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
www.aids2014.org
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
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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
www.aids2014.org
In the beginning….
….the first 25 years of HIV/AIDS
1981
Pneumocystis pneumonia Slim’s disease
1984
1983
www.aids2014.org
Modes & probabilities of HIV transmission
Estimated risk per
1000 exposures
Type of Exposure
Parenteral
•
Blood Transfusion
•
Needle-sharing during injection drug use
7
•
Percutaneous (needle-stick)
3
900
Sexual
•
Receptive anal intercourse
5
•
Receptive peno-vaginal intercourse
1
•
Insertive anal intercourse
1
•
Insertive peno-vaginal intercourse
•
Unprotected sex with HIV-infected individuals on ART
0.5
<0.13
Mother to child
•
Without prevention measures
250
•
With prevention measures including ARV prophylaxis
10
www.aids2014.org
Source: adapted from www.cdc.gov
Global AIDS response – first 25 years
Millions
50
45
40
35
30
25
20
15
10
5
People living with HIV
0
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
www.aids2014.org
Global AIDS response – first 25 years
First cases of unusual immune deficiency are
identified among gay men in the USA June 1981
Millions
Acquired Immune Deficiency Syndrome
(AIDS) defined
A heterosexual AIDS epidemic is
revealed in Africa
50
45
The first HIV antibody test
becomes available
35
Global Fund to fight
AIDS, TB and Malaria
HAART
launched
WHO and UNAIDS
launch the
"3 x 5" initiative
Brazil becomes the
first developing
country to provide
ART
HIV identified as
cause of AIDS May 1983
40
First regimen to
reduce MTCT of HIV
Global Network of People
living with HIV/AIDS (GNP+)
30
The WHO launches
the Global
Programme on AIDS
25
The first therapy for
AIDS - zidovudine/
AZT - is approved
for use in the USA
20
15
President Bush
announces
PEPFAR
UNAIDS
created
The UN General
Assembly Special
Session on HIV/AIDS
2010 International AIDS
Conference in Durban
10
5
People living with HIV
0
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
www.aids2014.org
Global number of people living with HIV
& number of HIV-related deaths: 1990-2005
5
Estimated number of people living
with HIV (Millions)
35
4
30
25
3
20
2
15
10
1
5
0
1990
www.aids2014.org
1995
2000
2005
Source: UNAIDS Global Report 2014
2010
0
2015
Estimated AIDS deaths (millions)
40
Global number of people living with HIV
& HIV-related deaths: Changes post-2005
5
Estimated number of people living
with HIV (Millions)
35
4
30
25
3
20
2
15
10
1
5
0
1990
www.aids2014.org
1995
2000
2005
Source: UNAIDS Global Report 2014
2010
0
2015
Estimated AIDS deaths (millions)
40
Global number of new HIV infections in
adults and children: 1990-2013
Number of new HIV infections
(Millions)
4,0
1 000
3,5
3,0
800
2,5
600
2,0
1,5
400
1,0
200
0,5
0,0
1990
www.aids2014.org
1995
2000
2005
2010
Source: UNAIDS Global Report 2014
0
2015
Estimated number new HIV
infections in children (thousands)
1 200
4,5
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
www.aids2014.org
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
www.aids2014.org
-60
-40
-20
0
20
40
60
Effectiveness (%)
Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011
80
100
Clinical trial evidence for preventing
sexual HIV transmission – July 2011
Effect size
(95%CI)
HPTN 052 - 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
www.aids2014.org
-60
-40
-20
0
20
40
60
Effectiveness (%)
Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011
80
100
Sexual transmission
prevention
Prevention
in IDUs
Clinical trial evidence for preventing
sex/IDU HIV transmission – July 2013
