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The evolving HIV epidemic in South Africa

The evolving HIV epidemic in South Africa. Salim S. Abdool Karim, MBChB, PhD and Quarraisha Abdool Karim, PhD. The authors.

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The evolving HIV epidemic in South Africa

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  1. The evolving HIV epidemic in South Africa Salim S. Abdool Karim, MBChB, PhD and Quarraisha Abdool Karim, PhD

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

  5. South Africa's HIV/AIDS epidemic • About 10% of global burden of infection • Major and Minor 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 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.

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

  7. Introduction of HIV in SA: Pre 1987 • 1982 – First reported cases of AIDS • Epidemic largely limited to: • - Men who have sex with men • - Transfusion recipients and • - Haemophiliacs • Clade B

  8. HIV infection in selected groups from 1985 - 1987 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. HIV Infection in ANC attendees in South Africa 40 30 HIV prevalence (%) 20 10 0 1988 1990 1992 1994 1996 1998 2000 2002 Source: Department of Health

  10. 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

  11. 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

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

  13. 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.

  14. 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

  15. 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

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

  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 • 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 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: • - 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. Conclusion • 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

  23. Acknowledgements • 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

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