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 20 August 2003

NUMBER OF PEOPLE LIVING WITH HIV/AIDS Adults 38.6 million Women 19.2 million Children under 15 years3.2 million Total42 million PEOPLE NEWLY INFECTED WITH HIV in 2002 Adults4.2 million Women2 million Children under 15 year Total5 million Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS epidemic update Dec 2002

Latin America East Asia & Pacific Eastern Europe & Central \Asia Sub Saharan Africa Australia & New Zealand Caribbean North America North Africa & Middle East Western Europe South & South-East Asia Total: 42 million Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS epidemic update Dec 2002

Source: Department of Health HIV prevalence (%)

Source: Williams BG, Gouws E, Wilkinson D, Abdool Karim SS. Estimating HIV from Age Prevalence data e epidemic situation. Statistic in Medicine 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: Source: Williams BG, Gouws E, Wilkinson D, Abdool Karim SS. Estimating HIV from Age Prevalence data e epidemic situation. Statistic in Medicine 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: YearNPrev(%)(95% CI)Incidence % ( ) ( ) ( ) ( ) ( ) ( ) ( )10.2

0 < JUN/JUL 1992 Prevalence (%) 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:

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: Age Group %21.1%39.3%50.8% %18.8%36.4%47.2% %15.0%23.4%38.4% %3.4%23.0%36.4%

Total Age Incidence (%)

Year Person-months of follow-up Incidence Rate (%); 95% CI 1996/ ( ) ( ) ( ) Overall ( ) ( ) Source: Abdool Karim SS, Ramjee G and Gouws E – Data from COL-1492 trial

STDPrevalence (95% CI) (n=472) Incidence (95% CI) (n=198) T.Vaginalis36.1% (31.6; 40.6)114.0% (102; 126) N.Gonorrhoeae11.3% (8.4; 14.3)42.0% (34.8; 49.2 C.Trachomatis12.7% 9.4; 36.2)43.2% (34.8; 50.4) Syphilis31.9% (27.6; 36.2)- HIV51.3% (46.7; 55.8)18.2% (13.0; 23.0) 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:

All Women aged years (N=55 974) All Women aged years (N=55 974) Women with an STI Women with an STI Symptoms Recognized Symptoms Recognized Treatment Inadequate 8835% Adequate 16465% No % Yes 2522% Asymptomatic % Symptomatic % No STI % At Least One STI % 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

Source: Wilson J, N DOH Logistics FY2000 FY2001FY Fiscal Year Distribution / Cost Condom Pieces / Millions of Rands 250 Million Million Distribution in millions of pieces Investment in millions of Rand Projected cost Projected distribution pieces 358 Million

R7 2.5MilPieces R Pieces 1.3 Mil Pieces Distribution in millions of pieces Investment in millions of Rand Projected cost Projected distribution pieces FY2000FY2001FY2002 Fiscal Year Distribution / Cost Condom Pieces / Millions of Rands Source: Wilson J, N DOH Logistics

384 sequential condom recipients and their 5528 condoms 384 sequential condom recipients and their 5528 condoms Condoms after 5 weeks: Condoms after 5 weeks: % had been used % had been given away - 8.5% had been lost or discarded % were still available for use Wastage at 5 weeks is less than 10%. Wastage at 5 weeks is less than 10%. Extrapolating these data: at least 87 million condoms were used in sex in 2000 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:

Microbicides

WhenPreventionfails…

Source: Hlabisa Hospital Records

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 More women than men admittedMore women than men admitted 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,

AGE PERCENTAGE OF 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

Age Ratio /8 1998/ /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

Current epidemic in most of sub-Saharan Africa has 5 parallel effects: 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 Both prevention and treatment needed, preferably in integrated delivery

In sub-Saharan Africa, women are more severely affected by the HIV epidemicIn 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 methodCondom 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 epidemicMicrobicides have real potential to influence the course of the HIV epidemic