 –– 200 000]200 000]

East Asia51 00051 000

[27 000 [27 000 –– 86 000]86 000]Caribbean20 000

[14 000 – 27 000]

Total: 2.7 million (1.6 – 3.9 million)

Estimated adult and child deaths from AIDS, 2007

Western & Central Europe

80008000[4800 [4800 –– 17 000]17 000]

Middle East & North Africa27 00027 000

[20 000 [20 000 –– 35 000]35 000]Sub-Saharan Africa

1.5 million1.5 million[1.3 [1.3 –– 1.7 million]1.7 million]

Eastern Europe & Central Asia

58 000 58 000 [41 000 [41 000 –– 88 000]88 000]

South & South-East Asia

340 000340 000[230 000 [230 000 –– 450 000]450 000]Oceania

10001000[<1000 [<1000 –– 1400]1400]

North America23 000

[9100 – 55 000]

Latin America63 00063 000

[49 000 [49 000 –– 98 000]98 000]

East Asia40 00040 000

[24 000 [24 000 –– 63 000]63 000]Caribbean14 000

[11 000 – 16 000]

Total: 2.0 million (1.8 – 2.3 million)

Over 7400 new HIV infections a day in 2007

• More than 96% are in low and middle income countries

• About 1000 are in children under 15 years of age

• About 6300 are in adults aged 15 years and older of whom:— almost 50% are among women— about 45% are among young people (15-24)

A global view of HIV infection33 million people [30–36 million] living with HIV, 2007

2.2

HIV prevalence (%) in adults in the Caribbean, 2007

17

• Stable statistics: new infections, AIDS cases, AIDS-related deaths

• Demographics changing– Younger– MSM– Women– Communities of color

• 25-33% unaware of HIV infection

Trends in HIV Infection: United States

• Stable statistics: new infections, AIDS cases, AIDS-related deaths

• Demographics changing– Younger– MSM– Women– Communities of color

• 25-33% unaware of HIV infection

Number HIV infected 850,000 - 950,000

Number unaware of their HIV infection 180,000 - 280,000

Awareness of Serostatus among Persons with HIV, United States

Estimated Number of New HIV Infections, Overall and by Gender, 2006

Figure 6. Estimated Number of New HIV Infections, Overall and by Gender, 2006

http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/incidence.htm

Estimated Rates of New HIV Infections, by Race/Ethnicity, 2006

Figure 4. Estimated Rates of New HIV Infections, by Race/Ethnicity, 2006

http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/incidence.htm

Cumulative AIDS Cases for30 States and Florida MSAs 12/31/06

1 NY 177,262 17 SC 13,4062 CA 142,918 18 TN 12,5163 FL 105,614 19 WA 11,8264 TX 70,127 11,286

56,804 20 MO 11,0775 NJ 49,528 21 AZ 10,4226 IL 33,902 9,9157 PA 33,782 22 CO 8,7738 GA 31,965 8,7459 MD 30,571 23 AL 8,70210 MA 19,395 24 IN 8,29511 LA 17,740 25 MS 6,69812 VA 16,979 6,095

16,674 26 OR 6,01513 NC 16,072 27 NV 5,76214 OH 15,095 28 OK 4,86215 MI 15,054 29 MN 4,84516 CT 14,899 30 WI 4,136

TAMPA/ST. PETE

WEST PALM BEACH

FT. LAUDERDALEJACKSONVILLE

ORLANDO

MIAMI

CDC HIV/AIDS Surveillance Report, Vol. 18, 2006.

HIV TransmissionBody fluids that transmit

the virusBlood

Semen (including pre - cum)

Vaginal Secretions

Breast milk

HIV Risk Factors

Unprotected sexual contact since 1978• Anal >>> vaginal >>> oral

Recreational blood exposureOccupational blood or bodily fluid exposureReceipt of tissue or blood productsPartner or birth mother with above risks

HIV and WomenOne of the fastest growing groupsIncreased frequency and severity of GYN disorders

– HPV– Cervical intraepithelial neoplasia– Candida vaginitis– PIDInvasive cervical cancer: AIDS-defining

CDC HIV-associated conditions

How long after a possible exposure should I wait to get tested for HIV?

