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; and Glenn 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
1983
1984

5. Modes & probabilities of HIV transmission
Type of Exposure
Estimated risk per 1000 exposures
Parenteral
Blood Transfusion
900
Needle-sharing during injection drug use 7
Percutaneous (needle-stick) 3
Sexual
Receptive anal intercourse 5
Receptive peno-vaginal intercourse 1
Insertive anal intercourse
Insertive peno-vaginal intercourse
0.5
Unprotected sex with HIV-infected individuals on ART
<0.13
Mother to child
Without prevention measures
250
With prevention measures including ARV prophylaxis 10
Source: adapted from

6. Global AIDS response – first 25 years
Millions 50 45 40 35 30 25 20 15 10 5
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 6

7. Global AIDS response – first 25 years
First cases of unusual immune deficiency are identified among gay men in the USA June 1981
First regimen to reduce MTCT of HIV
Global Fund to fight AIDS, TB and Malaria
Acquired Immune Deficiency Syndrome (AIDS) defined
WHO and UNAIDS launch the "3 x 5" initiative
Millions
HAART launched 50 45 40 35 30 25 20 15 10 5
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 7

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 adults and 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. Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011
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)
-130
-60
-40
-20 20 40 60 80
100
Effectiveness (%)
Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011

13. Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011
Clinical trial evidence for preventing sexual HIV transmission – July 2011
Effect size
(95%CI)
HPTN 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)
-130
-60
-40
-20 20 40 60 80
100
Effectiveness (%)
Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011

14. Sexual transmission prevention
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 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 Coital microbicide for women
39% (6; 60)
RV144 - HIV vaccine
31% (1; 51)
MTN Daily microbicide for women
15% (-21; 40)
FEM-PrEP - Daily oral PrEP for women
6% (-52; 41)
-60
-20 20 40 60 80
100
Effectiveness (%)
Source: adapted from Abdool Karim SS. Lancet 2013

15. ARV prophylaxis HIV PREVENTION Male circumcision Treatment of STIs
Auvert B, PloS Med 2005
Gray R, Lancet 2007
Bailey R, Lancet 2007
Treatment of STIs
Grosskurth H, Lancet 2000
Microbicides
for women
Abdool Karim Q, Science 2010
Female Condoms
Male Condoms
HIV
PREVENTION
Grant R, NEJM 2010 (MSM)
Baeten J , NEJM 2012 (Couples)
Paxton L, NEJM 2012 (Heterosexuals)
Choopanya K, Lancet 2013 (IDU)
Oral pre-exposure prophylaxis
HIV Counselling and Testing
Coates T, Lancet 2000
Sweat M, Lancet 2011
Post Exposure
prophylaxis (PEP)
Scheckter M, 2002
Treatment for prevention
Cohen M, NEJM, 2011
Donnell D, Lancet 2010
Tanser, Science 2013
Behavioural Intervention
Abstinence
Be Faithful
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 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:

18. Annual number of voluntary medical male circumcisions, 2009–2012
Number of male circumcisions
Source: UNAIDS Global Report 2013

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

20. Needle exchange programs in selected countries, 2010 vs 2012
See if can include Indonesia and Australia
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
% 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
Rank
Country
% of people with HIV in the world 1
South Africa
18% 2
Nigeria 9% 3
India 6% 4
Kenya 5% 5
Mozambique 4% 6
Uganda 7
Tanzania 8
Zimbabwe 9
USA 10
Malawi 3%
Remaining countries
39%
33%
61%
Zambia
Source: UNAIDS Global Report 2014

25. Top 20 countries: People living with HIV
Zambia
South Africa
Nigeria
India
Kenya
Mozambique
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. HIV status, Retention in care & Adherence
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. The HIV burden in sub-Saharan Africa in 2013:
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, million new infections, 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
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
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
Placeholder map
N=437,025
This map shows the global burden of HIV among adult women sex workers up through There are data from 79 countries and over 430,000 women.
Source: Beyrer, et al, The Lancet, 2014.

34. HIV incidence in 18-35 year women in this community:
9.1 per 100 women-yrs (95% CI: )
Source: Abdool Karim Q et al, Science 2010
HIV incidence in year women in this community:
9.1%
HIV prevalence in young pregnant women in rural
South Africa ( )
Age Group
(Years)
HIV Prevalence
(N=1029)
≤16
8.4%
17-18
18.6%
19-20
25.4%
21-22
32.8%
23-24
44.8%
Source: Abdool Karim Q, 2014

35. % (95% Confidence Interval)
HIV prevalence in school boys & girls in rural South Africa (Grades 9 & 10)
Female (n= 1423)
2.6 ( )
6.1 ( )
13.6 ( )
24.7 ( )
Age Group (years)
HIV Prevalence (2010)
% (95% Confidence Interval)
Male (n=1252)
15
1.0 ( )
16-17
1.1 ( )
18-19
1.5 ( )
≥20
1.8 ( )
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
F18-A +
M21-C
F14-C +
community
person
School C
F21-A + F16-A
F17-B + M20-C
School B
F21-B = Female, 21 years, from School B
M20-C = Male, 20 years, from School C
Green colour = 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 elimination and eradication not 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. Next: Epidemic control in all age groups
There is already a Global Plan for the elimination of new HIV infections in 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. Know your local epidemic!
What will it take to reach epidemic control?
Know your local epidemic!
Know your Hotspots & Key Populations

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