MALAYSIA:

Taking Stock of HIV Prevention

Dr. Christopher KC Lee Infectious Disease Unit Department of Medicine Hospital Sungai Buloh

HIV / AIDS:
The Global Burden

Global estimates for adults and children, 2005

People living with HIV

38.6 million [33.4 46.0 million]

New HIV infections in 2005

Deaths due to AIDS in 2005

4.1 million [3.4 6.2 million]

2.8 million [2.4 3.3 million]

Global summary of the HIV and AIDS epidemic, 2005

Number of people living with HIV in 2005
Total Adults Women Children under 15 years Total Adults Children under 15 years Total Adults Children under 15 years 38.6 million [33.4 46.0 million] 36.3 million [31.4 43.4 million] 17.3 million [14.8 20.6 million] 2.3 million [1.7 3.5 million] 4.1 million [3.4 6.2 million] 3.6 million [3.0 5.4 million] 540 000 [420 000 670 000] 2.8 million [2.4 3.3 million] 2.4 million [2.0 2.8 million] 380 000 [290 000 500 000]

People newly infected with HIV in 2005 AIDS deaths in 2005

Adults and Children Estimated to Be Living With HIV, 2005

Eastern Europe and Central Asia North America 1.4 million 720,000 1.3 million East Asia 680,000 North Africa and Middle East 440,000 Caribbean Southern and 330,000 Southest Asia 7.6 million Sub-Saharan Africa Latin America 24.5 million Oceania 1.6 million 78,000
Western/ Central Europe

UNAIDS, 2006. Available at: http://www.unaids.org.

Estimated number of adults and children newly infected with HIV, 2005
Western & Eastern Europe Central Europe & Central Asia North America
[34 000 65 000]

43 000

[18 000 33 000]

22 000

[150 000 650 000] East Asia [55 000 290 000]

220 000

Caribbean
[26 000 54 000]

37 000

North Africa & Middle East

[38 000 210 000]

97 000

64 000

South & South-East Asia

830 000

Latin America
[100 000 420 000]

Sub-Saharan Africa
[2.3 3.1 million]

[530 000 2.3 million]

140 000

2.7 million

Oceania
[3500 55 000]

7200

Total: 4.1 (3.4 6.2) million

Estimated adult and child deaths from AIDS, 2005

Western & Eastern Europe Central Europe & Central Asia North America
[11 000 26 000]

18 000

12 000
[<15 000]

[36 000 75 000] East Asia [20 000 49 000]

53 000

Caribbean
[19 000 36 000]

27 000

North Africa & Middle East

[20 000 62 000]

33 000

37 000

South & South-East Asia

560 000

Latin America
[47 000 76 000]

Sub-Saharan Africa
[1.7 2.3 million]

[370 000 810 000]

59 000

2.0 million

Oceania
[1900 5500]

3400

Total: 2.8 (2.4 3.3) million

Estimated number of children (<15 years) newly infected with HIV, 2005
Western & Eastern Europe Central Europe & Central Asia North America
[<1000]

500

[<400]

200

[1400 3900]

2300

East Asia
[1000 4100]

Caribbean
[2100 5800]

3700

North Africa & Middle East

[3200 12 000]

2300

6900

South & South-East Asia

44 000

Latin America
[3500 8000]

Sub-Saharan Africa
[370 000 590 000]

[23 000 75 000]

5000

470 000

Oceania
[400 2800]

1100

Total: 540 000 (420 000 670 000)

Over 11 000 new HIV infections a day in 2005

More than 95% are in low and middle income countries

About 1500 are in children under 15 years of age About 10 000 are in adults aged 15 years and older of whom: almost 50% are among women over 40% are among young people (15-24)

2006 International AIDS Conference:

Time to Deliver
Between 2003 and 2005 . . . for each new person who got treatment for HIV, about 10 people became infected. Even during our greatest advance, we are falling behind. - Bill Gates If you oppose the distribution of condoms, something is more important to you than saving lives. Lets agree that every life has equal worth, and saving lives is the highest ethical act. - Melinda Gates Empowering women to protect themselves seems so elemental, and yet when I hear people pontificating against AIDS and acting as if we can do everything through abstinence, I think they don't know what most women are up against in too many parts of the world today. - Bill Clinton

2006 International AIDS Conference:

Time to Deliver
The (South African) government has a lot to atone for. Im of the opinion they can never attain redemption. Stephen Lewis

Today, we have a real opportunity to deliver like never before . . yet still the epidemic continues to outpace us . . . We must demand action over rhetoric and research over ideology - Helene Gayle, MD
Indeed, we will have failed unless we dramatically and rapidly expand by millions the numbers of people around the world with access to antiretroviral drugs and simultaneously scale up prevention. - Mark Wainberg, PhD

