GITA RAMJEEGITA RAMJEEHIV Prevention Research UnitHIV Prevention Research Unit

South AfricanSouth African

Medical Research CouncilMedical Research Council

“ “Meeting the Challenge of HIV/AIDS in Meeting the Challenge of HIV/AIDS in South Africa: Exploring Future Strategy South Africa: Exploring Future Strategy

and Tactics to Expand the National and Tactics to Expand the National ResponseResponse.”.”

COUNCIL ON FOREIGN RELATIONSCOUNCIL ON FOREIGN RELATIONS

Cape Town, 21Cape Town, 21stst January 2010 January 2010

HIV PREVENTIONHIV PREVENTION

SOUTH AFRICAN NATIONAL STRATEGIC PLANSOUTH AFRICAN NATIONAL STRATEGIC PLAN(2007-2011)(2007-2011)

Reduce the number of new infections by 50%

Reduce impact of HIV/AIDS on individuals, families, communities and society by expanding access to an appropriate package of treatment, care and support to 80% of all people diagnosed with HIV

AIM

SOUTH AFRICAN NSP FOR HIV/AIDSSOUTH AFRICAN NSP FOR HIV/AIDS

FOUR KEY PRIORITY AREAS TO REACH THE AIMS OF SA NSPFOUR KEY PRIORITY AREAS TO REACH THE AIMS OF SA NSPP

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PRIORITY AREA 1: 50% REDUCTION IN HIV PRIORITY AREA 1: 50% REDUCTION IN HIV INCIDENCE BY 2011INCIDENCE BY 2011

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GOALS

1

REDUCE VULNERABILITY

TO HIV INFECTION AND THE IMPACT OF

AIDS

• Mitigate the impact of poverty

• Accelerate programs to

empower women and educate men

• Address gender based violence

• Enabling environment for HIV

testing

• Leadership support for NSP goals

• Strengthen cohesion in

communities/support family as institution

• Build AIDS competent

communities

OBJECTIVES

• Behavior change programs

• Interventions target young people

• Open discussions between parents and

children

•Workplace prevention programs

•Prevention programs for higher risk populations

•Package included in relevant health services

• Promote male sexual health

• Reduce drug use in young people

• Accessibility of sexual assault care

•Prevention programs for HIV+ people

• Broaden mother to child transmission services to include

other related services and target

groups

• Scale up and improve quality of PMTCT to reduce

MTCT to < 5%

•Among health care providers in the

formal, informal and traditional settings

using infection control procedures

•Exposure to infected blood

associated with traditional and complementary

practices

• Injecting drug use and unsafe sexual

practices

• Safe supplies of blood and blood

products

2

REDUCE SEXUAL

TRANSMISSION OF HIV

3

REDUCE MOTHER-TO-

CHILD TRANSMISSION

OF HIV

4

MINIMISE THE RISK OF HIV

TRANSMISSION THROUGH

BLOOD AND BLOOD

PRODUCTS

DO WE KNOW OUR EPIDEMIC? DO WE KNOW OUR EPIDEMIC?

Approximately 5.5 million people are infected

South Africa – country with highest number of people infected

HIV prevalence amongst pregnant women – ANC survey 2008 –

29.1% (28.3 – 29.9). Prevalence of 40.2% among women aged 30-34

years.

HIV prevalence among pregnant women – 24.8% (2001); 26.5%

(2002); 27.9% (2003); 29.5% (2004); 30.2% (2005); 29.1% (2006)

and 28.0% (2007)

WHAT DO WE KNOW?WHAT DO WE KNOW?

HIV incidence women aged 20-29 = 5.6% (6x that of males in the same group)

Lack of awareness of HIV prevention

Multiple sexual partnerships

Intergenerational sex

Low condom use/poor condom negotiation

VCT – Increased from 2005-2008

WHAT DO WE KNOW? Cont.WHAT DO WE KNOW? Cont.

