HIV & PEPFAR

Question 1

Lecture outcomes

Answer 1

By the end of this lecture, you should be able to:
* Define what HIV and AIDS mean
* Identify the main risk factors for HIV/AIDS and describe
how they differ across regions and countries
* Understand the drivers of the HIV pandemic
* Describe the main preventive strategies that can be used to
control HIV/AIDS

Question 2

What is HIV?

Answer 2

• Human Immunodeficiency Virus (HIV), the virus that causes
  AIDS - identified as a retrovirus in 1983.
• Two serotypes: HIV-1 (most common type) and HIV-2; both are
  zoonotic in origin; HIV-1 from chimpanzees and HIV-2 from
  sooty mangabeys.
• HIV is found in semen, blood, vaginal and anal fluids, and
  breast milk
• Passed from one person to another when infected blood, semen, or vaginal secretions come in contact
  with an uninfected person’s broken skin or mucous membranes.
• Infected pregnant women can pass HIV to their baby during pregnancy, delivery and breast-feeding.
• Other: transfusion of blood and blood products, organ transplantation and occupational exposure
• People with HIV have the HIV infection (termed HIV positive).

Question 3

HIV timeline

Answer 3

Question 4

What is AIDS?

Answer 4

• AIDS (Acquired Immunodeficiency
  Syndrome)
• Syndrome – A group of symptoms that
  collectively indicate or characterize the
  disease.
• AIDS characterized by a weakening of
  the immune system - the end stage of the
  HIV infection
• Currently no cure however HIV is now a
  manageable chronic health condition
  using antiretroviral therapy

Question 5

What is AIDS?

Answer 5

AIDS defining illnesses
Candidiasis of oesophagus or respiratory tract
Invasive cervical cancer
Cryptosporidial diarrhoea
Cytomegalovirus disease
AIDS dementia/HIV encephalopathy
Kaposi’s sarcoma
Disseminated or pulmonary TB
Pneumocystis pneumonia (PCP)
Toxoplasmosis of brain
Wasting syndrome due to HIV
…. And others

Question 5

Risk defined as:

Answer 5

“an aspect of personal behaviour or lifestyle, an
environmental exposure or an inborn or inherited
characteristic which on the basis of epidemiological evidence
is known to be associated with health-related condition(s)
considered important to prevent” (Last 2001)

Question 6

Who is at risk of HIV?

Answer 6

• High risk ‘behaviours’:
• Unprotected anal or vaginal sex with exchange of body
  fluids
• IV drug use with shared needles/equipment
• Infant of a mother with HIV – during pregnancy, birth and
  breast feeding
• Having another sexually transmissible infection (STI) e.g.
  syphilis, herpes, chlamydia, gonorrhoea
• Recipient of blood products (not in Australia anymore)
• Some needle stick activities – tattooing, piercing
• Occupational risk – surgeons, dentists, lab workers

Question 7

Global summary AIDS epidemic 2022

Answer 7

Question 8

Regional HIV and AIDS statistics and features  2022

Answer 8

Question 8

Prevalence of HIV by
region

Answer 8

Question 9

New infections by population 2020

Answer 9

Question 10

Sub-Saharan Africa

Answer 10

• 25.6 million people living with HIV/AIDS in Sub-Saharan
  Africa
• Only 14% of world’s population – but 67% of HIV case
  s
• Main route of transmission is heterosexual intercourse
• Of the 3600 new HIV infections a day, about 50% of them are
  in Sub-Saharan Africa
• Every week 4000 adolescent girls and young women aged
  15-24 years became infected in 2022: 3100 (77.5%) occurred in
  Sub-Saharan Africa

Question 10

Sub-Saharan Africa - gender

Answer 10

Significant differences between young
women and men:
* Six in seven new HIV infections among
adolescents aged 15–19 years are among
girls.
* Young women aged 15–24 years are twice as
likely to be living with HIV than men.

