# Presentation: 216411

## 20 August 2003

- Deputy Vice-Chancellor (Research), University of Natal
- Director: CAPRISA - Centre for the AIDS Programme of Research in SA
- Professor in Clinical Epidemiology, Columbia University
- Adjunct Professor in Medicine, Cornell University

***20 August 2003***

- Salim S. Abdool Karim

**HIV/AIDS and STIs in Women: **
**the urgent need for an **
**efficacious microbicide**

## NUMBER OF PEOPLE LIVING WITH HIV/AIDS 

**Adults ****	****	****38.6 million****Women ****	****	****19.2 million****Children under 15 years****	****3.2 million**
**Total****	****	****42 million**
**PEOPLE NEWLY INFECTED WITH HIV in 2002**** **
**Adults****	****	****4.2 million****Women****	****	****2 million****Children under 15 year****	****800 000**
**Total****	****	****5 million**

- Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO).
- AIDS epidemic update Dec** **2002

**Worldwide HIV prevalence & incidence**

## 1 500 000

**Latin America **
**1 500 000**

**East Asia & Pacific**
**1 200 000**

**Eastern Europe & Central \Asia**
**1 200 000**

**Sub Saharan Africa **
**29 400 000**

**Australia ****& New Zealand**
**15 000**

**Caribbean**
**440 000**

**North America**
**980 000**

**North Africa & ****Middle East**
**550 000**

**Western Europe**
**570 000**

**South & South-East Asia**
**6 000 000**

**Total: 42 million**

**Worldwide prevalence**

- Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO).
- AIDS epidemic update Dec** **2002

## 0

**0**

**10**

**20**

**30**

**40**

**1988**

**1990**

**1992**

**1994**

**1996**

**1998**

**2000**

**2002**

- HIV prevalence (%)

**HIV Infection in ANC attendees in South Africa**

## aged 15-49: 1992-2001

- Source:  Williams BG, Gouws E, Wilkinson D, Abdool Karim SS. Estimating HIV from Age Prevalence data e  epidemic  situation. Statistic in Medicine 2000.
- Gouws E, Williams BG, Sheppard HW, Enge B, Abdool Karim SS. High incidence of HIV-1 in South Africa using a standardized algorithm for recent HIV seroconversion. J AIDS 2002; 29: 531-535.

**aged 15-49: 1992-2001**

| Year | N | Prev(%)(95% CI) | Incidence % |
| --- | --- | --- | --- |
| 1992 | 884 |  4.2 (3.0-5.7) | 2.0 |
| 1993 | 709 |  7.9 (6.0-10.1) | 3.3 |
| 1995 | 314 | 14.0 (10.4-18.4) | 7.1 |
| 1997 | 4731 | 27.2 (25.9-28.5) | 10.2 |
| 1998 | 3166 | 29.9 (28.4-31.6) | 10.5 |
| 1999 | 3001 | 34.0 (32.5-35.7) | 10.3 |
| 2001 | 906 | 36.1 (32.9-39.2) | 10.2 |

**Prevalence and  incidence of HIV: Hlabisa clinic attendees**

## Age and gender distribution of HIV infection 

**Age and gender distribution of HIV infection **
**in South Africa**

**0**

**<9**

**10-14**

**JUN/JUL 1992**

**Prevalence (%)**

**15-19**

**20-24**

**25-29**

**30-39**

**40-49**

**2**

**4**

**6**

**8**

**10**

**Female**

**Male**

- Source: Abdool Karim Q, Abdool Karim SS, Singh B, Short R, Ngxongo S. Prevalence of HIV infection in Rural South Africa.  AIDS 1992; 6: 1535 - 1539

## Temporal trends in the age-specific prevalence of HIV infection

- Source: Wilkinson D, Abdool Karim SS,  Williams B, Gouws E. High HIV incidence and prevalence among young women in rural South Africa: developing a cohort for Intervention Trials. J Acquir Immune Defic Syndr 2000; 23: 405-409

| Age Group | 1992 | 1995 | 1998 | 2001 |
| --- | --- | --- | --- | --- |
| 20-24 | 6.9% | 21.1% | 39.3% | 50.8% |
| 25-29 | 2.7% | 18.8% | 36.4% | 47.2% |
| 30-34 | 1.4% | 15.0% | 23.4% | 38.4% |
| 35-39 | 0.0% | 3.4% | 23.0% | 36.4% |