Burden of HIV in Malaysia

MALAYSIA
First HIV case detected in 1986 as of 31st. December, 2005 : 70.559 cases notified to Ministry of Health
92 93 94 95 96 97 98 99 2000 2001 2002

7000 6000 5000

numbers

4000 3000 2000 1000 0

2003 2004 2005

Malaysia 31/12//05

1992 to 2005, years

Cummulative HIV infections

Malaysia 1993-2005
80000 70000 60000 50000 40000 30000 20000 10000 0 70559 64439 58012 51256 44278 38340 33233 28541 23917 19993 15396 11198 7805 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Cummulative AIDS cases

Malaysia 1993 - 2005
12000 10000 8000 6000 4000 2000 0 565 912 227 332 10663 9442 8294 7218 6025 4723 3555 2355 1480 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Yearly AIDS Deaths

Malaysia 1993 - 2005
Cummulative AIDS deaths: 8179 (31st. Dec, 2005)
1200 1000 800 600 400 200 0 165 55 80 271 473 689 975 874 882 881 700 1065 984 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Gender

Male

65,345 (92.6%) 5,214 (7.4%)

Female

TOTAL

70,559 (100%)

Malaysia 31/12/05

HIV in Malaysia Proportion of Men / Women by Year

100 90 80 70 60 50 40 30 20 10 0
19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03

percentage

Men Women

20 04

20 05

Age Distribution
78.5% : ages 20 - 39 yrs.
35000 30000 25000
numbers

20000 15000 10000 5000 0

Age groups in years

<13 13-19 20-29 30-39 40-49 >50 unknown

Malaysia 31/12/05

HIV : Routes of transmission

Homo / bisexuals 1025 IV drug users 52407 Heterosexuals 10124 Blood / blood products 28 Mother-to-child 541 Unknown 6431

No. 1.5% 74.3% 14.3% 0.04% 0.8% 9.1%

Malaysia 31/12/05

HIV Proportion by route of transmission

90 80 70 60
percentage

50 40 30 20 10 0

IDU Hetero Homo/Bi

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Percentages of IDUs reactive for HIV by year

30 25 20

15 10 5 0 89 90 91 92 93 94
Year

95

96

97

98

99 2000

Medically: What happens to those infected?

50% will have flu-like illness for about 2-6 weeks after exposure (Primary HIV illness) Will recover & enter a long asymptomatic phase (the latent period) Prolong asymptomatic period; Average period from infection to AIDS 8-10 years Viral load, plasma HIV RNA, remain at steady state. CD4 T-lymphocyte count fairly stable; rate of decline dependant on viral load CD4 cell count : production almost = destruction for sustained period of time

CD4 counts & Opportunistic Infections

1000

CD4
900 800 700 600 500 400 300 200 100 0
Years : mean survival ~ 10 yrs.

Asymptomatic

Mildly symptomatic

AIDS-defining illness

Examples of AIDS- defining

Illness (ADI)
Candidiasis: oesophagus, trachea, lungs Cervical ca., invasive Cryptococcosis, extrapulmonary Cryptosporidiosis: diarrhoea > 1 month CMV: except liver, spleen & lymph nodes Herpes simplex: ulcer > 1 month, lung, oesophagus HIV dementia HIV wasting (wt. loss> 10 %) Kaposis sarcoma Lymphoma, non-Hodgkins My. avium , disseminated My. tuberculosis PCP Pneumonia, recurrent, Salmonella septicaemis, recurrent Toxoplasmosis, internal organ

Implications of growing AIDS population

Increasing strain on health sector esp. hospital based services

- hospital beds

- human resource

- finances Social & developmental implications: - impact on families, communities, countries - political uncertainty / national threat

Prevalence of Opportunistic Infections among AIDS patients in India S. Singh, AIDS Reader 7(3);101-106, 1997 Infection Tuberculosis Toxoplasmosis Oropharyngeal candidiasis Cryptosporidiosis Cryptococcosis Systemic candidiasis Pneumocystis carinii pneumonia Isosporiasis Kaposi's sarcoma PrevalenceRate 40%-68% 10%-66% 58%-60% 4%-11% 5%-8% 4%-8% 0.4% 0.3% 0.27%

Health Sector Under Stress

A. Care & treatment for PLWHAs heavily taxing public health services in developing countries.

UNAIDS Photo Library

o Rwanda, 1990s treatment consumed 66% of public health spending. o 1997 Public health spending for AIDS > 2% of GDP in 7/19 African countries (total health spending 3-5% GDP) o AIDS take up 50% beds in Provincial Hospital, Chiang Mai; 39% Hospital Kenyatta, Nairobi, & 70% in Prince Regent Hospital, Bujumbura, Burundi

Health Sector Under Stress

B. Other patients do not get beds in hospitals & die due to late treatment. C. TB rapidly increasing, kills 1/3 PLWHAs, increases TB risk in community at large o World Bank 25% of HIV-negative people who die of TB in the future would not have been infected with the bacillus in the absence of AIDS.

o New AIDS therapies increases health sector expenditure in infrastructure, drugs, training and personnel.

