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  1. State of the Art: Epidemiology and Access Salim S. Abdool Karim Director: CAPRISA Chair: UNAIDS Scientific Expert Panel Pro Vice-Chancellor (Research): University of KwaZulu-Natal Associate Member, Ragon Institute of MGH, MIT and Harvard Professor in Clinical Epidemiology, Columbia University Adjunct Professor of Medicine, Cornell University

  2. A tribute to Joep Lange & all those on flight MH17 Clockwise from top left: MH17 flight path and crash point; Joep Lange; Jacqueline van Tageren; Lucie van Mens; Martine de Schutter; Pim de Kuijer; andGlenn Raymond Thomas

  3. Overview • In the beginning… the first 25 years of HIV/AIDS • A changing HIV/AIDS epidemic: Recent trends • Two key factors impacting HIV epidemiology: • Series of new HIV prevention research results • Growth in resources for scale-up of treatment and prevention • Ongoing challenges • Envisioning a future… • Conclusion

  4. In the beginning…. ….the first 25 years of HIV/AIDS 1981 Slim’s disease Pneumocystis pneumonia 1984 1983

  5. Modes & probabilities of HIV transmission Source: adapted from www.cdc.gov

  6. 50 45 40 35 30 25 20 15 10 5 0 Global AIDS response – first 25 years Millions People living with HIV 1980 ‘81 ‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 Source: UNAIDS 2008

  7. 50 45 40 35 30 25 20 15 10 5 0 Global AIDS response – first 25 years First regimen to reduce MTCT of HIV First cases of unusual immune deficiency are identified among gay men in the USA June 1981 Global Fund to fight AIDS, TB and Malaria Acquired Immune Deficiency Syndrome (AIDS) defined WHO and UNAIDS launch the "3 x 5" initiative HAART launched Millions A heterosexual AIDS epidemic is revealed in Africa Brazil becomes the first developing country to provide ART HIV identified as cause of AIDS May 1983 The first HIV antibody test becomes available Global Network of People living with HIV/AIDS (GNP+) The WHO launches the Global Programme on AIDS President Bush announces PEPFAR The first therapy for AIDS - zidovudine/ AZT - is approved for use in the USA The UN General Assembly Special Session on HIV/AIDS UNAIDS created 2010 International AIDS Conference in Durban People living with HIV 1980 ‘81 ‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 The chronology above summarises the ‘BIG Picture’ of AIDS – from the UNAIDS website Source: UNAIDS 2008

  8. Global number of people living with HIV & number of HIV-related deaths: 1990-2005 Source: UNAIDS Global Report 2014

  9. Global number of people living with HIV & HIV-related deaths: Changes post-2005 Source: UNAIDS Global Report 2014

  10. Global number of new HIV infections in adultsand children: 1990-2013 Source: UNAIDS Global Report 2014

  11. Overview • In the beginning… the first 25 years of HIV/AIDS • A changing HIV/AIDS epidemic: Recent trends • Two key factors impacting HIV epidemiology: • Series of new HIV prevention research results • Growth in resources for scale-up of treatment and prevention • Ongoing challenges • Envisioning a future… The End of AIDS as a public health threat • Conclusion

  12. Clinical trial evidence for preventing sexual HIV transmission – July 2010 Effect size (95%CI) Medical male circumcision 54% (38; 66) Mwanza - STD treatment 42% (21; 58) RV144 - HIV vaccine 31% (1; 51) Effectiveness (%) • Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011

  13. Clinical trial evidence for preventing sexual HIV transmission – July 2011 Effect size (95%CI) HPTN 052 - ART for prevention 96% (73; 99) PartnersPrEP- Daily PrEP for discordant couples 73% (49; 85) TDF2 - Daily PrEP for heterosexual men and women 62% (22; 84) Medical male circumcision 54% (38; 66) iPrEX- Daily PrEP for MSM 44% (15; 63) Mwanza - STD treatment 42% (21; 58) CAPRISA 004 – Coital microbicide for women 39% (6; 60) RV144 - HIV vaccine 31% (1; 51) Effectiveness (%) • Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011

  14. Clinical trial evidence for preventing sex/IDU HIV transmission – July 2013 Effect size (95%CI) Prevention in IDUs Bangkok Tenofovir Study - Daily oral PrEP for IDUs 49% (10; 72) HPTN 052 - ART for prevention 96% (73; 99) PartnersPrEP - Daily PrEP for discordant couples 73% (49; 85) TDF2 - Daily PrEP for heterosexual men and women 62% (22; 84) Medical male circumcision 54% (38; 66) Sexual transmission prevention iPrEX - Daily PrEP for MSM 44% (15; 63) Mwanza - STD treatment 42% (21; 58) CAPRISA 004 - Coital microbicide for women 39% (6; 60) RV144 - HIV vaccine 31% (1; 51) 15% (-21; 40) MTN 003 - Daily microbicide for women FEM-PrEP - Daily oral PrEP for women 6% (-52; 41) Effectiveness (%) • Source: adapted from Abdool Karim SS.Lancet 2013