**Temporal trends in the age-specific prevalence of HIV infection**
** ****in antenatal clinic attendees in Hlabisa**

## 0

**infection in ANC attendees in Hlabisa**

- 2

- 4

- 6

- 8

- 10

- 12

- 14

- 16

- 15-19

- 20-24

- 25-29

- 30-34

- 35-39

- 40-44

- Total

**Age **

**Incidence (%)**

- 1998

- 2001

## HIV incidence rates in a cohort of South African

| Year | Person-months of follow-up | Incidence Rate (%); 95% CI  |
| --- | --- | --- |
| 1996/97 | 996 | 16.8 (8.0-26.0) |
| 1998 | 1644 | 18.2 (11.0-25.0) |
| 1999 | 780 | 20.0 (9.0-31.0) |
| Overall (1996-99) | 3420 | 18.2 (13.0-23.0) |

- Source: Abdool Karim SS, Ramjee G and Gouws E – Data from COL-1492 trial

**HIV incidence rates in a cohort of South African**
**sex workers in the COL-1492 trial**

## Baseline Prevalence Rates and the 1996 - 1999 Incidence Rates 

| STD | Prevalence (95% CI)
(n=472) | Incidence (95% CI)
(n=198) |
| --- | --- | --- |
| T.Vaginalis | 36.1% (31.6; 40.6) | 114.0% (102; 126) |
| N.Gonorrhoeae | 11.3% (8.4; 14.3) | 42.0% (34.8; 49.2 |
| C.Trachomatis | 12.7% 9.4; 36.2) | 43.2% (34.8; 50.4) |
| Syphilis | 31.9% (27.6; 36.2) | - |
| HIV | 51.3% (46.7; 55.8) | 18.2% (13.0; 23.0) |

**Baseline Prevalence Rates and the 1996 - 1999 Incidence Rates **
**of STD’s and HIV: Truck Stop Sex Workers**

- Source*:*** **Ramjee G, Abdool Karim SS, Morar NS, Gwamanda Z, Xulu G, Ximba T, Gouws E. Acceptability of a vaginal microbicide among female sex workers. S Afr Med J 1999; 89: 673-676.

## Sexually Transmitted Diseases: Burden

**All Women aged **
**15-49 years **
**(N=55 974)**

**Women with **
**an STI**

**Symptoms**
**Recognized**

**Treatment**

**Inadequate**

**88**

**35%**

**Adequate**

**164**

**65%**

**No**

**6 994**

**98%**

**Yes**

**252**

**2%**

**Asymptomatic**

**6 697**

**48%**

**Symptomatic**

**7 246**

**52%**

**No STI**

**42 031**

**75%**

**At Least One STI**

**13 943**

**25%**

- Source: Wilkinson D, Abdool Karim SS, Harrison A, Lurie M, Colvin M, Connolly C, Sturm AW. Unrecognised Sexually Transmitted Infections in Rural South Africa African Women - The Hidden Epidemic. Bull WHO 1999; 77: 22-28

