1. Salim S. Abdool Karim, MBChB, PhD and Quarraisha Abdool Karim, PhD

2. Salim S Abdool Karim, MBChB, PhD, is a clinical infectious diseases epidemiologist whose current research interests are in microbicides and vaccines to prevent HIV infection and implementation of antiretroviral therapy in resource constrained settings. Quarraisha Abdool Karim, PhD, is an infectious diseases epidemiologist whose current research interests are in understanding the evolving HIV epidemic in South Africa; factors influencing acquisition of HIV infection in adolescent girls; and sustainable strategies to introduce HAART in resource-constrained settings.

3. At the end of this lecture the student will: Be able to define transmission dynamics of HIV Have an understanding of the evolution of the HIV epidemic in South Africa through 5 distinct periods Know the distinct features of the South African HIV epidemic Gain knowledge of the essential interventions against HIV/AIDS.

4. Prevalence Prevalence - How much disease at a point in time - Existing infected people Implications for health impact Implications for health impact Indicates the need for health care Indicates the need for health care Incidence rate Incidence rate - New infections in those without the infection - Rate at which new infections are acquired over a period of time over a period of time More sensitive for assessing growth of epidemic More sensitive for assessing growth of epidemic Sensitive marker of effect of interventions Sensitive marker of effect of interventions

5. Source: Abdool Karim Q, Abdool Karim SS. South Africa: Host to a new and emerging HIV epidemic. Sex Trasm Inf 1999; 75: 139-140 Abdool Karim Q, Abdool Karim SS. Epidemiology of HIV infection in South Africa. AIDS 1999; 13: S4 - S7. About 10% of global burden of infection About 10% of global burden of infection Major and Minor epidemic Major and Minor epidemic Distinctive features of major epidemic Distinctive features of major epidemic - Prior to 1987 HIV infection rare in general pop - High prevalence - Highest rates of infection in young women - Predominantly subtype C

6. Source: National Department of Health, Pretoria, South Africa 0 10 20 30 40 19881990199219941996199820002002 HIV prevalence (%)

7. 1982 – First reported cases of AIDS 1982 – First reported cases of AIDS Epidemic largely limited to: Epidemic largely limited to: - Men who have sex with men - Transfusion recipients and - Haemophiliacs Clade B Clade B

8. YearProvinceGroupN% 1985KwaZulu NatalRural community4410 1986TransvaalMiners17 0210.01 TransvaalSex workers1 2000 1987KwaZulu NatalAntenatal women5000 Outpatient2680 Source: Abdool Karim SS. Making AIDS a notifiable disease- is it an appropriate policy for South Africa? S Afr Med J, 1999; 89: 609-611 Dusheiko GM. Regional prevalence of hepatitis B, delta, and human immunodeficiency virus infection in southern Africa: a large population survey. Am J Epidemiol. 1989; 129(1):138-45.

9. Source: Department of Health 0 10 20 30 40 19881990199219941996199820002002 HIV prevalence (%)

10. 0 <910-14 JUN/JUL 1992 Prevalence (%) 15-1920-2425-2930-3940-49 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

11. Source: Department of Health 0 10 20 30 40 19881990199219941996199820002002 HIV prevalence (%)

12. Year Person-months of follow-up Incidence Rate (%); 95% CI 1996/97996 16.8 (8.0-26.0) 19981644 18.2 (11.0-25.0) 1999780 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

13. Source: Williams BG, Gouws E, Wilkinson D, Abdool Karim SS. Estimating HIV from Age Prevalence data e epidemic situation. Statistic in Medicine 2000. YearNPrev(%)(95% CI)Incidence % 1992884 4.2 (3.0-5.7)2.0 1993709 7.9 (6.0-10.1)3.3 199531414.0 (10.4-18.4)7.1 1997473127.2 (25.9-28.5)10.2 1998316629.9 (28.4-31.6)10.5 1999300134.0 (32.5-35.7)10.3 200190636.1 (32.9-39.2)10.2

14. 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 Group1992199519982001 20-246.9%21.1%39.3%50.8% 25-292.7%18.8%36.4%47.2% 30-341.4%15.0%23.4%38.4% 35-390.0%3.4%23.0%36.4%

15. Source: Department of Health 0 10 20 30 40 19881990199219941996199820002002 HIV prevalence (%)

16. Source: Dept. Health – 12th National HIV and Syphilis Sero-prevalence survey of women attending public antenatal clinics in South Africa 2001 0 10 20 30 40 KwaZulu- Natal Mpumalanga Gauteng Free State North West East Cape Limpopo Northern Cape Western Cape Province Prevalence (%) 1999 2000 2001

17. Source: Hlabisa Hospital Records

18. 54% of Medical in-patients were HIV+54% of Medical in-patients were HIV+ 84% of HIV+ met WHO AIDS case criteria84% of HIV+ met WHO AIDS case criteria 56% HIV+ co-infected with tuberculosis56% HIV+ co-infected with tuberculosis Case fatality rates: HIV+ = 22% vs HIV- = 9%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

19. 15-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-69 1996-1998 1999-2000 AGE 0 50 100 150 200 250 300 350 PERCENTAGE OF 1985-1990 AVERAGE 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

20. 0.000 0.500 1.000 1.500 2.000 2.500 3.000 3.500 15-1920-2425-2930-3435-3940-4445-4950-5455-5960-64 Age Ratio 1994 1996 1997/8 1998/99 1999/2000 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

21. Current epidemic phase has 5 parallel effects: Current epidemic phase 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 - Rapidly rising deaths - Increase in numbers of orphans Essential to intervene with: Essential to intervene with: - Prevention of new infections - PMTCT programmes - Care including OI prophylaxis and ARV treatment - Social services for families impacted by AIDS deaths - Programs and social services for orphans

22. HIV affecting mainly young women in SA, highlighting the importance of: HIV affecting mainly young women in SA, highlighting the importance of: - interventions targeting youth - addressing gender inequity - greater involvement of men in prevention programs South Africa is experiencing a devastating epidemic South Africa is experiencing a devastating epidemic

23. Sources of Data Sources of Data - National Department of Health, Pretoria, South Africa - Debbie Bradshaw, South African Medical Research Council - Rob Dorrington, University of Cape Town - Brian Williams, WHO, Geneva - Eleanor Gouws, WHO, Geneva - Cheryl Baxter, CAPRISA