1. Pro Vice-Chancellor (Research), University of KwaZulu-Natal Director: CAPRISA - Centre for the AIDS Programme of Research in SA Professor in Clinical Epidemiology, Columbia University Adjunct Professor in Medicine, Cornell University Presented at the: Council on Foreign Relations Global Health Meeting, Cape Town 21 January 2010 HIV prevention in South Africa: Is the NSP target of 50% reduction in HIV incidence feasible? A response… Salim S. Abdool Karim

2. Overview What is the 50% target? Why is the 50% target not attainable?  Mature epidemic: High HIV prevalence drives high HIV incidence  Current HIV prevention strategies and tools do not address prime source of new HIV infections  Drivers of HIV epidemic in South Africa need long- term structural solutions What is attainable? Conclusion

3. What is the 50% target? Target HIV incidence in Durban(based on 7 studies):  Estimated in 2007 : ± 6 per 100 person-years  NSP target in 2011 : ± 3 per 100 person-years Target 2011 HIV incidence for S. Africa? Unknown Years of studySource of DataHIV incidence (per 100wy) 2003-2006 Diaphragm 7.0 2004-2007 Carraguard 5.9 2005-2007 Cellulose Sulphate 5.9 2005-2007 HPTN 035 4.9 2005-2009 MDP 301 6.1 2006-2008 CAPRISA 002 7.2 2006-2008 CAPRISA 050/051 6.4

4. Source: Data from South African Department of Health Antenatal Surveys. www.doh.gov.za/ Initiation of the generalised epidemic Rapid spread of HIVAIDS mortality phase Why is the 50% target not attainable? The mature HIV epidemic in South Africa

5. Mature epidemic: High HIV prevalence drives high incidence Durban Women (STD clinic) n=1259 Durban Sex Workers n=776 HIV prevalence59.3%59.4% HIV Incidence rate /100 p-yrs 6.47.2 14-19 yrs17.226.1 20-24 yrs5.48.9 ≥25 yrs4.45.2

6. Prime source of HIV infection: Inter-generational sex in young women HIV prevalence (%)

7. Existing proven HIV prevention strategies - ABCCC:  A bstinence  B ehaviour  C ondoms  C ounselling and Testing  C ircumcision Which of these HIV prevention strategies address the vulnerability in young women? Current HIV prevention does not address prime source of new HIV infections

8. Number of intervention trials or studies anywhere in the world that have demonstrated a reduction in HIV incidence in young women? Zero

9. Drivers of HIV epidemic in South Africa need long-term structural solutions 1.Sexual networking patterns 2.Migrant labour and migration 3.Gender inequity and gender violence 4.Self perception of risk

10. What is attainable? Implementation of priority action steps 1: “know your epidemic” (synthesis & meeting) 2: scale-up of behavioural, prevention of mother-to-child transmission, and HIV testing interventions 3: implement circumcision for HIV prevention 4: legislative interventions on sex work, gender violence, and migrant labour Concerted effort to find ways to reduce HIV in young women eg. a 50% effective strategy could put the NSP target within reach Source: Abdool Karim SS, Churchyard G, Abdool Karim Q, Lawn S. Lancet 2009

11. Conclusion Target HIV incidence for the NSP is unknown The 50% target is not currently attainable We can, however, achieve:  Scale-up and better quality implementation of known effective HIV prevention strategies  Search for new ways to reduce HIV incidence in young women Make some progress towards the 50% target We should set a more realistic NSP prevention target