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The HIV and TB epidemics: Past lessons from future directions

The HIV and TB epidemics: Past lessons from future directions. Presented at the: Provincial Partnership Conference, Pietermartizburg 9 October 2009. Salim S. Abdool Karim Pro Vice-Chancellor (Research): University of KwaZulu-Natal Director: CAPRISA

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The HIV and TB epidemics: Past lessons from future directions

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  1. The HIV and TB epidemics:Past lessons from future directions Presented at the: Provincial Partnership Conference, Pietermartizburg 9 October 2009 Salim S. Abdool Karim Pro Vice-Chancellor (Research): University of KwaZulu-Natal Director: CAPRISA Professor in Clinical Epidemiology, Columbia University Adjunct Professor of Medicine, Cornell University

  2. Overview • Introduction • The HIV and TB epidemics in South Africa • South African achievements in AIDS and TB • Key challenges in HIV/AIDS in KwaZulu-Natal • The way forward: – recommendations in the Lancet Series • Working together

  3. The evolving HIV epidemic in Africa Morocco Algeria Western Sahara Libya Egypt Mauritania Mali Niger Senegal Benin Chad Burkina Faso Ghana Sudan Guinea Guinea Bissau Nigeria Sierra Leone Somalia Ethiopia Central Afr Rep Liberia Togo Cameroon Cote D’Ivoire Congo Uganda Kenya Gabon Zaire Tanzania Data unavailable Angola 0 - 0.99% Malawi Zambia Mozambique 1 - 4.9% Zimbabwe Namibia Botswana 5 - 9.9% South Africa Swaziland 10 - 19.9% Lesotho ≥20% 1984 1994 2003 Source: adapted from Abdool Karim SS. The African Experience. In: Kenneth Mayer and HF Pizer (eds) The AIDS Pandemic: Impact on science and society. 2005

  4. Success against AIDS in Africa: The declining HIV epidemic in Uganda HIV prevalence rates in pregnant women in Uganda from 1985 to 2001 Source: Stoneburner RL, Low-Beer D. Population –level HIV declines and behaviour risk avoidance in Uganda. Science 2004; 304: 714-718

  5. Failure against AIDS in AfricaThe HIV epidemic in South Africa 35 Initiation of the generalised epidemic Rapid spread of HIV AIDS mortality phase 30 25 20 HIV Prevalence (%) 15 10 5 0 2008 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 HIV prevalence in pregnant women attending public antenatal clinics in South Africa 1989-2006 Source: Data from South African Department of Health Antenatal Surveys . www.doh.gov.za/

  6. Age & gender distribution ofHIV infection in South Africa 10 Male Female 8 6 Prevalence (%) 4 2 0 <9 10-14 15-19 20-24 25-29 30-39 40-49 >49 Source: Abdool Karim Q, Abdool Karim SS, Singh B, Short R, Ngxongo S. AIDS 1992; 6: 1535-9

  7. 1995 Northern Province Gauteng Mpumalanga North West Free State KwaZulu Natal Northern Cape Eastern Cape Western Cape The HIV and TB epidemics in South Africa HIV Prevalence (%) 2000 2005 No data 1.0-4.9 5.0-9.9 10.0-14.9 15.0-19.9 20.0-24.9 >25 TB caseload (1000’s) No data 1-10 11-20 21-30 31-40 41-50 >50

  8. The TB crisis in South Africa • Annual TB case notification rate is: 720/100,000 (WHO - 940/100,000) • In 2006, 341,165 TB cases in SA • SA was ranked fourth worst in the world for TB • TB drug resistance serious problem symptomatic of poor TB cure • national cure rate = 57.7% • MDR-TB cases = over 14,000 cases each year • XDR-TB cases = >300 in KwaZulu-Natal • Annual TB mortality increased 2.8-fold from 78/100,000 in 1990 to 218/100,000 in 2006

  9. Selected TB indicators forSouth Africa in 2006

  10. Selected AIDS indicators forSouth Africa in 2006

  11. Selected 2006 AIDS indicators for KwaZulu-Natal and South Africa

  12. HIV prevalence estimates by district among antenatal clinic attendees, South Africa, 2007

  13. Temporal trends in HIV prevalence in ANC attendees in Vulindlela: 2001-2008

  14. HIV + pregnant women who received ARVs to reduce the risk of MTCT Source: Department of Health. Progress report on declaration of commitment on HIV and AIDS 2005. Pretoria, South Africa: South African Department of Health, 2008.