Ref: South African National HIV Prevalence, Incidence, Behavior and Communication Survey 2008

HSRC SURVEY 2008 HSRC SURVEY 2008 NSP GOAL – MONITORING AND EVALUATIONNSP GOAL – MONITORING AND EVALUATION

Reduction in HIV prevalence among children

Reduction in HIV prevalence among youth

except KZN and Mapumalanga

Increased awareness of HIV serostatus – up

scaling VCT

Reported condom use ↑ from 57% 2002 →

87% 2008

↑ National communication program

Large number of HIV infected individuals

Young women continue to be at risk of HIV

infection

Increase in intergenerational sex

Increase in multiple partnerships – Free State

Reported condom use low in Western Cape

HIV prevention knowledge declined in some

provinces

Government Khomanani campaign on HIV

prevention – lowest reach of all national

programs

N = 20,826 (15,031 HIV testing)N = 20,826 (15,031 HIV testing)

SUCCESSESSUCCESSES CHALLENGESCHALLENGES

Ref: HSRC Report

HIV INCIDENCE IN COHORTS OF WOMEN FROM HIV INCIDENCE IN COHORTS OF WOMEN FROM TRIALS UNDERTAKEN BY HPRU (MRC)TRIALS UNDERTAKEN BY HPRU (MRC)

Clinical Trial Years of study City/regionN

(non-intervention arm)

HIV incidence in non-intervention arm (per 100wy)

COL 1492 (Sex workers) 1996-2000 Durban 93 16.5

Cellulose Sulphate 2005-2007 Durban 295 5.9

Carraguard 2004-2007 Durban 726 5.9

Pretoria 1158 3.3

Cape Town 1110 3.0

Diaphragm 2003-2006 Durban 742 7

JHB 505 3.3

HPTN 035 2005-2008 Durban 704* 4.6*

Hlabisa 350* 9.1*

MDP 301 2005-2009 Durban 880 6.1

Mtubatuba 411 4.3

JHB 868 5

** Overall

HIV PREVALENCE AND INCIDENCE IN HIV PREVALENCE AND INCIDENCE IN OTHER GROUPSOTHER GROUPS

HIV prevalenceHIV incidence/100WY95% CI

Reference

Migrant men 26% (Lurie, Williams et al. 2003a)

Migrant couples (migrant man + non-migrant woman)

35%(Lurie, Williams et al. 2003b)

Truck drivers 56% - (Ramjee, Gouws et al. 2002)

Women 25-29 years 33% - (Shisana, Rehle et al. 2009)

Rural women 30.2% 6.8 (4.2-9.4) (Caprisa 050/051, Caprisa 002)

Urban women 59.3% 5.9 (1.2-10.7) (Caprisa 050/051, Caprisa 002)

Commercial sex workers 59.4% 7.9 (4.1-9.6) (Caprisa 050/051, Caprisa 002)

Risk factors for HIV seroconversion (Hazard ratio)

Non-cohabiting women 3.43 (95% CI 1.83-6.42) Ramjee et al. (unpublished)

Women under 30 years 4.0 (95% CI 1.4-11.7) Ramjee et al. (unpublished)

Women with incident STIs

Syphilis 13.3 (95% CI 1.4, 128.9)

Ramjee et al. (unpublished)Chlamydia 8.2 (95% CI 2.6, 26.3)

Gonorrhoea 4.7 (95% CI 1.1, 20.0)

Lurie, M., B. Williams, et al. (2003a). "The impact of migration on HIV-1 transmission in South Africa: A study of migrant and nonmigrant men and their partners." Sexually Transmitted Diseases 30(2): 149-156.Lurie, M., B. Williams, et al. (2003b). "Who infects whom? HIV-1 concordance and discordance among migrant and non-migrant couples in South Africa." AIDS 17(15): 2245-2252.Ramjee, G., Gouws, et al. (2002). "Prevalence of HIV among truck drivers visiting sex workers in KwaZulu-Natal, South Africa." Sexually Transmitted Diseases 29(1): 44-49.Shisana, O., T. Rehle, et al. (2009). South African national HIV prevalence, incidence, behaviour and communication survey 2008:A turning tide among teenagers?, HSRC Press.Karim, SSA; Kharsany, A: Caprisa 050/051 and Caprisa 002 HIV incidence data, CAPRISA - Centre for the AIDS Programme of Research in South Africa

STI PREVALENCE AT SOUTH AFRICAN SITES IN STI PREVALENCE AT SOUTH AFRICAN SITES IN STUDIES UNDERTAKEN BY HPRUSTUDIES UNDERTAKEN BY HPRU

