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  1. STI Epidemiology: Global and Zimbabwe Danuta Kasprzyk, PhD Daniel Montaño, PhD Update on Sexually Transmitted Infections (STIs) September 28, 2009

  2. Global Burden of STD: WHO Estimates, 2002 • Overall • 2.9 million deaths (5.2% of total) • 91.9 million DALYs (6.3%) all • STDs excluding HIV • 179,673 deaths (6.2% of all due to unsafe sex) • 11,347,067 DALYs (12.2% of all due to unsafe sex) • Cervical cancer • 238,814 deaths (8.2% of all due to unsafe sex) • 3,286,698 DALYs (3.4% of all due to unsafe sex) WHO Global Burden of Disease Project

  3. WHO Estimates of Global Burden of Curable STI in Adults Estimated Curable Year Global population STI Cases 1990 5.27 billion 198 million* 1995 5.69 billion 333 million 1999 5.98 billion 340 million 2005 6.46 billion pending *earlier methodology

  4. HIV/AIDS Global Data • AIDS cases were reported around the world in the early to mid-eighties • AIDS started out as reporting from disease cluster/outbreak investigations • First cases reported: • US and Europe: 1981-1982 • Africa – central: 1983 • Africa – southern: 1984, 1985 • Asia – Thailand: 1985

  5. Adults and children estimated to be living with HIV as of end 2007 Eastern Europe & Central Asia 1.5 million Western/Central Europe 730 000 North America 1.2 million North Africa & Middle East 380 000 South & SEast Asia 4.2 million Caribbean 230 000 Sub-Saharan Africa 22 million Latin America 1.7 million Oceania 74 000 Total: 33 (30 – 36) million

  6. Estimated number of adults and childrennewly infected with HIV during 2007 Eastern Europe & Central Asia 150 000 Western/Central Europe 31 000 North America 46 000 East Asia 92 000 North Africa & Middle East 35 000 Caribbean 17 000 South & SE Asia 340 000 Oceania 13 000 Latin America 100 000 Sub-Saharan Africa 1.9 million Total: 2.7 (2.2–3.2) million

  7. Estimated adult and child deaths from HIV/AIDS during 2007 Eastern Europe & Central Asia 58 000 Western/ Central Europe 8 000 North America 23 000 East Asia 40 000 North Africa & Middle East 36 000 Caribbean 14 000 South & SE Asia 270 000 Oceania 1 000 Sub-Saharan Africa 1.5 million Latin America 63 000 Total: 2.1 (1.8–2.3) million

  8. Estimated number of adult and child deaths due to AIDS globally, 1990–2007 3.0 Millions 2.5 2.0 Number of adult and child deaths due to AIDS 1.5 1.0 0.5 0 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05 06 07 Year This bar indicates the range 3

  9. 8 7 6 5 4 3 2 1 0 Estimated adult (15–49 years) HIV prevalence rate (%) globally and in Sub-Saharan Africa, 1990–2007 Sub-Saharan Africa Adult HIV preva-lence rate (%) Global 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year 2

  10. Regional HIV and AIDS statistics, 2001 and 2007 Adult prevalence (%) Adult & child deaths due to AIDS 2001 2007 2007 2001 Sub-Saharan Africa 1.6 million [1.5 – 2.0 million] 1.4 million [1.3 – 1.9 million] 5.0% [4.6% – 5.5%] 5.8% [5.5% – 6.6%] Middle East & North Africa 25 000 [20 000 – 34 000] 22 000 [11 000 – 39 000] 0.3% [0.2% – 0.4%] 0.3% [0.2% – 0.4%] South and South-East Asia 270 000 [230 000 – 380 00] 170 000 [120 000 – 220 000] 0.3% [0.2% – 0.4%] 0.3% [0.2% – 0.4%] East Asia 32 000 [28 000 – 49 000] 12 000 [8200 – 17 000] 0.1% [<0.2%] <0.1% [<0.2%] Latin America 58 000 [49 000 – 91 000] 51 000 [44 000 – 100 000] 0.5% [0.4% – 0.6%] 0.4% [0.3% – 0.5%] Caribbean 11 000 [9800 – 18 000] 14 000 [13 000 – 21 000] 1.0% [0.9% – 1.2%] 1.0% [0.9% – 1.2%] Eastern Europe & Central Asia 55 000 [42 000 – 88 000] 8000 [5500 – 14 000] 0.9% [0.7% – 1.2%] 0.4% [0.3% – 0.6%] Western & Central Europe 12 000 [<15 000] 10 000 [<15 000] 0.3% [0.2% – 0.4%] 0.2% [0.1% – 0.3%] North America 21 000 [18 000 – 31 000] 21 000 [18 000 – 31 000] 0.6% [0.5% – 0.9%] 0.6% [0.4% – 0.8%] Oceania 1200 [<500 – 2700] <500 [1100] 0.4% [0.3% – 0.7%] 0.2% [0.1% – 0.3%] TOTAL 0.8% [0.7% - 0.9%] 0.8% [0.7% - 0.9%] 2.1 million[1.9 – 2.4 million] 1.7 million[1.6 – 2.3 million] 1

