Understanding the Epidemiology

and Transmission Dynamics

of the HIV/AIDS Pandemic

James Chin, MD, MPH

Clinical Professor of Epidemiology
School of Public Health, University of California, Berkeley
E-mail: jchin@socrates.berkeley.edu

CCIH, May 2003

 Two HIV/AIDS Paradigms
1. In the absence of effective HIV/AIDS prevention and
control programs, it is just a matter of time before HIV
epidemics will occur in all current low HIV prevalence
populations.
“Let's stop the nonsense of trying to determine a 'natural
limit' to the [AIDS] epidemic in Asia and the Pacific…”
2. HIV prevalence can only rise to the levels permitted by
the patterns and prevalence of HIV risk behaviors and
therefore HIV epidemics will not occur in populations
with low levels of HIV risk behaviors.
“It is epidemiologic nonsense to deny that there are no
natural limits to epidemic HIV transmission based on the
pattern(s) and prevalence of HIV risk behaviors!”
 Natural History of HIV Infection
• Infection is probably lifelong, and severe
immune deficiency will develop in up to half of
infected adults within 7-8 years.
• Annual progression rates from HIV infection to
AIDS is similar in Haiti, Thailand, Uganda, and
“Western” countries.
• Once sufficient immune damage occurs, the
infected person becomes susceptible to
opportunistic infections and cancers.
• These infections and cancers are surrogate
indicators of the immunodeficiency due to HIV
• Survival after the onset of AIDS is, in the
absence of anti-HIV treatment, short and is
usually less than 1 year in developing countries.
 Sexual Transmission of HIV
• Results from sex partner studies – per coital act:
Padian (USA): Male to female = 1/1,000
Female to male = 1/8,000
Gray (Uganda): Male to female = 1/1,000
Female to male = 1/900
• Facilitating factors (are not co-factors!) include any
factor that can cause lesions in the genital or rectal
epithelium such as: any concurrent STD, especially
ulcerative ones like genital herpes (HSV-2) and
chancroid; “dry sex”; lack of male circumcision(?);
frequent and traumatic sex, etc., etc.
• Anal intercourse is probably more efficient for HIV
transmission because of increased tissue trauma.
 Patterns of Sexual HIV Transmission
• The epidemic pattern, where Ro of HIV is > 1, has
only occurred where there are: (a) high-risk patterns
of sex partner exchange and mixing, i.e., having
multiple and concurrent sex partners; and (b) a high
prevalence of factors that can facilitate the sexual
transmission of HIV.
• The non-epidemic pattern, where Ro of HIV is, on
average, < 1, occurs from HIV-infected persons
(regardless of how they were infected) to their
regular sex partner(s). Further HIV spread from
these regular partners (i.e., the epidemic pattern) can
only occur if these partners have other sex partners.
• HIV prevalence will not exceed one percent of the
total 15-49 year old population unless the epidemic
pattern is prevalent in the heterosexual population.
 HIV/AIDS Numbers
 Cumulative incidence – the total number (HIV,
AIDS, or AIDS deaths) since the start of the
pandemic. These numbers are generally not
used anymore except for historical purposes.

 HIV prevalence—refers to persons living with an

HIV infection at a given time. Prevalence can be
expressed as a number or a rate). Prevalence is
usually estimated for the 15-49 year old
population and not for the total population.

 HIV prevalence is estimated from data, and all

other HIV/AIDS numbers (annual incidence, etc.
are estimated using some HIV/AIDS model.
 Understanding HIV/AIDS Numbers
 Reported numbers of HIV infections or AIDS
cases are usually grossly under-reported!
 Official numbers may be reported cases or may
be officially estimated cases.
 Estimated numbers may be derived by a
government expert group or can be the estimated
number of an individual or an external agency.
 Actual numbers or the real numbers represent
the “Holy Grail” for epidemiologists. They can, at
best, be estimated via an objective process using
the most reasonable assumptions and data
available.
How Reliable are HIV Prevalence Estimates?
• Estimation of HIV prevalence is more of an art than a
science. With the known vagaries inherent in HIV
serologic data and the limitations of the data, methods,
and assumptions used, estimation of HIV numbers
cannot be precise.
• However, current UNAIDS/WHO estimates of most
national HIV/AIDS numbers are reasonably accurate.
• For high (> 1% of the 15-49 year old population) HIV
prevalence countries, estimates can be off by up to
50%; for moderate (> 0.1% < 1%) HIV prevalence
countries, estimates can easily be off by 1-2 folds, and
for low (> 0.1%) HIV prevalence countries, estimates
can be off by several folds!
 Estimated HIV Prevalence in 10,000
Pregnant Females
Country Number HIV Transmission
1 Botswana 3,800 Primarily heterosexual
2 South Africa 2,000 Primarily heterosexual
3 Haiti 600 Primarily heterosexual
4 Cambodia 280 Primarily heterosexual
5 Thailand 140 Heterosexual, & IDU
6 India (1-300) 50 Mostly heterosexual
7 Malaysia 3 Primarily IDU
8 Indonesia 2 Primarily IDU
9 Philippines 1 No epidemic HIV spread
10 DPR Korea <1 No epidemic HIV spread
Risk Behaviors and Disease
Alcohol and alcoholism

Smoking and lung cancer

Sexual risk behaviors and HIV/AIDS

 Gradient of Sexual HIV Risk Behaviors
Highest – (A) “Bathhouse” type settings for MSM where
large numbers of MSM had up to 10-20 sex contacts in
a single day or night. (B) Large brothel type
establishments where FSW have thousands of male
clients per year.
Moderate – Unprotected vaginal or anal intercourse
with multiple partners on a concurrent basis and
involving many different sex partners per year.
Examples include MSM in moderate size sex networks,
“Indirect” FSW in bars, etc., and a large percent
(20-40%) of some “general” populations in SSA.
Low – Unprotected sexual intercourse with several
different partners per year, but mostly on a serial basis.
 Concluding Comments (1)
• The common thread that runs through all epidemic
HIV transmission is that the major HIV risk
behavior groups affected (MSM, IDU, FSW and
their clients) are all socially marginalized and they
engage in socially unaccepted and often illegal
behavior(s), whereas non-epidemic sexual HIV
transmission is generally via legally and morally
sanctioned sex.
• The risk behaviors for epidemic HIV transmission
(unprotected sexual intercourse with multiple and
concurrent sex partners) and sharing drug
injecting equipment with many other IDU are
difficult subjects for official agencies and
especially religious groups to deal with.
 Concluding Comments (2)
• All communities, including social and religious
institutions, must understand and accept that
cultural, social, religious, economic and many
other factors influence and/or determine the
patterns and prevalence of sex outside of
mutually monogamous sex relationships.
• Not all “immoral” sex poses a significant risk of
sustained or epidemic HIV transmission. A
pattern of multiple and concurrent sex partners is
required to sustain epidemic HIV transmission.
• Substance abuse problems such as IDU should
be managed primarily as a public health problem
and not as a criminal or “social evils” problem.
 Take Home Message/Question
• Epidemic HIV transmission requires risk
behaviors such as having unprotected sexual
intercourse with multiple and concurrent sex
partners or routinely sharing needles and
syringes with other IDU.
• The primary question that Christian
organizations should ponder is:
Would Christ just fixate on the ABCs of HIV
prevention or would he also aggressively
support the 100% condom program for all
casual and commercial sex, and promote
needle exchange programs for IDU?