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Deputy Vice-Chancellor (Research), University of Natal

HIV/AIDS and STIs in Women: the urgent need for an efficacious microbicide. 20 August 2003. Salim S. Abdool Karim. Deputy Vice-Chancellor (Research), University of Natal Director: CAPRISA - Centre for the AIDS Programme of Research in SA

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Deputy Vice-Chancellor (Research), University of Natal

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  1. HIV/AIDS and STIs in Women: the urgent need for an efficacious microbicide 20 August 2003 Salim S. Abdool Karim 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

  2. Worldwide HIV prevalence & incidence NUMBER OF PEOPLE LIVING WITH HIV/AIDS Adults 38.6 millionWomen 19.2 millionChildren under 15 years 3.2 million Total 42 million PEOPLE NEWLY INFECTED WITH HIV in 2002 Adults 4.2 millionWomen 2 millionChildren under 15 year 800 000 Total 5 million Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS epidemic update Dec2002

  3. Worldwide prevalence Eastern Europe & Central \Asia 1 200 000 Western Europe 570 000 North America 980 000 East Asia & Pacific 1 200 000 North Africa & Middle East 550 000 Caribbean 440 000 South & South-East Asia 6 000 000 Australia & New Zealand 15 000 Sub Saharan Africa 29 400 000 Latin America 1 500 000 Total: 42 million Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS epidemic update Dec2002

  4. HIV Infection in ANC attendees in South Africa 40 30 20 HIV prevalence (%) 10 0 1988 1990 1992 1994 1996 1998 2000 2002 Source: Department of Health

  5. Prevalence and incidence of HIV: Hlabisa clinic attendees 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.

  6. Age and gender distribution of HIV infection in South Africa 10 Male JUN/JUL 1992 Female 8 6 Prevalence (%) 4 2 0 <9 10-14 15-19 20-24 25-29 30-39 40-49 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

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

  8. Temporal trends in age-specific incidence rates of HIV infection in ANC attendees in Hlabisa 16 1998 14 2001 12 10 8 Incidence (%) 6 4 2 0 15-19 20-24 25-29 30-34 35-39 40-44 Total Age

  9. HIV incidence rates in a cohort of South African sex workers in the COL-1492 trial Source: Abdool Karim SS, Ramjee G and Gouws E – Data from COL-1492 trial

  10. 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.

  11. Sexually Transmitted Diseases: Burden in a Rural South African district All Women aged 15-49 years (N=55 974) No STI 42 031 75% Women with an STI Asymptomatic Symptoms Recognized At Least One STI 6 697 48% 13 943 25% Symptomatic No Treatment 7 246 52% 6 994 98% Inadequate Adequate Yes 88 35% 164 65% 252 2% 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

  12. South African HIV/AIDS prevention programme: Increase in male condom distribution / cost 400 Distribution in millions of pieces 358 Million 300 Investment in millions of Rand Condom Pieces / Millions of Rands Projected distribution pieces 267 Million 250 Million 200 Projected cost 100 R103,8m @R0,29c R61,4m @R0,23c R47,5m @R0.19c FY2000 FY2001 FY2002 Fiscal Year Distribution / Cost Source: Wilson J, N DOH Logistics

  13. National HIV/AIDS Prevention Programme: Increase in Female Condom distribution / Cost R18,5 Million @R7.50 20 Distribution in millions of pieces 15 Investment in millions of Rand Condom Pieces / Millions of Rands Projected distribution pieces 10 Projected cost R7 Million @R5.40 600 000 Pieces 1.3 Mil Pieces 2.5Mil Pieces 5 R3.2 Million @R5.30 FY2000 FY2001 FY2002 Fiscal Year Distribution / Cost Source: Wilson J, N DOH Logistics

  14. The fate of free male condoms distributed to the public in South Africa in 1999 • 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.

  15. Microbicides

  16. When • Prevention • fails…

  17. Tuberculosis caseload and antenatal HIV prevalence in Hlabisa district Source: Hlabisa Hospital Records

  18. 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

  19. 350 300 250 200 PERCENTAGE OF 1985-1990 AVERAGE 150 100 50 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 Age specific mortality rate 1985 baseline for men 1996-1998 1999-2000 AGE 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. Age specific mortality rate 1985 baseline for women 3.500 3.000 2.500 1994 1996 2.000 1997/8 Ratio 1998/99 1.500 1999/2000 1.000 0.500 0.000 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Age 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. Conclusion • 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

  22. Conclusion cont.. • 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

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