Effect size
(95%CI)
Bangkok Tenofovir Study - Daily oral PrEP for IDUs
49% (10; 72)
HPTN 052 - 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)
MTN 003 - Daily microbicide for women
15% (-21; 40)
FEM-PrEP - Daily oral PrEP for women
6% (-52; 41)
-60
www.aids2014.org
-20
0
20
Effectiveness (%)
Source: adapted from Abdool Karim SS. Lancet 2013
40
60
80
100
ARV
prophylaxis
Male
circumcision
Auvert B, PloS Med 2005
Gray R, Lancet 2007
Bailey R, Lancet 2007
Treatment of
STIs
Grosskurth H, Lancet 2000
Microbicides
for women
Female Condoms
Abdool Karim Q, Science 2010
Oral pre-exposure
prophylaxis
HIV
PREVENTION
HIV Counselling
and Testing
Grant R, NEJM 2010 (MSM)
Baeten J , NEJM 2012 (Couples)
Paxton L, NEJM 2012 (Heterosexuals)
Choopanya K, Lancet 2013 (IDU)
Post Exposure
prophylaxis (PEP)
Scheckter M, 2002
Male Condoms
Coates T, Lancet 2000
Sweat M, Lancet 2011
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
Total annual resources for AIDS in
low and middle income countries
Domestic (public and private)
International
18
16
USD (Billions)
14
12
10
8
6
4
2
0
2001
2002
2003
2004
2005
2006
2007
2008
www.aids2014.org
Source: UNAIDS 2012. Together we will end AIDS
2009
2010
2011
Scale-up of HIV counselling & testing
in selected countries, 2007 vs 2011
Proportion of adults who received
HIV counselling and testing (%)
70
50% ↑
2007
2011
60
50
40
6 fold ↑
2.5 fold ↑
3.5 fold ↑
4 fold ↑
30
20
10
0
Zimbabwe
www.aids2014.org
Lesotho
Swaziland
Source: www.unaids.org
Rwanda
Botswana
Annual number of voluntary medical
male circumcisions, 2009–2012
Number of male
circumcisions
1 800 000
1 600 000
1 400 000
1 200 000
1 000 000
800 000
600 000
400 000
200 000
0
2009
2012
18
www.aids2014.org
Source: UNAIDS Global Report 2013
Condom use at last sex among
MSM (%)
Condom use among MSM
in selected countries, 2007 vs 2011
100
2007
2011
80
60
40
20
0
Ukraine Vietnam Senegal Bahamas
www.aids2014.org
Cote Australia Thailand
d'Ivoire
Source: www.unaids.org
USA
Needle exchange programs in
selected countries, 2010 vs 2012
Number of syringes distributed per
person who injects drugs
250
2010
2012
200
150
100
50
0
Indonesia
www.aids2014.org
Afghanistan
Viet Nam
Tajikistan
Source: UNAIDS Global report 2013
Mauritius
Belarus
Increasing antiretroviral therapy
coverage by region
% ART
coverage
100
Number of people receiving ART increased
from ~2 million in 2005 to ~13 million in 2013
80
60
40
20
0
% of people eligible who are receiving ART
(based on 2010 WHO guidelines)
www.aids2014.org
Source: UNAIDS Global report 2013
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
www.aids2014.org
Source: UNAIDS Global Report 2014
2013 Global HIV epidemic at a glance
6,000 new
HIV
infections
each day
2 out of 3 new
HIV infections
are in subSaharan Africa
www.aids2014.org
Source: UNAIDS Global Report 2014
1 out of 3
new HIV
infections are
in youth
(15-24yr)
Top 10 countries: People living with HIV
Rank Country
1 South Africa
South Africa
Remaining countries
Nigeria
India
Kenya
Zambia
USA
% of people with
HIV in the world
18%
2 Nigeria
9%
3 India
6%
4 Kenya
5%
5 Mozambique
4%
6 Uganda
4%
7 Tanzania
4%
8 Zimbabwe
4%
9 USA
4%
Zambia
10 Malawi
3%
Mozambique
Uganda
Zimbabwe
Tanzania
Remaining
countries
www.aids2014.org
Source: UNAIDS Global Report 2014
39%
33%
61%
Top 20 countries: People living with HIV
1. South Africa
2.
Nigeria
3.
India
4.
Kenya
5. Mozambique
Top 20 for new HIV
infections differs
only by 2 countries
6. Uganda
7. Tanzania
8. Zimbabwe
9.
USA
10. Zambia
11. Malawi
12. China
13. Ethiopia
14. Russia
15. Brazil
Indonesia
16.
17. Cameroon
18. D.R.Congo
Thailand
19.
