1. GITA RAMJEE HIV Prevention Research Unit South African Medical Research Council “Meeting the Challenge of HIV/AIDS in South Africa: Exploring Future Strategy and Tactics to Expand the National Response.” “Meeting the Challenge of HIV/AIDS in South Africa: Exploring Future Strategy and Tactics to Expand the National Response.” COUNCIL ON FOREIGN RELATIONS Cape Town, 21 st January 2010 HIV PREVENTION

2. SOUTH AFRICAN NATIONAL STRATEGIC PLAN (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

3. SOUTH AFRICAN NSP FOR HIV/AIDS FOUR KEY PRIORITY AREAS TO REACH THE AIMS OF SA NSP PREVENTION TREATMENT, CARE & SUPPORT HUMAN & LEGAL RIGHTS MONITORING, RESEARCH & SURVEILLANCE

4. PRIORITY AREA 1: 50% REDUCTION IN HIV INCIDENCE BY 2011 PREVENTION 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/suppor t 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

5. 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?

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

7. HSRC SURVEY 2008 NSP 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) SUCCESSES CHALLENGES Ref: HSRC Report

8. HIV INCIDENCE IN COHORTS OF WOMEN FROM TRIALS UNDERTAKEN BY HPRU (MRC) Clinical TrialYears of studyCity/region N (non-intervention arm) HIV incidence in non-intervention arm (per 100wy) COL 1492 (Sex workers)1996-2000Durban9316.5 Cellulose Sulphate2005-2007Durban2955.9 Carraguard2004-2007Durban7265.9 Pretoria11583.3 Cape Town11103.0 Diaphragm2003-2006Durban7427 JHB5053.3 HPTN 0352005-2008Durban704*4.6* Hlabisa350*9.1* MDP 3012005-2009Durban8806.1 Mtubatuba4114.3 JHB8685 * * Overall

9. HIV PREVALENCE AND INCIDENCE IN OTHER GROUPS HIV prevalence HIV incidence/100WY 95% CI Reference Migrant men26% (Lurie, Williams et al. 2003a) Migrant couples (migrant man + non- migrant woman) 35% (Lurie, Williams et al. 2003b) Truck drivers56%- (Ramjee, Gouws et al. 2002) Women 25-29 years33%- (Shisana, Rehle et al. 2009) Rural women30.2%6.8 (4.2-9.4) (Caprisa 050/051, Caprisa 002) Urban women59.3%5.9 (1.2-10.7) (Caprisa 050/051, Caprisa 002) Commercial sex workers59.4%7.9 (4.1-9.6) (Caprisa 050/051, Caprisa 002) Risk factors for HIV seroconversion (Hazard ratio) Non-cohabiting women3.43 (95% CI 1.83-6.42) Ramjee et al. (unpublished) Women under 30 years4.0 (95% CI 1.4-11.7) Ramjee et al. (unpublished) Women with incident STIs Syphilis13.3 (95% CI 1.4, 128.9) Ramjee et al. (unpublished) Chlamydia8.2 (95% CI 2.6, 26.3) Gonorrhoea4.7 (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

10. STI PREVALENCE AT SOUTH AFRICAN SITES IN STUDIES UNDERTAKEN BY HPRU Clinical TrialsYears of studyCity/region NSTI prevalence at screening/enrolment COL 14921996-2000 Durban-- Cellulose Sulphate2005-2007 Durban295 * 18% * Carraguard2004-2007 Durban148521% Pretoria240224% Cape Town231531% Diaphragm2003-2006 Durban-Chlamydia 8.5%; Gonorrhoea 2.7% JHB-Chlamydia 6.9%; Gonorrhoea 1.1% HPTN 0352005-2007 Durban702Chlamydia 7%; Gonorrhoea 1%; HSV2 47%; Syphilis 2% Hlabisa346Chlamydia 8%; Gonorrhoea 1%; HSV2 47%; Syphilis 1% MDP 3012005-2009 Durban2391Chlamydia 12%; Gonorrhoea 3%; HSV2 56%; Syphilis 3% Mtubatuba1177Chlamydia 5%; Gonorrhoea 7%; HSV2 68%; Syphilis 7% JHB2499Chlamydia 12%; Gonorrhoea 3%; HSV2 46%; Syphilis 3% * STI Incidence

11. INCIDENCE OF NEW STI EPISODES TREATED AT PHC FACILITIES IN SA (2000-2006) Ref: DHIS, National Department of Health PROVINCEIncidence in percentage (%) 2000200120022003200420052006Average Eastern Cape6.26.04.85.46.35.46.05.6 Free State5.16.05.34.64.34.23.84.8 Gauteng5.34.95.04.43.63.24.24.4 KwaZulu-Natal109.08.47.87.16.97.28.1 Limpopo7.28.88.77.67.16.55.77.4 Mpumalanga5.27.15.84.75.14.85.15.4 Northern Cape2.93.73.84.24.13.63.43.7 North West8.07.36.55.8 4.94.56.1 Western Cape3.63.7 2.23.12.83.03.2 South Africa3.63.7 2.23.12.83.03.2 South Africa6.46.56.15.45.34.85.05.6

12. HIV PREVENTION Male circumcision Voluntary counseling and testing Prevention of MTCTHarm reduction programs for injecting drug use Prevention and treatment of STI Behavior change Condoms WHAT WORKS IN HIV PREVENTION

13. Prevention treatment of STI VCT, BEHAVIORIAL CHANGE AND CONDOM PROMOTION Voluntary counseling and testing HIV positive Transmission risk and other counseling Condom promotion Treatment of STI Partner reduction Mental health HIV preventionBehavior change Risk reduction counseling Condom promotion Condom promotion Treatment of STI Treatment of STI Partner reduction Partner reduction HIV negative Resources:  Medical Care  Targeted behavior counseling  Support counseling  Monitoring and evaluation

14. TRANSMISSION RISK BEHAVIORS OF HIV POSITIVE INDIVIDUALS HIV Viral Load CD4 Cell Counts (Fauci, Pantaleo, Stanley & Weismann, 1996) HIV 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 Risk Need targeted and tailored counseling POSITIVE PREVENTION:

15. Support HIV care centers Develop community based HIV care centers Treatment of OI CD4 monitoring HIV prevention trial sites or VCT site PARTNERSHIPS WITH PEPFAR IN MEETING THE GOALS OF THE NSP Partnership with local DOH Counseling and testing Partnership with PEPFAR COMMUNITY BASED Treatment for HIV STI treatment Positive Prevention DOH support monitoring and evaluation PEPFAR structural and human resources support

16. HEALTH 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

17. STRUCTURAL FACTORS AND INTERVENTIONS FOR HIV PREVENTION C. Bonell et al. Social Science and Medicine 63 (2006) 1136 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 support Women 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

18. RESEARCH ON OTHER HIV PREVENTION TECHNOLOGIES * 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.

19. WHAT IS NEEDED TO ACHIEVE THE GOALS OF THE 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

20. 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

21. 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.