1. 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

2. 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 year800 000 Total5 million Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS epidemic update Dec 2002

3. Latin America 1 500 000 East Asia & Pacific 1 200 000 Eastern Europe & Central \Asia 1 200 000 Sub Saharan Africa 29 400 000 Australia & New Zealand 15 000 Caribbean 440 000 North America 980 000 North Africa & Middle East 550 000 Western Europe 570 000 South & South-East Asia 6 000 000 Total: 42 million Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS epidemic update Dec 2002

4. Source: Department of Health 0 10 20 30 40 19881990199219941996199820002002 HIV prevalence (%)

5. Source: Williams BG, Gouws E, Wilkinson D, Abdool Karim SS. Estimating HIV from Age Prevalence data e epidemic situation. Statistic in Medicine 2000. 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: 531-535. Source: Williams BG, Gouws E, Wilkinson D, Abdool Karim SS. Estimating HIV from Age Prevalence data e epidemic situation. Statistic in Medicine 2000. 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: 531-535. YearNPrev(%)(95% CI)Incidence % 1992884 4.2 (3.0-5.7)2.0 1993709 7.9 (6.0-10.1)3.3 199531414.0 (10.4-18.4)7.1 1997473127.2 (25.9-28.5)10.2 1998316629.9 (28.4-31.6)10.5 1999300134.0 (32.5-35.7)10.3 200190636.1 (32.9-39.2)10.2

6. 0 <910-14 JUN/JUL 1992 Prevalence (%) 15-1920-2425-2930-3940-49 2 4 6 8 10 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: 1535 - 1539

7. 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 Age Group1992199519982001 20-246.9%21.1%39.3%50.8% 25-292.7%18.8%36.4%47.2% 30-341.4%15.0%23.4%38.4% 35-390.0%3.4%23.0%36.4%

8. 0 2 4 6 8 10 12 14 16 15-1920-2425-2930-3435-3940-44Total Age Incidence (%) 1998 2001

9. Year Person-months of follow-up Incidence Rate (%); 95% CI 1996/97996 16.8 (8.0-26.0) 19981644 18.2 (11.0-25.0) 1999780 20.0 (9.0-31.0) Overall (1996-99)3420 18.2 (13.0-23.0) Source: Abdool Karim SS, Ramjee G and Gouws E – Data from COL-1492 trial

10. 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: 673-676.

11. All Women aged 15-49 years (N=55 974) All Women aged 15-49 years (N=55 974) Women with an STI Women with an STI Symptoms Recognized Symptoms Recognized Treatment Inadequate 8835% Adequate 16465% No 6 99498% Yes 2522% Asymptomatic 6 69748% Symptomatic 7 24652% No STI 42 03175% At Least One STI 13 94325% 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

12. Source: Wilson J, N DOH Logistics 300 200 FY2000 FY2001FY2002 400 R61,4m @R0,23c Fiscal Year Distribution / Cost Condom Pieces / Millions of Rands R47,5m @R0.19c 250 Million 100 267 Million R103,8m @R0,29c Distribution in millions of pieces Investment in millions of Rand Projected cost Projected distribution pieces 358 Million

13. R7 Million @R5.40 2.5MilPieces R18,5Million@R7.50 R3.2 Million @R5.30 600 000 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 5 10 15 20 Source: Wilson J, N DOH Logistics

14. 384 sequential condom recipients and their 5528 condoms 384 sequential condom recipients and their 5528 condoms Condoms after 5 weeks: Condoms after 5 weeks: - 43.7% had been used - 21.8% had been given away - 8.5% had been lost or discarded - 26.0% 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: 789-793.

15. Microbicides

16. WhenPreventionfails…

17. Source: Hlabisa Hospital Records

18. 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, 386-389

19. 15-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-69 1996-1998 1999-2000 AGE 0 50 100 150 200 250 300 350 PERCENTAGE OF 1985-1990 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

20. 0.000 0.500 1.000 1.500 2.000 2.500 3.000 3.500 15-1920-2425-2930-3435-3940-4445-4950-5455-5960-64 Age Ratio 1994 1996 1997/8 1998/99 1999/2000 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

21. 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

22. 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