Clinical Trials Years of study City/region N STI prevalence at screening/enrolment

COL 1492 1996-2000 Durban - -

Cellulose Sulphate 2005-2007 Durban 295 18% **

Carraguard 2004-2007 Durban 1485 21%

Pretoria 2402 24%

Cape Town 2315 31%

Diaphragm 2003-2006 Durban - Chlamydia 8.5%; Gonorrhoea 2.7%

JHB - Chlamydia 6.9%; Gonorrhoea 1.1%

HPTN 035 2005-2007Durban 702 Chlamydia 7%; Gonorrhoea 1%;

HSV2 47%; Syphilis 2%

Hlabisa 346 Chlamydia 8%; Gonorrhoea 1%; HSV2 47%; Syphilis 1%

MDP 301 2005-2009Durban 2391 Chlamydia 12%; Gonorrhoea 3%;

HSV2 56%; Syphilis 3%

Mtubatuba 1177 Chlamydia 5%; Gonorrhoea 7%; HSV2 68%; Syphilis 7%

JHB 2499 Chlamydia 12%; Gonorrhoea 3%; HSV2 46%; Syphilis 3%

* STI Incidence

INCIDENCE OF NEW STI EPISODES TREATED AT INCIDENCE OF NEW STI EPISODES TREATED AT PHC FACILITIES IN SA (2000-2006)PHC FACILITIES IN SA (2000-2006)

INCIDENCE OF NEW STI EPISODES TREATED AT INCIDENCE OF NEW STI EPISODES TREATED AT PHC FACILITIES IN SA (2000-2006)PHC FACILITIES IN SA (2000-2006)

Ref: DHIS, National Department of Health

PROVINCE Incidence in percentage (%)

2000 2001 2002 2003 2004 2005 2006 Average

Eastern Cape 6.2 6.0 4.8 5.4 6.3 5.4 6.0 5.6

Free State 5.1 6.0 5.3 4.6 4.3 4.2 3.8 4.8

Gauteng 5.3 4.9 5.0 4.4 3.6 3.2 4.2 4.4

KwaZulu-Natal 10 9.0 8.4 7.8 7.1 6.9 7.2 8.1

Limpopo 7.2 8.8 8.7 7.6 7.1 6.5 5.7 7.4

Mpumalanga 5.2 7.1 5.8 4.7 5.1 4.8 5.1 5.4

Northern Cape 2.9 3.7 3.8 4.2 4.1 3.6 3.4 3.7

North West 8.0 7.3 6.5 5.8 5.8 4.9 4.5 6.1

Western Cape 3.6 3.7 3.7 2.2 3.1 2.8 3.0 3.2

South Africa 3.6 3.7 3.7 2.2 3.1 2.8 3.0 3.2

South Africa 6.4 6.5 6.1 5.4 5.3 4.8 5.0 5.6

HIV PREVENTION

HIV PREVENTION

Male circumcisionMale circumcision

Voluntary counseling and testing

Voluntary counseling and testing

Prevention of MTCTPrevention of MTCT

Harm reduction programs for injecting drug use

Harm reduction programs for injecting drug use

Prevention and treatment of STI

Prevention and treatment of STI

Behavior changeBehavior change

CondomsCondoms

WHAT WORKS IN HIV PREVENTIONWHAT WORKS IN HIV PREVENTIONWHAT WORKS IN HIV PREVENTIONWHAT WORKS IN HIV PREVENTION

Prevention treatment of STI

Prevention treatment of STI

VCT, BEHAVIORIAL CHANGE VCT, BEHAVIORIAL CHANGE AND CONDOM PROMOTIONAND CONDOM PROMOTION

VCT, BEHAVIORIAL CHANGE VCT, BEHAVIORIAL CHANGE AND CONDOM PROMOTIONAND CONDOM PROMOTION

Voluntary counseling and testing

HIV positive

Transmission risk and other counseling

• Condom promotion• Treatment of STI• Partner reduction

• Mental health

HIV prevention

Behavior change

Risk reduction Risk reduction counselingcounseling

• Condom promotionCondom promotion• Treatment of STITreatment of STI• Partner reductionPartner reduction

