The HIV and TB epidemics:Past lessons from future directions

Presented at the:Provincial Partnership Conference, Pietermartizburg

9 October 2009

Salim S. Abdool KarimPro Vice-Chancellor (Research): University of KwaZulu-Natal

Director: CAPRISAProfessor in Clinical Epidemiology, Columbia University

Adjunct Professor of Medicine, Cornell University

Overview

• Introduction

• The HIV and TB epidemics in South Africa

• South African achievements in AIDS and TB

• Key challenges in HIV/AIDS in KwaZulu-Natal

• The way forward:

– recommendations in the Lancet Series

• Working together

The evolving HIV epidemic in Africa

GhanaBenin

Data unavailable

0 - 0.99%

1 - 4.9%

5 - 9.9%

10 - 19.9%

≥20%

20031984 1994

Algeria

Mauritania

Morocco

SenegalMali

Niger

Burkina Faso

Cote D’Ivoire TogoLiberia

Sierra LeoneGuinea Bissau

GuineaChad

Cameroon

Nigeria

Central Afr Rep

LibyaEgypt

Sudan

EthiopiaSomalia

KenyaUganda

Zaire

Tanzania

Angola

ZambiaMozambique

Malawi

Zimbabwe

BotswanaNamibia

South Africa

Lesotho

Swaziland

GabonCongo

Western Sahara

Source: adapted from Abdool Karim SS. The African Experience. In: Kenneth Mayer and HF Pizer (eds) The AIDS Pandemic: Impact on science and society. 2005

Source: Stoneburner RL, Low-Beer D. Population –level HIV declines and behaviour risk avoidance in Uganda. Science 2004; 304: 714-718

Success against AIDS in Africa:The declining HIV epidemic in Uganda

HIV prevalence rates in pregnant women in Uganda from HIV prevalence rates in pregnant women in Uganda from 1985 to 20011985 to 2001

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

0

5

10

15

20

25

30

35

1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

HIV

Pre

vale

nce

(%

)H

IV P

reva

len

ce (

%)

HIV prevalence in pregnant women attending public antenatal clinics in South Africa 1989-2006

Initiation of the generalised epidemic

Rapid spread of HIV AIDS mortality phase

Failure against AIDS in AfricaThe HIV epidemic in South Africa

2008

Source: Abdool Karim Q, Abdool Karim SS, Singh B, Short R, Ngxongo S. AIDS 1992; 6: 1535-9

Age & gender distribution ofHIV infection in South Africa

00

<9<9 10-1410-14

Pre

vale

nce

(%

)P

reva

len

ce (

%)

15-1915-19 20-2420-24 25-2925-29 30-3930-39 40-4940-49

22

44

66

88

1010

FemaleFemaleMaleMale

>49>49

No data

1.0-4.9

5.0-9.9

10.0-14.9

15.0-19.9

20.0-24.9

>25

HIV Prevalence (%) 20001995

Western Cape

Eastern Cape

Northern Cape

North West

Free State

Mpumalanga

Northern ProvinceGauteng

KwaZuluNatal

2005

No data

1-10

11-20

21-30

31-40

41-50

>50

TB caseload (1000’s)

The HIV and TB epidemics in South Africa

The TB crisis in South Africa

• Annual TB case notification rate is: 720/100,000 (WHO - 940/100,000)

• In 2006, 341,165 TB cases in SA

• SA was ranked fourth worst in the world for TB

• TB drug resistance serious problem symptomatic of poor TB cure national cure rate = 57.7% MDR-TB cases = over 14,000 cases each year XDR-TB cases = >300 in KwaZulu-Natal

• Annual TB mortality increased 2.8-fold from 78/100,000 in 1990 to 218/100,000 in 2006

Selected TB indicators forSouth Africa in 2006

TB INDICATOR

Number of people living with TB 482,000

TB case notification rate 720/100,000

TB treatment

Number of new TB cases diagnosed 272,296

Proportion of TB cases cured (2005) 58%

# of cases completing TB treatment but without sputa to confirm cure (2005)

13%

Number of TB deaths 105,000

Selected AIDS indicators forSouth Africa in 2006

HIV INDICATOR

Number of people living with HIV in South AfricaHIV Prevalence

5,400,00029.3%

HIV prevention

Number of people receiving VCT testing in 2006/2007 1,610,775

Number of male condoms distributed 376 million

Number of female condoms distributed 3.6 million

Number of pregnant women who received nevirapine % of pregnant eligible women receiving nevirapine

186,64662%

HIV treatment

Number of patients initiating antiretroviral therapy Proportion of patients eligible for ART who received it

273,40035.8%

Number of AIDS deaths 345,640

Selected 2006 AIDS indicators for KwaZulu-Natal and South Africa

INDICATOR KZN NationalNumber of people living with HIV HIV Prevalence in women attending antenatal clinics

± 3 million37.4%

(35 - 39)

5,400,00029.1%

(28 - 29)HIV preventionProportion of pregnant women eligible for nevirapine who received it 60% 62%

HIV treatmentNumber of patients initiating ART Proportion of patients eligible for antiretroviral therapy who received it

77,516

?