20. Cote d’Ivoire
14.7 million = 42%
21.5 million = 61%
Zambia
25.6 million = 73%
28 million = 80%
www.aids2014.org
Source: UNAIDS Global Report 2014
34 years on: AIDS is still far from over
3 Key Challenges
1. Dysfunctional health systems
– Failing to convert efficacious treatment & prevention
interventions fully for maximum effectiveness
2. Most new HIV infections now occur in Key
Populations – the highest prevention priority
–
–
–
–
Young women in Africa
Sex Workers
MSM & Transgender individuals
IDU
3. Stigma, discrimination & legislative hurdles
– Major obstacle to prevention & care
www.aids2014.org
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)
100%
100%
PLWH who know their HIV status
(HIV Testing)
45%
45%
PLWH receiving ART
(ART initiated in Eligibles)
39%
39%
PLWH with supressed viral load
29%
(Retained in care/good adherence) 29%
0%
20%
40%
People covered
www.aids2014.org
Source: Global AIDS report, 2014, UNIADS
60%
80%
100%
People no longer covered
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, 1.5 million new infections, 1.1 million deaths
www.aids2014.org
Sources: UNAIDS Global Report 2014 & Kaiser Foundation Report, 2013
HIV prevalence in new TB cases, 2012
~13% of 8.6 million new TB cases were in people with HIV
320 000 deaths were from HIV-associated TB
www.aids2014.org
Source: WHO TB Report 2013
MSM bear disproportionate
burden of the HIV epidemic
20
HIV prevalence in all adults
Percentage
1490%
980%
HIV prevalence in MSM
358%
1027%
15
10
330%
1220%
5
0
Western and
Central and
South and
North America
central Europe South America southeast Asia
www.aids2014.org
Source: Beyrer et al, The Lancet, 2012
Eastern
Europe and
central Asia
Sub-Saharan
Africa
HIV
prevalence
in MSM in
Africa
HIV prevalence
in MSM:
Range:
6% in Egypt
to
31% in Cape Town
www.aids2014.org
Source: Griensven et al. Current Opinion in HIV and AIDS 2009
HIV prevalence among
people who inject drugs
30
HIV prevalence (%)
25
Pakistan
20
15
10
5
0
2005
www.aids2014.org
2006
2008
Source: Mumtaz GR et al. PLoS Medicine; 2014
2011
Global HIV prevalence among adult
women sex workers, 2013
www.aids2014.org
Source: Beyrer, et al, The Lancet, 2014.
HIV incidence in
18-35 year women
in this community:
9.1%
HIV prevalence in
young pregnant
women in rural
South Africa (2009-2012)
Age Group HIV Prevalence
(Years)
(N=1029)
9.1 per 100 women-yrs
(95% CI: 7 - 12)
www.aids2014.org
Source: Abdool Karim Q et al, Science 2010
≤16
8.4%
17-18
18.6%
19-20
25.4%
21-22
32.8%
23-24
44.8%
Source: Abdool Karim Q, 2014
HIV prevalence in school boys & girls
in rural South Africa (Grades 9 & 10)
HIV Prevalence (2010)
% (95% Confidence Interval)
Age
Group
(years)
Male (n=1252)
Female (n= 1423)
15
1.0 (0.0 - 2.2)
2.6 (1.2 - 4.0)
16-17
1.1 (0.2 - 2.0)
6.1 (2.6 - 9.6)
18-19
1.5
≥20
(0 - 3.7)
13.6 (9.0 - 18.1)
1.8 (0 - 3.9)
24.7 (6.3 - 43.1)
www.aids2014.org
Source: Abdool Karim Q, et al Sex Transm Infect 2014
Phylogenetic analysis to identify HIV
transmission networks in rural SA schools
M13-A + M18-C
Gag gene (p17p24 fragment) sequences from 118
learners (88F & 30M) and 135 community sequences
F16-E
+
F18-E
F14-C +
community
person
F18-A
+
M21-C
School E
School D
Main Road
School C
F21-A + F16-A
F17-B + M20-C
F21-B = Female, 21 years, from School B
M20-C = Male, 20 years, from School C
Green colour = line linking cluster in map
School B
School A
www.aids2014.org
Source: Kharsany et al. AIDS Research & Human Retroviruses 2014
Stigma: Major impediment to HIV
prevention and treatment
www.aids2014.org
Source: UNAIDS Together we will end AIDS 2012
Stigma, discrimination & legislative hurdles
www.aids2014.org
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
www.aids2014.org
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
www.aids2014.org
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
www.aids2014.org
Source: Cremin I. et al. AIDS 2013
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
www.aids2014.org
Source: Kiragu K. UNAIDS 2013
What will it take to reach epidemic control?
Know your local epidemic!
Know your Hotspots & Key Populations
http://aidsvu.org/treatment-sites-or-care-services/hiv-testing-site-locator/
www.aids2014.org
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
www.aids2014.org
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
www.aids2014.org
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
www.aids2014.org