  11. Regional HIV and AIDS statistics, 2001 and 2007 Adults & children living with HIV Adults & children newly infected with HIV 2007 2001 2001 2007 Sub-Saharan Africa 22.0 million [20.9 – 24.3 million] 20.9 million [19.7 – 23.6 million] 1.9 million [1.4 – 2.4 million] 2.2 million [1.7 – 2.7 million] Middle East & North Africa 380 000 [270 000 – 500 000] 300 000 [220 000 – 400 000] 40 000 [16 000 – 65 000] 41 000 [17 000 – 58 000] 4.2 million [3.3 – 5.1 million] 3.5 million [2.9 – 4.5 million] 330 000 [180 000 – 740 000 450 000 [150 000 – 800 000] South and South-East Asia East Asia 740 000 [620 000 – 960 000] 420 000 [350 000 – 510 000] 52 000 [21 000 – 220 000] 77 000 [4900 – 130 000] Latin America 1.7 million [1.4 – 1.9 million] 1.3 million [1.2 – 1.6 million] 140 000 [47 000 – 220 000] 130 000 [56 000 – 220 000] Caribbean 230 000 [210 000 – 270 000] 190 000 [180 000 – 250 000] 20 000 [15 000 – 23 000] 20 000 [17 000 – 25 000] Eastern Europe & Central Asia 1.5 million [1.2 – 2.1 million] 630 000 [490 000 – 1.1 million] 110 000 [70 000 – 290 000] 230 000 [98 000 – 340 000] Western & Central Europe 730 000 [600 000 – 1.1 million] 620 000 [500 000 – 870 000] 27 000 [19 000 – 86 000] 32 000 [19 000 – 76 000] North America 1.1 million [480 000 – 1.9 million] 1.1 million [390 000 – 1.6 million] 54 000 [38 000 – 68 000] 44 000 [40 000 – 63 000] Oceania 74 000 [53 000 – 120 000] 26 000 [19 000 – 39 000] 13 000 [ 11 000 – 26 000] 3800 [ 3000 – 5600] TOTAL 33.2 million[30.6 – 36.1 million] 29.0 million[26.9 – 32.4 million] 2.7 million[2.2 – 3.2 million] 3.2 million[2.1 – 4.4 million] 1

  12. Global summary of the HIV epidemic, December 2007 Number of people living with HIV Total 33.2 million (30.6 – 36.1 M) People newly infected with HIV in 2007 Total 2.5 million (1.8 – 4.1 M) Deaths due to AIDS in 2007 2.1 million (1.9 – 2.4 M) The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information..

  13. Children (<15 years) estimated to be living with HIV, 2007 Eastern Europe & Central Asia 12 000 [9100 – 15 000] Western & Central Europe 1300 [<1000 – 1800] North America 4400 [2600 – 7300] East Asia 7800 [5300 – 11 000] Middle East&North Africa 26 000 [18 000 – 34 000] Caribbean 11 000 [9400 – 12 000] South & South-East Asia 140 000 [110 000 – 180 000] Sub-Saharan Africa 1.8 million [1.7 – 2.0 million] Latin America 44 000 [37 000 – 58 000] Oceania 1100 [1200] Total: 2.0 million (1.9 – 2.3 million)

  14. Estimated deaths in children (<15 years) from HIV/AIDS during 2007 Eastern Europe & Central Asia 1600 Western Europe < 200 North America < 200 East Asia 1 200 North Africa & Middle East 4 400 Caribbean 1 200 South & South-East Asia 17 000 Sub-Saharan Africa 240 000 Latin America 3 100 Oceania < 500 Total: 270 000 (250 000 – 290 000)

  15. Estimated number of children (<15 years) newly infected with HIV, 2007 Eastern Europe & Central Asia 3200 [2400 – 4300] Western & Central Europe <200 [<100] North America <500 [<200] East Asia 2000 [1200 – 3100] Middle East&North Africa 5700 [3800 – 8000] Caribbean 1800 [1500 – 2100] South & South-East Asia 21 000 [14 000 – 29 000] Sub-Saharan Africa 330 000 [300 000 – 360 000] Latin America 4600 [4200 – 8300] Oceania <1000 Total: 370 000 (330 000 – 410 000)