HIV negative

Resources:

Medical Care

Targeted behavior counseling

Support counseling

Monitoring and evaluation

TRANSMISSION RISK BEHAVIORS OF TRANSMISSION RISK BEHAVIORS OF HIV POSITIVE INDIVIDUALSHIV POSITIVE INDIVIDUALS

TRANSMISSION RISK BEHAVIORS OF TRANSMISSION RISK BEHAVIORS OF HIV POSITIVE INDIVIDUALSHIV POSITIVE INDIVIDUALS

HIV Viral LoadHIV Viral Load

CD4 Cell Counts CD4 Cell Counts

(Fauci, Pantaleo, Stanley & Weismann, 1996)(Fauci, Pantaleo, Stanley & Weismann, 1996)

HIV Transmission Risk BehaviorsHIV Transmission Risk Behaviors

Ref: Lisa A. Eaton et al. JANAC, Vol 20, No 1, Jan/Feb 2009

Model of HIV Disease Progression in Relation to HIV Transmission RiskModel of HIV Disease Progression in Relation to HIV Transmission Risk

Need targeted and tailored counselingNeed targeted and tailored counseling

POSITIVE PREVENTION:POSITIVE PREVENTION:

Support HIV care centers

Support HIV care centers

Develop community

based HIV care centers

Develop community

based HIV care centers

Treatment of OI

Treatment of OI

CD4 monitoring

CD4 monitoring

HIV prevention trial sites or VCT site

HIV prevention trial sites or VCT site

PARTNERSHIPS WITH PEPFAR IN MEETING THE PARTNERSHIPS WITH PEPFAR IN MEETING THE GOALS OF THE NSPGOALS OF THE NSP

PARTNERSHIPS WITH PEPFAR IN MEETING THE PARTNERSHIPS WITH PEPFAR IN MEETING THE GOALS OF THE NSPGOALS OF THE NSP

Partnership with local

DOH

Partnership with local

DOH

Counseling and testing

Counseling and testing

Partnership with PEPFAR

Partnership with PEPFAR

COMMUNITY BASEDCOMMUNITY BASED

Treatment for HIV

Treatment for HIV

STI treatment

STI treatment

Positive PreventionPositive Prevention

DOH support monitoring

and evaluation

DOH support monitoring

and evaluation

PEPFAR structural and

human resources support

PEPFAR structural and

human resources support

HEALTH SYSTEMS STRENGTHENINGHEALTH SYSTEMS STRENGTHENING

Integration of HIV prevention, treatment and care coupled with TB

diagnosis treatment and care

Invest in re-building health infrastructure

Enhance human resource capacity

In service training

Increase output of healthcare service workers from training

institution

Increase primary healthcare service

Reliance of community-based healthcare workers

STRUCTURAL FACTORS AND INTERVENTIONS STRUCTURAL FACTORS AND INTERVENTIONS FOR HIV PREVENTION FOR HIV PREVENTION

C. Bonell et al. Social Science and Medicine 63 (2006) 1136

EXAMPLE:EXAMPLE:

Setting/mode of HIV transmission

South Africa/ heterosexual transmission among

young people

Examples of a structural factor influencing HIV

transmission

Examples of potential structural interventions

Poverty and gender inequality

Impact mediated for young women by sexual relationships being an important source of potential income and supportWomen may be

badly placed to negotiate safer

sex

Change in global aid or trade

policies

Legislative changes to promote higher

incomes and employment for

women

Provision of basic income grants or

increasing access to microfinance credit for

poor households

RESEARCH ON OTHER RESEARCH ON OTHER HIV PREVENTION TECHNOLOGIESHIV PREVENTION TECHNOLOGIES

Global research investment/Donor support (millions of US$) 2008*

Prospective infections prevented/% reduction in infections

Implementation challenges

Vaccine 868 24% reduction over 15 years in developing world (50% effective vaccine given to 30% of the population) [1]

Selection of, and distribution to, appropriate target population; behavioural disinhibition

Microbicide 244 682 000 in SSA over three years (2002 estimates based on 60% effective product used by 20% of eligible pop.) [2]

