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
PR
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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.