Disease Synergies and HIV Transmission Linking Millennium Development Goals and HIV

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Disease Synergies andHIV TransmissionLinking
Millennium Development Goals and HIV

• Eileen Stillwaggon
• AIDS 2006
• XVI International AIDS Conference

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What drives an epidemic to 40 prevalencein
some countriesand less than 1 in others?
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Median age at first intercourse (selected
countries, by gender) Country Male Female U
nited States 16 17 Great Britain 17 17 Haiti
18 19 Tanzania 18 17 Zimbabwe 19 19 Der
ived from Singh S, et al. 2000. Gender
Differences in the Timing of First Intercourse
Data from 14 Countries, International Family
Planning Perspectives 26(1)2128, 43.
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23 of US men report 20 or more female partners
Source John O. G. Billy, Koray Tanfer, William
R. Grady, and Daniel H. Klepinger. 1993. The
Sexual Behavior of Men in the United States,
Family Planning Perspectives 25(2)5260.
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41 of US women report 4 or more male
partners 23 of US women report 6 male
partners
Source Kathryn Kost and Jacqueline Darroch
Forrest. 1992. American Womens Sexual Behavior
and Exposure to Risk of Sexually Transmitted
Diseases, Family Planning Perspectives
24(6)244254.
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Canada first-year college students with more
than 10 sexual partners Men 21 Women 9
Source N. MacDonald, G. Wells, W. Fisher, et al.
1990. High-Risk STD/HIV Behavior among College
Students, Journal of the American Medical
Association 263(23)31553159.
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Canada first-year college students with 5 or
more sexual partners Men 40 Women 25
Source N. MacDonald, G. Wells, W. Fisher, et al.
1990. High-Risk STD/HIV Behavior among College
Students, Journal of the American Medical
Association 263(23)31553159.
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Genital herpes simplex virus type 2 -
seroprevalence, by age,(197680) and (198894)
Note Bars indicate 95 confidence
intervals. National Health and Nutrition
Examination Survey
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Immune system

• Skin and mucous membranes
• First line of defense
• Natural Killer cells, macrophages
• Non-adaptive and adaptive immunity
• B cells
• adaptive immunity
• T cells

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Protein-energy malnutrition reduces

• integrity of skin and mucous membranes
• T-cell production

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Iron-deficiency anemia reduces production of

• B cells
• T cells
• Natural Killer (NK) cells

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Zinc deficiencyreduces

• Natural Killer cell activity
• T-cell production
• integrity of the skin as a barrier to infection

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Vitamin-A deficiency

• reduces production of
• NK cells
• T cells
• B cells
• reduces skin and mucosal integrity

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Vitamin-A deficiency

• reduces production of
• NK cells
• T cells
• B cells
• reduces skin and mucosal integrity
• increases viral load

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Maternal malnutritionincreasesmother-to-child
transmission

• Anemia increases
• viral shedding in the birth canal

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Global Distribution of Malaria
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Malaria

• causes chronic immune activation
• depresses immune response

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Malaria

• causes chronic immune activation
• depresses immune response
• increases HIV replication
• increases viral load in people with HIV

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Malaria

• causes chronic immune activation
• depresses immune response
• increases HIV replication
• increases viral load in people with HIV
• increases MTC transmission of HIV
• increases sexual transmission of HIV

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Malaria

• HIV increases malarial parasite load in the
  blood, increasing malaria transmission.
• Coinfection with malaria contributes to ARV
  treatment failure in malaria-endemic areas.

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Distribution of Lymphatic Filariasis
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Helminths (Worms)

• More than 80 of people in poor communities have
  at least one type of worm

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Helminths (Worms)

• More than 80 of people in poor communities have
  at least one type of worm
• Virtually all children in urban slums, shanty
  towns, and rural villages have worms

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Helminths (Worms)

• Roundworm, hookworm, whipworm
• infect 25 to 35 of world population
• cause blood loss in intestines
• cause anemia
• cause Vitamin-A deficiency
• cause loss of appetite
• increase energy cost

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Helminths (Worms)

• Roundworm, hookworm, whipworm
• hyperactivate the immune system
• depress immune response
• increase susceptibility to HIV
• increase HIV viral load and
• HIV transmission

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Distribution of Schistosomiasis hematobium
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Schistosomiasis (bilharzia)

• S. hematobium (urinary schistosomiasis) infects
• 33 of Africans, over 200 million people.

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Schistosomiasis (bilharzia)

• S. hematobium (urinary schistosomiasis) infects
• 33 of Africans, over 200 million people.
• Causes blood loss, malnutrition, anemia

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Schistosomiasis (bilharzia)

• S. hematobium (urinary schistosomiasis) infects
• 33 of Africans, over 200 million people.
• Causes blood loss, malnutrition, anemia
• In endemic areas, 75 of women with urinary
  schistosomiasis also have genital infection.

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Schistosomiasis (bilharzia)

• Worms and ova of S. hematobium infect the vagina,
  uterus, vulva, and cervix.

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Schistosomiasis (bilharzia)

• Worms and ova of S. hematobium infect the vagina,
  uterus, vulva, and cervix.
• S. hematobium lesions are indistinguishable from
  STDs without biopsy.

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Schistosomiasis (bilharzia)

• Worms and ova of S. hematobium infect the vagina,
  uterus, vulva, and cervix.
• S. hematobium lesions are indistinguishable from
  STDs without biopsy.
• Lesions provide direct access to the blood stream
  for HIV.

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Schistosomiasis (bilharzia)

• Worms and ova of S. hematobium infect the vagina,
  uterus, vulva, and cervix.
• S. hematobium lesions are indistinguishable from
  STDs without biopsy.
• Lesions provide direct access to the blood stream
  for HIV.
• Worms and ova produce inflammation, attracting CD
  4 cells to the cervix and other sites in the
  reproductive tract.

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S. hematobium in Tanzania
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S. hematobium in South Africa and Swaziland
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What is causing the epidemic of HIV/AIDS?
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I N x P x Twhere I is probability of
sexual infection,N is the number of
partners,P is the prevalence rate in the
population, and T is the per-contact
transmission risk, which is assumed to be the
same for every population. One risk fits all.
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I N x P x T

• T V C (or T V x C )
• risk of transmission vulnerability
  contagiousness
• V f standard risk, H, M, F, TB, STD, SCH, .
  . .
• C g standard risk, H, M, F, TB, STD,
  
  SCH, . . .

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AIDS is aDevelopment Issue
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