  16. Estimated number of children under 18 orphaned by AIDS in sub-Saharan Africa (1990–2007) 12 Millions 10 8 6 4 2 0 2007 1990 1995 2000 2002 2003 2004 2005 2006 Source: UNAIDS/WHO, 2008 6.2

  17. This bar indicates the range Estimated number of people living with HIV globally, 1990–2007 40 Millions 30 Number of people living with HIV 20 10 0 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05 06 07 Year 1

  18. Percent of adults (15+) living with HIV who are female, 1990–2007 70 Sub-Saharan Africa 60 GLOBAL 50 Percent female (%) Caribbean 40 Asia 30 E Europe & C Asia 20 Latin America 10 0 1990 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 2007 Year

  19. Estimated number of adults and children living with HIV, by region, 1990–2007 40 Millions Oceania 35 Middle East & North Africa Eastern Europe & Central Asia 30 Latin America and Caribbean North America and W & C Europe Number of people living with HIV 25 Asia Sub-Saharan Africa 20 15 10 5 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year

  20. 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) • For every 2 individuals put on treatment, 5 are newly infected

  21. HIV/AIDS in sub-Saharan Africa2006-2007

  22. HIV prevalence in adults in sub-Saharan Africa, 1990−2005

  23. HIV prevalence (%) in adults (15–49) in Africa, 2007 2.8

  24. Estimated number of people living with HIV in sub-Saharan Africa, 1986–2006 30 Million 25 20 Number of people living with HIV 15 10 5 0 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 Year

  25. Estimated number of people newly infected with HIV in Sub-Saharan Africa, 1990–2007 Upper range Estimate 5 Millions Lower range 4 Number of people newly infected with HIV 3 2 1 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year

  26. Estimated number of adult and child deaths due to AIDS in Sub-Saharan Africa, 1990–2007 2.5 Millions 2.0 Number of adult and child deaths due to AIDS 1.5 1.0 0.5 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year This bar indicates the range

  27. Median HIV prevalence among women (15-49 years) attending antenatal clinics in consistent sites in southern African countries, 1998–2006 45 40 Botswana 35 Lesotho 30 Namibia 25 % HIV prevalence 20 South Africa 15 Swaziland 10 Zimbabwe 5 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year Sources: Various antenatal clinic surveys. 6

  28. Estimated number of people living with HIV and adult HIV prevalence Global HIV epidemic, 1990-2005* HIV epidemic in sub-Saharan Africa, 1985-2005* Number of people living with HIV (millions) % HIV prevalence, adult (15‒49) Number of people living with HIV (millions) % HIV prevalence, adult (15‒49) 50 5.0 30 15.0 12.5 25 40 4.0 20 10.0 30 3.0 7.5 15 20 2.0 5.0 10 10 1.0 2.5 5 0 0.0 0 0.0 1990 1995 2000 2005 1985 1990 1995 2000 2005 Number of people living with HIV *Even though the HIV prevalence rates have stabilized in sub-Saharan Africa, the actual number of people infected continues to grow because of population growth. Applying the same prevalence rate to a growing population will result in increasing numbers of people living with HIV. % HIV prevalence, adult (15-49) This bar indicates the range around the estimate 2.2

  29. Leadingcauses of death in Africa, 2000 22.6 25.0 20.0 15.0 % of Total 10.1 9.1 10.0 6.7 5.5 4.3 3.6 3.1 2.9 2.3 5.0 0.0 HIV/AIDS Malaria Perinatal conditions Tuber culosis Cerebro vascular disease Measles Lower respiratory infections Diarrhoeal disease Ischaemic Heart disease Maternal conditions Source: The World Health Report 2001, WHO

  30. Leading causes of disease burden in Africa, 2000 25.0 20.6 20.0 15.0 % of Total 10.1 8.6 10.0 6.3 6.1 4.5 3.6 2.8 1.8 1.9 5.0 0.0 HIV/AIDS Lower respiratory infections Diarrhoeal diseases Maternal conditions Other unintentional injuries* Malaria Perinatal conditions Measles Tuberculosis Pertussis * Unintentional injuries aside from traffic accidents, poisoning, falls, fires and drowning Source: The World Health Report 2001, WHO

  31. Impact of AIDS on life expectancy in five African countries, 1970–2010 70 65 60 Botswana 55 South Africa Life expectancy at birth (years) 50 45 Swaziland 40 35 Zambia 30 Zimbabwe 25 20 1970–1975 1980–1985 1990–1995 2000–2005 1975–1980 1985–1990 1995–2000 2005–2010 Source: United Nations Population Division (2004). World Population Prospects: The 2004 Revision, database. 4.1