Cultural resistance; distribution; manufacture; formulation; dosing regime/delivery system

PrEP 44 2.7-3.2 million in SSA over 10 years (90% effectiveness – targeted to those at highest behaviorial risk and prevention of behaviorial disinhibition [3]

Infrastructure for monitoring potential resistance; adherence challenges; distribution

Male circumcision 10 26 (PEPFAR – rollout) 50 (Gates Foundation – rollout)

6 million over next 20 years in SSA [4] – 60% protection

Development and funding of MC clinics; cultural resistance; development of new surgical techniques for use in less developed countries; training of medical staff

Condoms 66 (donor support) [5] 80% reduction (region non-specific) (97% efficacy under perfect conditions) [6]

Supply; distribution; cultural resistance; gender inequality; correct and consistent use

Overall implementation challenges: - Stigma - Cost (if not borne by government) - Perceived risk level of individuals in target population

* All figures from HIV Vaccines and Microbicides Resource Tracking Working Group Report “Adapting to realities: Trends in HIV prevention research funding 2000 to 2008”, except where indicated.1.IAVI: Estimating the impact of an AIDS vaccine in developing countries. 2009.2.Public Health Working Group of the Microbicide Initiative: The public health benefits of microbicides in lower-income countries: Model projections. 2002.3.Abbas UL, Anderson RM, Mellors JW: Potential impact of antiretroviral chemoprophylaxis on HIV-1 transmission in resource-limited settings. PLoS One 2007, 2:e875.4.Williams BG, Lloyd-Smith JO, Gouws E, Hankins C, Getz WM, Hargrove J, de Zoysa I, Dye C, Auvert B: The potential impact of male circumcision on HIV in sub-Saharan Africa. PLoS Med 2006, 3:e262.5.UNFPA: Donor support for contraceptives and condoms for STI/HIV prevention. 2008.6.Weller S, Davis-Beaty K: Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database of Systematic Reviews 2002.

WHAT IS NEEDED TO ACHIEVE THE GOALS OF WHAT IS NEEDED TO ACHIEVE THE GOALS OF THE NSP FOR PREVENTIONTHE NSP FOR PREVENTION

Resources•Human capital and financing

• Voluntary programs, community mobilisation, partnerships and

advocacy• Strengthening of health systems

• Structural intervention

POLITICAL LEADERSHIP AND COMMITMENT

Co-ordination• Including partnerships with

scientists/researchers• Integration of HIV prevention,

treatment and care• TB treatment and care

Targeted Intervention• Know your epidemic?

-Communities- Most at risk

Monitoring and Evaluation

•Staff performance accountability

• Monitoring procurement and delivery

• Patient-friendly and supportive delivery

Civil Society and Human Rights Mainstreaming

• Access to care• Addressing stigma

Operational Research (Evidence based) and

Implementation • Partnerships with local health

authorities and research institutions

Strategic Decisions on Deployment of Resources

SANAC

CONCLUSION CONCLUSION

South Africa has limited financial resources and sound polices but

lacks effective co-ordination, implementation, monitoring and

evaluation of evidence - based HIV prevention interventions

Urgent need to “know our epidemic” Synthesis of all available data on HIV prevalence and incidence

from sentinel surveillance, population-based surveys,

longitudinal cohort studies and projections based on

mathematical models. Identify key drivers of the epidemic; demographics and spatial

distribution for targeted intervention. Opportunity for policy makers and scientists to generate

evidence-based strategies for effective HIV prevention

CONCLUSION cont.CONCLUSION cont.

Scale up of prevention interventions that are known to work e.g.. Avoidance of concurrent partnerships, avoidance of large age difference sexual partners, effective tailored counseling for both HIV negative and positive individuals and aggressive condom promotion Development of policy to urgently implement male circumcision

programs coupled with health systems and operational research. Legislative and structural interventions for vulnerable populations

such as sex workers, victims of gender violence and migrant laborers e.g.. Legalization of sex workers Law enforcement of rape and violence against women Incentive to companies to minimize family separation through

migrant labor Integrate HIV prevention, health and care services with family and

TB treatment and care SANAC – representation from Government, research, civil society –

well placed to mobilize a social movement to address the HIV pandemic in South Africa.