  15. ARV prophylaxis Treatment of STIs Male circumcision Microbicides for women Grosskurth H, Lancet 2000 AuvertB, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007 Abdool Karim Q, Science 2010 Female Condoms Male Condoms HIV PREVENTION HIV Counselling and Testing Oral pre-exposure prophylaxis Coates T, Lancet 2000 Sweat M, Lancet 2011 Grant R, NEJM 2010 (MSM) Baeten J , NEJM 2012 (Couples) Paxton L, NEJM 2012 (Heterosexuals) Choopanya K, Lancet 2013 (IDU) Behavioural Intervention Post Exposure prophylaxis (PEP) Treatment for prevention • Abstinence • Be Faithful Scheckter M, 2002 Cohen M, NEJM, 2011 Donnell D, Lancet 2010 Tanser, Science 2013 Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included – this is on sexual transmission

  16. Total annual resources for AIDS in low and middle income countries Source: UNAIDS 2012. Together we will end AIDS

  17. Scale-up of HIV counselling & testing in selected countries, 2007 vs 2011 50% ↑ 2.5 fold ↑ 3.5 fold ↑ 6 fold ↑ 4 fold ↑ Source: www.unaids.org

  18. Annual number of voluntary medical male circumcisions, 2009–2012 Number of male circumcisions 1 800 000 1 600 000 1 400 000 1 200 000 1 000 000 800 000 600 000 400 000 200 000 0 2009 2012 Source: UNAIDS Global Report 2013

  19. Condom use among MSM in selected countries, 2007 vs 2011 Source: www.unaids.org

  20. Needle exchange programs in selected countries, 2010 vs 2012 Source: UNAIDS Global report 2013

  21. Increasing antiretroviral therapy coverage by region % ART coverage Number of people receiving ART increased from ~2 million in 2005 to ~13 million in 2013 100 80 60 40 20 0 % of people eligible who are receiving ART (based on 2010 WHO guidelines) Source: UNAIDS Global report 2013

  22. Despite impressive progress, the spread of HIV has yet to be controlled!In 2013, there were: 1.5 million HIV deaths 35 million living with HIV 2.1 million new infections Source: UNAIDS Global Report 2014

  23. 2013 Global HIV epidemic at a glance 6,000 new HIV infections each day 2 out of 3 new HIV infections are in sub-Saharan Africa 1 out of 3 new HIV infections are in youth (15-24yr) Source: UNAIDS Global Report 2014

  24. Top 10 countries: People living with HIV 33% 61% Zambia Source: UNAIDS Global Report 2014

  25. Top 20 countries: People living with HIV South Africa Nigeria India Kenya Mozambique Zambia Top 20 for new HIV infections differs only by 2 countries 14.7 million = 42% Uganda Tanzania Zimbabwe USA Zambia 21.5 million = 61% Malawi China Ethiopia Russia Brazil 25.6 million = 73% Indonesia Cameroon D.R.Congo Thailand Cote d’Ivoire 28 million = 80% Source: UNAIDS Global Report 2014

  26. 34 years on: AIDS is still far from over 3 Key Challenges • Dysfunctional health systems • Failing to convert efficacious treatment & prevention interventions fully for maximum effectiveness • Most new HIV infections now occur in Key Populations – the highest prevention priority • Young women in Africa • Sex Workers • MSM & Transgender individuals • IDU • Stigma, discrimination & legislative hurdles • Major obstacle to prevention & care

  27. ART scale-up: Health systems challenges in sub-Saharan African ART Programs: HIV status, Retention in care & Adherence People (≥15 years) living with HIV (PLWH) PLWH who know their HIV status (HIV Testing) PLWH receiving ART (ART initiated in Eligibles) PLWH with supressed viral load (Retained in care/good adherence) 100% 45% 39% 29% Source: Global AIDS report, 2014, UNIADS

  28. Sub-Saharan Africa’s disproportionate burden in the global HIV epidemic The HIV burden in sub-Saharan Africa in 2013: 25 million living with HIV, 1.5 million new infections, 1.1 million deaths Sources: UNAIDS Global Report 2014 & Kaiser Foundation Report, 2013

  29. HIV prevalence in new TB cases, 2012 ~13% of 8.6 million new TB cases were in people with HIV 320 000 deaths were from HIV-associated TB Source: WHO TB Report 2013

  30. MSM bear disproportionate burden of the HIV epidemic 358% 1027% 1490% 980% 330% 1220% Source: Beyrer et al, The Lancet, 2012