273,400

35.8%Number of AIDS deaths 113,082 345,640

HIV prevalence estimates by district among antenatal clinic attendees,

South Africa, 2007

Temporal trends in HIV prevalence in Temporal trends in HIV prevalence in ANC attendees in Vulindlela: 2001-2008ANC attendees in Vulindlela: 2001-2008

Year N Prev (%)

2001 349 32.4

2002 403 34.8

2003 225 40.8

2004 552 42.6

2005 361 37.4

2006 333 37.6

2007 361 34.4

2008 389 40.9

HIV + pregnant women who received ARVs to reduce the risk of MTCT

Source: Department of Health. Progress report on declaration of commitment on HIV and AIDS 2005. Pretoria, South Africa: South African Department of Health, 2008.

Number of Adults and Children on Comprehensive HIV/AIDS Treatment

South African TB/HIV achievements• Sustained increase in financial allocations to AIDS

Resources increased from R676 million to R3,6 billion

• Increase in male condom distribution and introduction of the female condom Male condoms increased from 8m (1994) to 376m (2006)

• Expansion of TB control efforts Surveillance for TB drug resistance has been enhanced The declaration of TB as a national emergency

• Research contributions in AIDS and TB Several great discoveries come from South Africa

• Scale up of the free AIDS Treatment programme Over 700,000 people in the public sector ART roll-out

HIV and TB in South Africa

• HIV and TB among the greatest challenges facing post-apartheid South Africa

• In 2007:

South Africa had 0·7% of world’s population, but 17% of the global burden of HIV infection, and one of the world’s worst TB epidemics, compounded by rising MDR and XDR-TB

HIV and TB in South Africa

• Social, economic and environmental conditions created by apartheid in form of overcrowded squatter settlements, migrant labour and deliberately under-developed health services created the milieu for HIV and TB to flourish

• During the Mbeki era, the response, characterised by denial, anti-science & obstruction, compounded the problem – 330,000 died needlessly during this time.

• However, the Zuma administration has created a dynamic new leadership that is ready and keen to address the challenges armed with the best available scientific information

• Decisive action is needed to implement evidence-based priorities to control HIV and TB

Priority action steps to achieve TB control in South Africa

1: improve TB cure rate: 58% to 85%

2: improve TB case detection rate: 62% to 70%

3: integration of HIV & tuberculosis services- 90% of HIV+ patients screened for TB- 90% of TB patients screened for HIV

4: identify and treat drug-resistant TB- 85% of re-treatment cases screened

Priority action steps for HIV prevention in South Africa

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

Priority action steps for HIV treatment in South Africa

1: scale-up HIV testing: 7% to 25% per annum

2: initiate ART in all patients with a CD4-cell count below 350 cells per µL

3: maintain viral suppression in patients on ART

4: integrate HIV prevention & treatment services

The paradox is poor health outcomes despite good policies and relatively

high health expenditure

A lack of health improvement despite major investments

5 main areas where contradictions help explain the discordance between high investments and poor outcomes

South Africa’s high burden of disease

Figure 2: National burden of diseaseData sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo. DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.

Population: 45 M

Percentage of total

22%

9%

6%

4%

4%

4%

3%

3%

3%

2%

2%

2%

2%

2%

2%

2%

1%

Figure 2: National burden of diseaseData sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo. DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.

Population: 48 MPopulation: 153 M

Population: 45 M

Percentage of total

22%

9%

6%

4%

4%

4%

3%

3%

3%

2%

2%

2%

2%

2%

2%

2%

1%

South Africa’s high burden of disease

Minister of Health Motsoaledi2009 Budget speech, Parliament

• Some factors contributing to problems in the health system:– lack of managerial skills within health institutions;– delayed response to quality improvement

requirements;– inability of individuals to take responsibility for their

actions;– poor disciplinary procedures and corruption;– significant problems in clinical areas related to training

and poor attitude of staff; and lastly– inadequate staffing levels in all areas

Lancet Series: Five key tasks

1. Leadership & stewardship

2. Effective & accountable managers at all levels

3. Planning, development & training for a service-driven and effectual health workforce

4. National Health Insurance

5. Innovative implementation of priority actions outlined in the Lancet series, such as PHC services, HIV prevention, MCH packages, etc

Working together to fight denial and stigma

Working together, we will not let AIDS take away our dream of freedom & prosperity