• Most HIV tests are antibody tests that measure the antibodies your body makes against HIV. It can take some time for the immune system to produce enough antibodies for the antibody test to detect, and this time period can vary from person to person. This time period is commonly referred to as the "window period." Most people will develop detectable antibodies within 2to 8 weeks (the average is 25 days). Even so, there is a chance that some individuals will take longer to develop detectable antibodies. Therefore, if the initial negative HIV test was conducted within the first 3 months after possible exposure, repeat testing should be considered >3 months after the exposure occurred to account for the possibility of a false-negative result. Ninety-seven percent of persons will develop antibodies in the first 3 months following the time of their infection. In very rare cases, it can take up to 6 months to develop antibodies to HIV.

Maternal-Fetus Transmission Rate(Vertical Transmission)

Total rate: 13-60%– US: 25-30%– Europe: as low as 13%– Africa: 50-60%In utero: <10% Peripartum: 40-70%Breast-feeding: 0.5% per month riskMost important factor is maternal viral load

Viral Load and MTCT (US)

Garcia, et al NEJM 1990;341:394

Mother’s Viral Load Transmission Rate< 1,000 copies 0%

1,000 to 10,000 16.5%10,000 to 50,000 21.3%

50,000 to 100,000 30.9%> 100,000 40.6%

HIV/AIDS in the Elderly

Elderly (CDC): over 50 years of age10% of diagnosed AIDS cases: elderlyMore males and African AmericansOften not tested due to perceived low riskLate diagnosis commonHIV encephalopathy and wasting commonDementia

MMWR, 55:44-14 September 2006

HIV Testing Guidelines in HC Settings MMWR, September 2006

Intended for all HC providers, public and private, all types of HC settingsMajor revisions:

– HIV screening recommended for patients after notification that testing will be performed unless patient declines (opt-out screening)

– High risk patients should be screened annually– General consent for medical care should be

sufficient to encompass HIV testing consent– Prevention counseling should not be required

with HIV testing or screening programs

Pregnant Women:– HIV screening as part of prenatal

screening– Inform patient that HIV screening will be

performed; patient can opt-out– General medical consent is adequate– Repeat in 3rd trimester in high-risk settings

HIV Testing Guidelines in HC Settings MMWR, September 2006

HIV Diagnostic Tests

ANTIBODY TESTS ELISA Serum run twiceWestern blot Confirmatory

SpecimensVenous Lab standardRapid OraQuick® and othersOral OraSure® (mail)Home Home Access®

VIRAL RNA TESTSPCR or bDNA Earliest diagnosis

TESTRESULTTIMES:

1-7 days3-20 minutes1-2 weeks1-2 weeks

1-2 weeks

ELISA, enzyme-linked immunosorbent assay; PCR, polymerase chain reaction.

Rapid HIV Antibody DetectionOraQuick Advance Rapid Antibody

Test Fingerstick blood, serum, oral fluids

– Results in 20 minutes– $20-30FDA approved, CLIA waivedNegative test: definitivePositive test: needs standard serology confirmation

Rapid HIV Antibody DetectionResults in 20 minutes

Occupational exposureWomen in labor with unknown HIV

statusClients unlikely to return for visitsOutreachERs

Estimation of HIV Incidence in USCenters for Disease Control

• New assay (BED HIV-1) can differentiate new vs. long-standing HIV infection

• 6,684 remnant specimens tested in 2006 from 22 states– 2,133 (31%) classified as recent– Statistical extrapolation → 56,300 new

infections in 2006 (previously 40,000)• 22.8 per 100,000 population

• New infections concentrated in• Black: 45% • MSM: 53% JAMA, 300:5, August 6, 2008

Viral Load/CD4 count

Viral load: amount of HIV RNA in blood– Goal: undetectable– PCR: most common– bDNA: less common– Use consistent testingCD4 cell count and percent

– <200: AIDS– CD4 %: less variability

Course of Untreated HIV Infection

Time of Infection 10 - 15 Years

CD

4 T

Cel

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HIV

RN

A/V

iral Load

Viral Load: quantification of HIV RNAin the blood

CD4 Lymphocytes: surrogate markers ofimmune function

Virus destroys CD4 cellsDeclining CD4 count → increased riskfor infection and complications

ANTIRETROVIRAL DRUGSANTIRETROVIRAL DRUGS

Targets for Antiretroviral Drugs

Available Fixed Dose HAART Combinations