The evolving HIV

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
lt9
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
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
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
1.500
1998/99
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

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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