  32. Percentage of distribution of deaths by age in southern Africa, 1985–1990 and 2000–2005 40 35 30 25 Percentage of total deaths 20 15 10 5 0 0–4 5–19 20–29 30–39 40–49 50–59 60+ Age-groups : 1985-1990 2000-2005 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat (2005). World Population Prospects: The 2004 Revision. Highlights. New York: United Nations. 4.2

  33. Estimated impact of AIDS on under-five mortality rates 2002–2005, selected countries in sub-Saharan Africa 42 Botswana 106 98 Kenya 118 Lesotho 71 123 Without AIDS 43 Namibia 78 With AIDS 43 South Africa 74 Swaziland 73 143 142 Zambia 173 78 Zimbabwe 117 0 20 40 60 80 100 120 140 160 180 200 Deaths per 1,000 live births Sources: UNICEF (2005); United Nations Population Division, World Population Prospects: The 2004 Revision, database. 4.6

  34. The Zimbabwe AIDS Epidemic: Summary • First reported case: 1984 • Prevalence peaked in 1998 at over 30% • Overall 2007 HIV prevalence ~ 15.6% • Estimated 1.3 million PLWHA • 1.1 million adults • ~133,000 children • Estimated 135,000 new infections annually • Estimated 180,950 annual deaths • ~ 3,500 individuals weekly deaths

  35. Zimbabwe HIV Prevalence Overall Adult 2005 (ZDHS) Urban: 17% Rural: 15% Total Prevalence % <15.2 15.2 – 16.7 16.7 – 18.4 18.5 – 19.7 >19.7

  36. The Zimbabwe AIDS Epidemic Annual Trends (1990 – 2007): HIV prevalence People Living with HIV

  37. The Zimbabwe AIDS Epidemic

  38. The Zimbabwe AIDS Epidemic Trends in ARV Coverage: Adults PMTCT

  39. Zimbabwe: HIV and AIDS • AIDS knowledge is universal: 96% of women have heard of AIDS; 99% of men • 17% of women can’t cite a way of avoiding AIDS; 7% of men • Most widely cited ways: • condom use (76% men; 66% women); • limit sexual partners (69% men; 63% women)

  40. Trends in partners and condom use Data Sources: ZDHS

  41. The Zimbabwe AIDS Epidemic: Trends • Decline in prevalence 15-49 year olds • 2005 = 19.4% • 2007 = 15.6% • Decline in prevalence in 15-24 year olds Antenatal clinics • 2004 = 17.4% • 2006 = 13.1% • Decline of HIV prevalence related to: • Slight reduction in average number of partners and • Increased condom use

  42. Zimbabwe: HIV and AIDS • An estimated 504,583 individuals were tested for HIV in Jan – Oct 2007 • 281,003 in stand alone sites, e.g. VCTs • 223,580 in health facilities, including ANCs, TB clinics, hospitals, etc. • Testing: • 12% women; 9% men • Those who know their results: 6.6% women; 6.6% men • 60% of untested men and women say they want to be tested

  43. HIV CPOL Prevention Trial • NIMH funded, Multi-national Collaborative Trial to test HIV/STD prevention intervention • First multi-national test of the Community Popular Opinion Leader (CPOL) Model Intervention: • Prevention intervention based on diffusion model • Multi-site: Conducted in 5 countries • China/UCLA; India/JHU; Peru/UCSF-UCLA; Russia/Medical College of WI; Zimbabwe/Battelle • Two armed, randomized, community-level Trial • Assessment of effect through behavioral survey and biological sample data collection • Behavioral and biological endpoints • Three data collections points: • Baseline;12-month and 24-month follow-up • Intervention implementation after Baseline

  44. HIV CPOL Prevention Trial • Conducted in multiple phases • Used both qualitative and quantitative methods • Qualitative methods to provide data to tailor the intervention • Quantitative epidemiological study to determine HIV/STD prevalence and behavioral risks (2001) • RCT to Assess impact of CPOL intervention (2003-2007)

  45. Epidemiological Study: Design • Rural Villages outside 32 Growth Points • Random sample of 70 Participants • Over-sampling to insure that 50 agree to participate and provide specimens • Administration of a behavioral risk assessment • Collection of biological specimens

  46. Epidemiological Study: Methods • Ethnography team • Community preparation with selected villages • Enumerated and randomly select 70 households • Nursing team • Explained study to residents in each household • Enumerated household for all residents between 16-30 • Randomly selected participant • Obtained informed consent • Conducted ACASI interview • Conducted symptom assessment • Pretest counselling • Biologic sample collection(blood, urine, 3 swabs) • Treated syndromically as indicated

  47. Rural Household selected for inclusion Participant listening to explanation of ACASI, doing ACASI