Pro Vice-Chancellor (Research), University of KwaZulu-NatalDirector: CAPRISA - Centre for the AIDS Programme of Research in SA

Professor in Clinical Epidemiology, Columbia UniversityAdjunct Professor in Medicine, Cornell University

Presented at the:Council on Foreign Relations Global Health Meeting, Cape Town

21 January 2010

HIV prevention in South Africa:Is the NSP target of 50% reduction in HIV

incidence feasible? A response…

Salim S. Abdool Karim

Overview

• What is the 50% target?

• Why is the 50% target not attainable? Mature epidemic: High HIV prevalence drives high

HIV incidence Current HIV prevention strategies and tools do not

address prime source of new HIV infections Drivers of HIV epidemic in South Africa need long-

term structural solutions

• What is attainable?

• Conclusion

What is the 50% target?• Target HIV incidence in Durban(based on 7 studies):

Estimated in 2007 : ± 6 per 100 person-years NSP target in 2011 : ± 3 per 100 person-years

• Target 2011 HIV incidence for S. Africa? Unknown

Years of study Source of Data HIV incidence (per 100wy)

2003-2006 Diaphragm 7.0

2004-2007 Carraguard 5.9

2005-2007 Cellulose Sulphate 5.9

2005-2007 HPTN 035 4.9

2005-2009 MDP 301 6.1

2006-2008 CAPRISA 002 7.2

2006-2008 CAPRISA 050/051 6.4

Source: Data from South African Department of Health Antenatal Surveys . www.doh.gov.za/

Initiation of the generalised epidemic

Rapid spread of HIV AIDS mortality phase

Why is the 50% target not attainable?The mature HIV epidemic in South Africa

Mature epidemic: High HIV prevalence drives high incidence

Durban Women (STD clinic)

n=1259

Durban Sex Workers

n=776

HIV prevalence 59.3% 59.4%

HIV Incidence rate /100 p-yrs

6.4 7.2

14-19 yrs 17.2 26.1

20-24 yrs 5.4 8.9

≥25 yrs 4.4 5.2

Prime source of HIV infection:Inter-generational sex in young women

HIV

pre

vale

nce

(%)

• Existing proven HIV prevention strategies - ABCCC: Abstinence Behaviour Condoms Counselling and Testing Circumcision

• Which of these HIV prevention strategies address the vulnerability in young women?

Current HIV prevention does not address prime source of new HIV infections

Number of intervention trials or studies anywhere in the world that have demonstrated a reduction in HIV incidence in young women?

Zero

Drivers of HIV epidemic in South Africa need long-term structural

solutions

1. Sexual networking patterns

2. Migrant labour and migration

3. Gender inequity and gender violence

4. Self perception of risk

What is attainable?

• Implementation of priority action steps

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

• Concerted effort to find ways to reduce HIV in young women eg. a 50% effective strategy could put the NSP target within reach

Source: Abdool Karim SS, Churchyard G, Abdool Karim Q, Lawn S. Lancet 2009

Conclusion

• Target HIV incidence for the NSP is unknown

• The 50% target is not currently attainable

• We can, however, achieve: Scale-up and better quality implementation of

known effective HIV prevention strategies Search for new ways to reduce HIV incidence

in young women

• Make some progress towards the 50% target

• We should set a more realistic NSP prevention target