  31. HIV prevalence in MSM in Africa HIV prevalence in MSM: Range: 6% in Egypt to 31% in Cape Town Source: Griensven et al. Current Opinion in HIV and AIDS 2009

  32. HIV prevalence among people who inject drugs Pakistan Source: Mumtaz GR et al. PLoS Medicine; 2014

  33. Global HIV prevalence among adult women sex workers, 2013 Source: Beyrer, et al, The Lancet, 2014.

  34. HIV prevalence in young pregnant women in rural South Africa (2009-2012) HIV incidence in 18-35 year women in this community: 9.1% • 9.1 per 100 women-yrs(95% CI: 7 - 12) • Source: Abdool Karim Q et al, Science 2010 Source: Abdool Karim Q, 2014

  35. HIV prevalence in school boys & girls in rural South Africa (Grades 9 & 10) Source: Abdool Karim Q, et al Sex Transm Infect 2014

  36. Phylogenetic analysis to identify HIV transmission networks in rural SA schools Gag gene (p17p24 fragment) sequences from 118 learners (88F & 30M) and 135 community sequences School E M13-A + M18-C School D F16-E + F18-E Main Road F14-C + community person F18-A + M21-C School C F17-B + M20-C F21-A + F16-A School B F21-B = Female, 21 years, from School B M20-C = Male, 20 years, from School C Greencolour = line linking cluster in map School A Source: Kharsany et al. AIDS Research & Human Retroviruses 2014

  37. Stigma: Major impediment to HIV prevention and treatment Source: UNAIDS Together we will end AIDS 2012

  38. Stigma, discrimination & legislative hurdles

  39. Overview • In the beginning… the first 25 years of HIV/AIDS • A changing HIV/AIDS epidemic: Recent trends • Two key factors impacting HIV epidemiology: • Series of new HIV prevention research results • Growth in resources for scale-up of treatment and prevention • Ongoing challenges • Envisioning a future… The End of AIDS as a public health threat • Conclusion

  40. Choosing a future… The End of AIDS • “The End of AIDS” is an aspirational vision • Epidemiological concepts of eliminationand eradicationnot readily applicable to AIDS as millions are living with HIV and no cure available • Key step to “The End of AIDS” is epidemic control • Epidemic control - Reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate intervention measures • Point where HIV no longer represents a public health threat and no longer among the leading causes of country’s disease burden • Mathematically defined as the point at which the reproductive rate of infection (R0) is below 1

  41. Is HIV epidemic control achievable?Without a vaccine or cure? Status quo + 100% ART at CD4 200 + Circumcision + Early ART + PrEP Yes, HIV epidemic control is achievable! However, a vaccine or cure is essential for elimination Source: Cremin I. et al. AIDS 2013

  42. There is already a Global Planfor the elimination of new HIV infectionsin children by 2015 ! 37-40% reduction between 2009 & 2012 Only slightly off-track for 2015 target Next: Epidemic control in all age groups Source: Kiragu K. UNAIDS 2013

  43. What will it take to reach epidemic control? Know your local epidemic! Know your Hotspots & Key Populations http://aidsvu.org/treatment-sites-or-care-services/hiv-testing-site-locator/

  44. What will it take to reach the ambitious target of epidemic control? • Act on knowledge of detailed local epidemiology • Build on successes ….learn from failures ….implement to scale • As the HIV epidemic changes – so too should our programs & interventions. Adapt with the changes! • Target hotspots, pockets and key populations that continue to sustain high HIV incidence – will need combinations of appropriate prevention strategies • Deal with underlying drivers such as legal barriers, stigma & social norms simultaneously • Continued funding & greater program efficiency • Biomedical, socio-behavioural and implementation science, incl. new innovations – vaccine and cure

  45. Conclusion • Impressive progress in scientific discovery, resource mobilisation, political commitment & implementation: • created a favourable HIV trajectory in the last decade • Now is the time for stepping up the pace • Focused effort on Key Populations needed, esp. the largest high-risk group - young women in Africa • The world cannot afford to miss this historic “tipping” point & risk losing momentum against AIDS • There are many challenges but it should not deter us! • We won’t end AIDS tomorrow…. …. but it has to be part of our long-term vision

  46. Acknowledgements • UNAIDS • Eleanor Gouws, Mary Mahy& Juliana Daher • CAPRISA • Quarraisha Abdool Karim • Cheryl Baxter & Ayesha Kharsany • Carolyn Williamson (University of Cape Town) • Simon Travers (University of Western Cape) • Peter Piot (LSTHM) • Ward Cates (FHI360) • Ida Cremin & Timothy Hallett (UCL) • Chris Beyrer (Johns Hopkins University) • UNAIDS – Lancet Commission: Working Group 1