Question 11

Vulnerability of young women

Answer 11

• Biological
• More at risk of infection due to vaginal anatomy: more surface area, prone to bruising
  particularly in younger women
• Social/cultural and economic factors
• Cross generational relationships: impossible to negotiate safe sex with older men
• Transactional sex: in exchange for money or gifts
• Age, economic and social disparity: exploitation
• Many women dependent on their husbands for finances and cultural acceptance
• Interpersonal violence

Question 11

Drivers of the HIV epidemic

Answer 11

• High levels of stigma and discrimination that:
• Prevent people from accessing preventative services: VCT Voluntary counselling and
  testing, buying condoms
• Prevent PLHIV from accessing treatment
• Prevent them from risk-reduction measures e.g. condom use, abstinence and correct
  condom use
• Prevent HIV-infected mothers from accessing prevention of mother to child (PMTCT)
  services (e.g. mother will continue to breast feed contrary to health workers advice)
• Poverty with wide disparity in wealth: complex relationship: wealthy people
  take advantage of poorer people, indulge in more sexual practices and more
  sexual partners

Question 11

Drivers of the HIV epidemic

“social, economic and structural factors that drive the
epidemic”

Answer 11

• Act at various levels and include biological, behavioural, social and
  psychological factors
• Gender inequality: Low social, economic and cultural status of women:
  women cannot ask their husbands to use condoms, cannot refuse sexual
  advances, marital rape, cannot leave for financial, cultural reasons
• Early sexual debut and early marriages (cannot negotiate for safe sex,
  biology not yet mature)

Question 12

HIV in Australia

Answer 12

• An estimated 28,870 people living with HIV
  in Australia in 2022
• 93% of those living with HIV were diagnosed
• Of those known PLHIV receiving ART, 98%
  have a suppressed viral load (above WHO
  target)
• 555 HIV notifications in 2022, a decline from
  1,068 in 2013
• Number of infections reduced due to more
  people being tested, people starting
  antiretroviral treatment early and Preexposure prophylaxis (PrEP) among gay and
  bisexual men but also COVID-19 restrictions

Answer 12

Answer 13

Answer 14

Answer 15

Answer 16

Answer 17

Answer 18

Answer 19

Question 20

Challenges with prevention

Answer 20

• Success is variable by region, country and populations within countries
• Lack of political commitment
• Lack of funding – many countries depend on donor funding
• Key populations left out of prevention strategies
• Marginalisation of key populations and criminalization
• Refusal by some governments to consider key populations at risk and
  harm reduction strategies and young people’s sexual and reproductive
  needs and rights
• Lack of female controlled strategies: have to rely on partners to use
  condoms, reduce sexual partners
• Lack of systematic prevention implementation

Answer 21

Question 22

The five prevention pillars for 2025

Answer 22

Question 23

Good news for HIV!

Answer 23

• Very many interventions in the field of HIV/AIDS
• Social interventions to manage stigma, empowerment issues, education of PLHIV and their
  families
• Medical advancements/innovations:
• Went from no treatment to antiretroviral therapy
• PREP – pre-exposure prophylaxis
• Latest treatments are long-acting injections
• Possibility of use of long-acting injections for prevention
• Possibility of a cure! https://hivcure.com.au/

Question 24

Summary

Answer 24

• HIV was identified as a retrovirus in 1983 and there are two serotypes HIV1 and HIV2
• HIV is passed from one person to another during sex, mother to child (during
  pregnancy, delivery and breast-feeding), unsafe injecting practices and during blood
  transfusion.
• AIDS – syndrome characterised by opportunistic infections
• Sub-Saharan Africa has the highest rates of HIV in the world and young women have
  higher rates than young men. Most children infected globally live in Sub-Saharan
  Africa
• Main risk factors differ between regions
• There are several social, environmental, economic, political and historical influences on
  the epidemic
• Though there have been major advancements in treatment, there is still room for
  improvement