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Slide 1-

Epidemiology of AIDS Dana Carr RN.,BHScN, MSc Epidemiology
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Outline HIV virology Epidemiology Compare rates in Africa and NA. Compare modes of transmission Dry Sex and I TRACK
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Human Immunodeficiency HIV Retro Virus (RNA) Subgroup Lentvirus (slow) Inert Fragile Protective envelope Attacks immune system Invades Helper T cell lymphocytes and macrophages (WBC) gp120 molecule attaches to the CD4 molecule on the T helper and macro
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HIV Virus
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Helper T cell the virus enters the nucleus of the WBC uses the DNA coding to replicate; T helper cells are destroyed releasing virus HIV virus entering macrophages replicate and them bud out of an intact cells.
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HIV Budding from macrophage
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HIV virus attacking T helper cell
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HIV the infectious agent Incubation period –variable 1-15 yrs w/o tx Transmission- sexual contact (increased risk with ulcerative STD’s , anal), sharing contaminated needles, transfusion, Reservoir – Human BBF Communicability – unknown presumed early onset extends through life Symptoms – opportunistic infection,ARC,AIDS
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HIV to AIDS
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Global transmission of HIV
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What’s in a Name? Definition of Epidemiology ‘epi’ upon ‘demos’ people ‘logos’- study of The study of what befalls a people (not the individual) Oxford Dictionary 1873 “branch of medical Science which treats epidemics” “epidemic’ related to disease (communicable)
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Epidemiology 2002 “ the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems” Study – surveillance, observation, research Distribution ‘ person, place time Determinants – biological, behavioral, physical, social and cultural Health related states or events – disease; wellness; behaviors Specified populations- characteristics Control of Health – prevention and promotion
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Principles of Epidemiology Basic science of public health Health and disease do not occur randomly in a population What is the probability of the event occuring and ‘who is at risk?’ Good research methods ‘garbage in ..garbage out’ Exposures and outcomes Probability of event occuring (rate) Comparing (rates) in different populations or the same population at different times Hypothesize why they are different
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Models of disease Transmission Epidemiological TRIAD Host Intrinsic factors that influence host susceptibility Agent Biological characteristic of agent Environment Extrinsic factors Opportunity for infection to occur
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Triad Cont’d - Determinants Agent factors: pathogenicity; virulence Host factors: age, gender; education; behaviors; culture Environmental: climate; geography; biological; socioeconomic, political
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Models of Disease ‘Web of Causation’ Metaphor for the complex, multifactoral causation of disease communicable and non-communicable
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Types of Studies Descriptive (leads to hypothesis development) Case study (one unusual case) Case series Survey - cross sectional Analytical Studies (hypothesis testing) Cohort – compare # case in exposed and unexposed groups Case- control - compare exposures in cases and non cases Ecological Studies – study exposure and outcomes in groups or populations (not individuals) eg Selenium and HIV
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Incidence vs prevalence Incidence –the number of NEW events/cases during a given period of time in a specified population (temporal) Prevalence – the number of events/cases at a designated time in a specified population (snapshot)
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Rates….Why use them? Rate = the # of events in a specified period population at risk during that time Rates are proportions Proportions can be compared Compare rates of events in different populations and hypothesis why they are different.
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Living with HIV infection Sub Sahara Africa Vs North America Sub sahara Africa 25.4 million Adult Prevalence 7.4% HIV1& HIV2 Mode of Transmission HETEROSEXUAL 70 -90 % new cases Vertical (mom to baby) Life expectancy – short 1-3 yrs (no tx) North America 1.0 million Adult Prevalence 0.3 HIV1 Mode of Transmission MSM (58%) IDU (20%) Life expectancy- 15-20 with tx
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Think about Triad: host; agent ; environment and how they relate to HIV To what extent does culture ie values beliefs; influence the spread of HIV How does culture impact prevention and control programs
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London School of Hygiene and Tropical Medicine (LSHTM) Multicentre Study on Factors Determining Differential Spread of HIV in 4 Cities in Sub Sahara Africa change in HIV prevalence among pregnant women during 10 year period (mid 80’s to mid 90’s) Cotonou (Benin) 0-0.6% Yaounde (Cameroon) 1 – 5.5% Kisumu (Kenya) ? – 25 % Ndola (Zambia) <5 – 25 %
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HIV transmission in Sub-sahara Africa 10% world population 2/3 of all people living with HIV Predominantly heterosexual transmission Estimate 70 to 90% all new cases Vertical Transmission
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Factors that increase probability of Transmission of HIV Biological – increase viral load, genital ulceration resulting from STD’s (HSV2) , dry sex practice; sex during menses; anal sex ; lack of circumcision Behavioral - Sexual partners (consecutive, concurrent); rate of partner change; contact with STW; anal sex; lack of Circumcision; dry sex Think about the overlap of cultural and biological risk factors
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Comparison of Prevalence of HIV during 10 yr period
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Multi centre study Methodology Cross sectional survey Sample population in each city: Males 600 to 900 Females approx 1000 Questionaire interview Sociodemographic Sexual behaviors Specimen collection and phys. examination Biological RF