**Sexually Transmitted Diseases: Burden**
**in a Rural South African district**

## Fiscal Year Distribution / Cost

**300**

**200**

**FY2000**

**FY2001**

**FY2002 **

**400**

**R61,4m**
**@R0,23c**

**Fiscal Year Distribution / Cost**

**Condom  Pieces / Millions of  Rands**

**R47,5m**
**@R0.19c**

**250**
**Million**

**100**

**267**
**Million**

**R103,8m**
**@R0,29c**

**Distribution in**
**millions of pieces**

**Investment in **
**millions of Rand**

**Projected cost**

**Projected **
**distribution pieces **

**358 **
**Million**

**South African HIV/AIDS prevention programme: **
**Increase in male condom distribution / cost**

## Fiscal Year Distribution / Cost

**R7**
**Million**
**@R5.40**

**2.5Mil**
**Pieces**

**R18,5**
**Million**
**@R7.50**

**R3.2**
**Million**
**@R5.30**

**600 000**
**Pieces**

**1.3 Mil**
**Pieces**

**Distribution in**
**millions of pieces**

**Investment in **
**millions of Rand**

**Projected cost**

**Projected **
**distribution pieces **

**FY2000**

**FY2001**

**FY2002 **

**Fiscal Year Distribution / Cost**

**Condom  Pieces / Millions of Rands**

**5**

**10**

**15**

**20**

- Source*: *Wilson J, N DOH Logistics

**National HIV/AIDS Prevention Programme: **
**Increase in Female Condom distribution / Cost**

##  384 sequential condom recipients and their 5528      	condoms 

** ****Condoms after 5 weeks:**
**	****	****	****	*****- 43.7% had been used***
***	******	******	******	******- 21.8% had been given away***
***	******	******	******	******- 8.5% had been lost or discarded***
***	******	******	******	******- 26.0% were still available for use***
** ****Wastage at 5 weeks is less than 10%. **
** ****Extrapolating these data: at least 87 million condoms were ****	****used in sex in 2000**

*Source: *Myer L, Mathews C, Little F, Abdool Karim SS. The fate of free male condoms distributed to the public in South Africa. *AIDS* 2001;**15**: 789-793.

**The fate of free male condoms distributed to the **
**public in South Africa in 1999**

## Microbicides

**Microbicides**

## When

**When**
**Prevention**
**fails...**

## Tuberculosis caseload and antenatal HIV prevalence 

- Source: Hlabisa Hospital Records

**Tuberculosis caseload and antenatal HIV prevalence **
**in Hlabisa district**

## 54% of Medical in-patients were HIV+

**AIDS in King Edward Hospital -1998**

**54% of Medical in-patients were HIV+**
**84% of HIV+ met WHO AIDS case criteria**
**More women than men admitted**
**56% HIV+ co-infected with tuberculosis**
**Case fatality rates: HIV+ = 22%   vs   HIV- = 9%**

- Source: Colvin M, Dawood S, Kleinschmidt I, Mullick S, Lalloo U. Int J STD AIDS 2001, 386-389

## Age specific mortality rate

- 1996-1998
- 1999-2000

**AGE**

**Age specific mortality rate**
**1985 baseline for men**

- Source: Dorrington R, Bourne D, Bradshaw D, Laubscher R, Timæus IM. The Impact of HIV/AIDS on Adult Mortality in South Africa. MRC Technical Report.  2001

## Age specific mortality rate

- 0.000

- 0.500

- 1.000

- 1.500

- 2.000

- 2.500

- 3.000

- 3.500

- 15-19

- 20-24

- 25-29

- 30-34

- 35-39

- 40-44

- 45-49

- 50-54

- 55-59

- 60-64

**Age**

**Ratio**

- 1994

- 1996

- 1997/8

- 1998/99

- 1999/2000

**Age specific mortality rate**
**1985 baseline for women**

- Source: Dorrington R, Bourne D, Bradshaw D, Laubscher R, Timæus IM. The Impact of HIV/AIDS on Adult Mortality in South Africa. MRC Technical Report.  2001

##  Current epidemic in most of sub-Saharan Africa has 5 parallel effects:

**	****- ****Continuing large numbers of new HIV infections**
**	****- Ongoing high mother-to-child transmission rates**
**	****- Rising morbidity and its impact on health services**
**	****- Rapid rise in the number of deaths**
**	****- Increase in numbers of orphans**
** ****Both prevention and treatment needed, preferably in integrated delivery**

**Conclusion**

## In sub-Saharan Africa, women are more severely affected by the HIV epidemic

**Condom uptake & use –  continues to increase**** but there is a clear & urgent need for a woman controlled method**
**Microbicides have real potential to influence the course of the HIV epidemic**

**Conclusion cont..**