  15. Number of Adults and Children on Comprehensive HIV/AIDS Treatment

  16. South African TB/HIV achievements • Sustained increase in financial allocations to AIDS • Resources increased from R676 million to R3,6 billion • Increase in male condom distribution and introduction of the female condom • Male condoms increased from 8m (1994) to 376m (2006) • Expansion of TB control efforts • Surveillance for TB drug resistance has been enhanced • The declaration of TB as a national emergency • Research contributions in AIDS and TB • Several great discoveries come from South Africa • Scale up of the free AIDS Treatment programme • Over 700,000 people in the public sector ART roll-out

  17. HIV and TB in South Africa • HIV and TB among the greatest challenges facing post-apartheid South Africa • In 2007: South Africa had 0·7% of world’s population, but 17% of the global burden of HIV infection, and one of the world’s worst TB epidemics, compounded by rising MDR and XDR-TB

  18. HIV and TB in South Africa • Social, economic and environmental conditions created by apartheid in form of overcrowded squatter settlements, migrant labour and deliberately under-developed health services created the milieu for HIV and TB to flourish • During the Mbeki era, the response, characterised by denial, anti-science & obstruction, compounded the problem – 330,000 died needlessly during this time. • However, the Zuma administration has created a dynamic new leadership that is ready and keen to address the challenges armed with the best available scientific information • Decisive action is needed to implement evidence-based priorities to control HIV and TB

  19. Priority action steps to achieve TB control in South Africa 1: improve TB cure rate: 58% to 85% 2: improve TB case detection rate: 62% to 70% 3: integration of HIV & tuberculosis services - 90% of HIV+ patients screened for TB - 90% of TB patients screened for HIV 4: identify and treat drug-resistant TB - 85% of re-treatment cases screened

  20. Priority action steps for HIV prevention in South Africa 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

  21. Priority action steps for HIV treatment in South Africa 1: scale-up HIV testing: 7% to 25% per annum 2: initiate ART in all patients with a CD4-cell count below 350 cells per µL 3: maintain viral suppression in patients on ART 4: integrate HIV prevention & treatment services

  22. A lack of health improvement despite major investments • 5 main areas where contradictions help explain the discordance between high investments and poor outcomes The paradox is poor health outcomes despite good policies and relatively high health expenditure

  23. South Africa’s high burden of disease Percentage of total 22% 9% 6% 4% 4% 4% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 1% Population: 45 M Figure 2: National burden of disease Data sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo. DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.

  24. South Africa’s high burden of disease Percentage of total 22% 9% 6% 4% 4% 4% 3% 3% 3% 2% 2% 2% 2% 2% 2% 2% 1% Population: 153 M Population: 48 M Population: 45 M Figure 2: National burden of disease Data sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo. DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.

  25. Minister of Health Motsoaledi2009 Budget speech, Parliament • Some factors contributing to problems in the health system: • lack of managerial skills within health institutions; • delayed response to quality improvement requirements; • inability of individuals to take responsibility for their actions; • poor disciplinary procedures and corruption; • significant problems in clinical areas related to training and poor attitude of staff; and lastly • inadequate staffing levels in all areas

  26. Lancet Series: Five key tasks • Leadership & stewardship • Effective & accountable managers at all levels • Planning, development & training for a service-driven and effectual health workforce • National Health Insurance • Innovative implementation of priority actions outlined in the Lancet series, such as PHC services, HIV prevention, MCH packages, etc

  27. Working together to fight denial and stigma

  28. Working together, we will not let AIDS take away our dream of freedom & prosperity

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