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Risk Factors Consistently more common in the high HIV prevalence Sites Parameters of Sexual Behavior young age at first sexual encounter (female) Young age at first marriage Large age difference between spouses Co factors in HIV transmission: HSV- 2 infection Trichomoniasis (females) Lack of male circumcision
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Risk Factors NOT Consistently more common in the high HIV prevalence Sites Parameters of sexual behavior High rate of partner change Sex with sex workers Concurrent partnerships Large age difference between non spousal partners Co- factors in HIV transmission Non-ulcerative STI’s (gono, chlamydia) Syphilis Dry sex Lack of condom use
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Everything you wanted to know about Dry Sex….. Documented in 11 countries in sub-Sahara Africa The practice of Dry Sex is the use of substances to dry the vagina prior to intercourse ‘Love Medicine’ women use to please men
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Methods Ingestion - tea or porridge Insertion – mixed with saliva or cloth Wiping – cloth or finger Juju belt – herbs worn around waist Body smearing substances
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Substances used for Dry Sex Plants: Leaves (cassava, tomatoe); Bark; roots; herbs, commercial products (soap,detergent salt, toothpaste,vicks) stones (crushed or powdered) animal products Cloth; tissue icecubes
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Culture of Dry sex Men prefer dry vagina; increase sensation; secretions not desirable; Women often economically dependant on men Marital fidelity and stability Taught to young girls as rites of passage by elders 13 andn 14yr olds pressured by older men to be sexually active
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Dry sex as a RF for HIV transmission Biological : direct or indirect injury to vaginal wall; facilitate transmission of HIV from infected male to susceptible female Portal of entry for HIV Increase WBC at site ; viral reservoir Decrease lactobacillus increase risk of HIV transmission Dry sex deterrent to condom use Condom breakage due to heat and dryness Faciltates transmission of virus from infected female to susceptible male ( lower viral load; increase shedding)
Slide 38-

Characteristics of Women who practice dry Sex in Ndola, Zambia 35.4% of women in study ingested substances (only 15 practiced insertion) Frequency of practice increased with age Women who were married were more likely to practice dry sex Only 5.4 % of all women who practiced dry sex used condoms 35% HIV positve; not significantly assoc with ingestion of substances for dry sex ; Sample size for insertion too small
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Do NA women practice a form of dry sex?? Douching for example What else do we do? Piercing? Tattooing
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Impact of culture in Transmission and prevention. Dry sex is embedded in their culture Is discontinuing practice an option? Condom negates effect of dry sex What are some options??
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Canada Estimates 2002 Adult Prevalence (15-49) 0.3% Total cases: 56,000 (46,000 to 66,000) HIV Heterosexual 10,000 (18%) High Risk Groups: MSM- 32,500 (58%) IDU –11,000 (20%) Aboriginal - 509 (3.1%)
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Estimated exposure category distributions (%) among new HIV infections by time period (PHAC HIV/AIDS Epi Update- May 2004)
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Aboriginal Population Aboriginal: only represent 3.3 % of the Canadian population but represent 3.1% of the reported HIV cases. (14.4 % all AIDS case) over represented in HIV epidemic IDU key mode of Transmission Significant impact on Aboriginal women Infected at younger age than non-Aboriginal
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Aboriginal HIV/AIDS Stats
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MSM Risk Behaviors unprotected anal sex with casual or regular partners Unsafe sex practice with known HIV –positive partner
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Injecting Drug Users Hi Risk Behaviors Sharing needles Sharing equipment Trading unprotected sex for money and Drugs incarceration
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Enhanced Surveillance of Hi Risk Groups Prevalence of HIV/AIDS in the general population low and these numbers don’t reflect the prevalence in hi risk groups enhanced surveillance of high risk groups is required to monitor trends in behaviors and disease Better able to target prevention and control measures
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North America:I TRACK survey Prevalence low in general population High risk groups MSM , IDU, Aborginal Enhanced surveillance in hi risk groups Target prevention meaures Consider the ‘cultural issue of IDU; MSM and aboriginal
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I TRACK Survey 2002 Enhanced surveillance of HIV/Hep C Risk Behaviors among Injecting Drug users in Canada Multi site surveillance Victoria, Regina, Sudbury, Toronto
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I TRACK Survey 4 sites – Victoria, Sudbury, Regina, Toronto ‘questionaire/interview- determinants; behaviors Blood sample – HIV/HEP C outcome
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Victoria Data/Results Estimate Population IDU – 1500 -3000 (RARE study) I TRACK study population – 150 recruited from needle exchange HIV prevalence – 16% Hep C – 79.3 % Co infection 16% (all HIV + were HepC+)
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Sociodemographic Gender: Male 70.7% Female 29.3% Mean Age: Male 37.8 Female 32.8 Ethnicity Aboriginal 20% Caucasian 32.7% Other 47.3% Education Completed College/univ – 12.7% Some Coll/Un – 19.3% SSGD – 22% Some HS – 46.0 %
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Injection Behavior Substances injected Cocaine 92.7% Heroin 73.3 % Dilaudid 50% Morphine 46.7% Frequency of Injection Everyday 44% At least 1/wk 36% Not every wk 17.3
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Hi Risk Behavior equipment use past 6mos Used Syringes 30.7% Used Equip 48 % Never use Condom for penetrative sex Women Regular partner 81.5% Casual 22.2% Client 0 % Men Regular partner 64 % Casual 19% Client 0%
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The Culture of Injecting Drugs Intimacy Illegality Bonding Value and beliefs