From Health Issue to Development Crisis

Destruction of social capital
Knowledge base of society Production sectors: agriculture, industry

Weakening of institutions
Governance, civil service, judiciary, armed forces, education, health Inhibition of private sector growth

Wider, deeper poverty

Economic Growth Impact of HIV (1990-97)

Growth Impact of HIV (1990-97) (80 developing countries)
0 Reduction in growth rate GDP per capita (%, per year) -0.2 -0.4 -0.6 -0.8 -1 -1.2 -1.4 -1.6 0 5 10 15 20 25 30 35

HIV Prevalence Rate (%)

Source: R. Bonnel (2000) Economic Analysis ofHIV/AIDS, ADF2000 Background paper, World Bank

AIDS - Developmental Crisis

Demographic Impact of AIDS

Botswana 2020 More adults aged 60 70 yrs than 40 50 yrs Small number of young adults support large number of young & old people
Projected population structure with & without the AIDS epidemic, Botswana 2020
Source: US Census Bureau, World Population Profile 2000

Household Impact
Survey: Impact of family member with AIDS households suffer in income.

Leads to fewer purchases & savings Thailand 1/3 family affected by AIDS 50% in agricultural output threatens food security 15% forced to take children out of school. > 50% elderly left to care for themselves.

AIDS Orphans
Children who lose their mothers or both parents to AIDS < age of 15 yrs 13.2 mil AIDS orphans; 95% in developing countries Before AIDS - 2% of children in developing countries were orphans. 1997, 7 11% of children were orphans AIDS orphans raised by elderly or left on their own. UNICEF/UNAIDS, 1999 AIDS orphans - high risk of malnutrition, illness, abuse, sexual exploitation by others. Also face stigma and discrimination.

HIV is hurting business

Impact of AIDS in sugar estate, Kenya a) Absenteeism (8,000 days of labour lost due to sickness between 95-97) b) Lower productivity (50% in the ratio of processed sugar from raw cane from 93-97) c) Higher overtime costs when healthy workers fill in for sick colleagues d) Spending on funerals 5 times between 89-97 e) Health costs > 10 times (3/4 HIV-related illness) HIV-related illness & death main reason people leaving company

Current Status: the HKL cohort

> 2800 patients registered since `92 New patients per year: ~ from 150 (1993) to about 565 (2005) patients 82% Malays IV drug users 78% Chinese infected through sex 70% education level : < Form 3 Employment: 79% blue-collared workers CLee,IDclinic,HKL

Is there any Good News ?

HIV Prevalence among antenatal women, Cambodia

1997-2000 (%) 3.2

3.0
2.8 2.6 2.4 2.2 1997 1998 1999 2000
Source : MOH Cambodia

Trend in HIV prevalence in 21 year old military conscripts in Thailand

5

HIV prevalence (%)

0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Source: Armed Forces Research Institute of Medical Sciences, Thailand

Prevention Strategies
Has to be individualised for countries, districts, communities, etc. Targetted vs Generalised Objective: Behavioural Change Community sensitive Gender sensitive Obstructive policies need to be addressed Multisectoral involvement often required

What has worked ?

HIV Education programs for schoolchildren various models Harm Reduction programs:
- methadone maintenance treatment - needle exchange programs

Targeted Condom promotion Women specific & sensitive programs Involvement of civil society religious, community leaders, corporate sector

H.A.A.R.T.
Highly Active AntiRetroviral Therapy

Declining morbidity & mortality among patients with advanced HIV infection
40 35 30 25 20 15 10 5 0
94 95 96 97
Pallella FJ et al, HIV Outpatient Study Investigations, N Engl J Med 1998; 338:853-860

100

75

50

Deaths
25

ARV
0

ARV drug Prices in Malaysia

1000 900 800 700 600 500 400 300 200 100 0 1999
* Expected new prices

Indinavir ddI Nevirapine AZT Efavirenz d4T 3TC

2000

2001

2002

2003*

Thank You
Do What you Can with what you Have Where you Are !
Theodore Roosevelt