www.aids2014.org state of the art: epidemiology and access salim s. abdool karim director: caprisa...
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www.aids2014.org
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
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Clockwise from top left: MH17 flight path and crash point; Joep Lange; Jacqueline van Tageren;
Lucie van Mens; Martine de Schutter; Pim de Kuijer; andGlenn Raymond Thomas
A tribute to Joep Lange & all those on flight MH17
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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
Slim’s disease Pneumocystis pneumonia
1983
1984
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Modes & probabilities of HIV transmissionType of Exposure Estimated risk per
1000 exposures
Parenteral
•Blood Transfusion 900
•Needle-sharing during injection drug use 7
•Percutaneous (needle-stick) 3
Sexual
•Receptive anal intercourse 5
•Receptive peno-vaginal intercourse 1
•Insertive anal intercourse 1
•Insertive peno-vaginal intercourse 0.5
•Unprotected sex with HIV-infected individuals on ART <0.13
Mother to child
•Without prevention measures 250
•With prevention measures including ARV prophylaxis 10
Source: adapted from www.cdc.gov
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People living with HIV
Millions
50
45
40
35
30
25
20
15
10
5
0
1980 ‘81 ‘05‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04
Global AIDS response – first 25 years
Source: UNAIDS 2008
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People living with HIV
First cases of unusual immune deficiency are identified among gay men in the USA June 1981
HIV identified as cause of AIDS May 1983
First regimen to reduce MTCT of HIV
Brazil becomes the first developing
country to provide ART
The first HIV antibody test becomes available
A heterosexual AIDS epidemic is revealed in Africa
HAART launched
The WHO launches the Global
Programme on AIDS
Acquired Immune Deficiency Syndrome (AIDS) defined
The first therapy for AIDS - zidovudine/ AZT - is approved for use in the USA
Global Network of People living with HIV/AIDS (GNP+)
Global Fund to fight AIDS, TB and Malaria
UNAIDS created
Millions
50
45
40
35
30
25
20
15
10
5
0
1980 ‘81 ‘05‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04
Global AIDS response – first 25 years
The chronology above summarises the ‘BIG Picture’ of AIDS – from the UNAIDS website
WHO and UNAIDS launch the
"3 x 5" initiative
President Bush announces
PEPFAR
2010 International AIDS Conference in Durban
The UN General Assembly Special
Session on HIV/AIDS
Source: UNAIDS 2008
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1990 1995 2000 2005 2010 20150
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
40,000,000
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
Es
tim
ate
d n
um
be
r o
f p
eo
ple
liv
ing
w
ith
HIV
(M
illi
on
s)
Es
tim
ate
d A
IDS
de
ath
s (
mil
lio
ns
)
Global number of people living with HIV & number of HIV-related deaths: 1990-2005
Source: UNAIDS Global Report 2014
www.aids2014.org
1990 1995 2000 2005 2010 20150
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
40,000,000
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
Es
tim
ate
d n
um
be
r o
f p
eo
ple
liv
ing
w
ith
HIV
(M
illi
on
s)
Es
tim
ate
d A
IDS
de
ath
s (
mil
lio
ns
)
Global number of people living with HIV & HIV-related deaths: Changes post-2005
Source: UNAIDS Global Report 2014
www.aids2014.org
1990 1995 2000 2005 2010 20150.0
500,000.0
1,000,000.0
1,500,000.0
2,000,000.0
2,500,000.0
3,000,000.0
3,500,000.0
4,000,000.0
4,500,000.0
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
Nu
mb
er
of
ne
w H
IV i
nfe
cti
on
s
(Mil
lio
ns
)
Es
tim
ate
d n
um
be
r n
ew
HIV
in
fec
-ti
on
s i
n c
hil
dre
n (
tho
us
an
ds
)
Source: UNAIDS Global Report 2014
Global number of new HIV infections in adults and children: 1990-2013
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
Clinical trial evidence for preventing sexual HIV transmission – July 2010
Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011
Effectiveness (%)-130 -60 -40 -20 0 20 40 60 80 100
Effect size (95%CI)
31% (1; 51)RV144 - HIV vaccine
Mwanza - STD treatment 42% (21; 58)
Medical male circumcision 54% (38; 66)
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Clinical trial evidence for preventing sexual HIV transmission – July 2011
Effectiveness (%)-130 -60 -40 -20 0 20 40 60 80 100
Effect size (95%CI)
CAPRISA 004 – Coital microbicide for women
31% (1; 51)
iPrEX - Daily PrEP for MSM 44% (15; 63)
TDF2 - Daily PrEP for heterosexual men and women 62% (22; 84)
HPTN 052 - ART for prevention 96% (73; 99)
PartnersPrEP - Daily PrEP for discordant couples 73% (49; 85)
RV144 - HIV vaccine
39% (6; 60)
Mwanza - STD treatment 42% (21; 58)
Medical male circumcision 54% (38; 66)
Source: Adapted from Abdool Karim SS & Abdool Karim Q. Lancet 2011
www.aids2014.org Effectiveness (%)-60 -20 0 20 40 60 80 100
Effect size (95%CI)
MTN 003 - Daily microbicide for women 15% (-21; 40)
CAPRISA 004 - Coital microbicide for women
31% (1; 51)
iPrEX - Daily PrEP for MSM 44% (15; 63)
TDF2 - Daily PrEP for heterosexual men and women 62% (22; 84)
HPTN 052 - ART for prevention 96% (73; 99)
PartnersPrEP - Daily PrEP for discordant couples 73% (49; 85)
FEM-PrEP - Daily oral PrEP for women 6% (-52; 41)
Sexu
al tr
ansm
issi
on
prev
entio
nPr
even
tion
in ID
Us
Bangkok Tenofovir Study - Daily oral PrEP for IDUs 49% (10; 72)
RV144 - HIV vaccine
39% (6; 60)
Mwanza - STD treatment 42% (21; 58)
Medical male circumcision 54% (38; 66)
Source: adapted from Abdool Karim SS. Lancet 2013
Clinical trial evidence for preventing sex/IDU HIV transmission – July 2013
Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included – this is on sexual transmission
Behavioural Intervention- Abstinence- Be Faithful
HIV Counselling and Testing
Coates T, Lancet 2000Sweat M, Lancet 2011
Male Condoms
Female Condoms
Treatment of STIs
Grosskurth H, Lancet 2000
Male circumcision
Auvert B, PloS Med 2005 Gray R, Lancet 2007Bailey R, Lancet 2007
Treatment for prevention
Cohen M, NEJM, 2011Donnell D, Lancet 2010Tanser, Science 2013
Microbicidesfor women
Abdool Karim Q, Science 2010
Grant R, NEJM 2010 (MSM)Baeten J , NEJM 2012 (Couples)Paxton L, NEJM 2012 (Heterosexuals)Choopanya K, Lancet 2013 (IDU)
Oral pre-exposure prophylaxis
Post Exposure prophylaxis (PEP)
Scheckter M, 2002
ARVprophylaxis
HIVPREVENTION
www.aids2014.orgSource: UNAIDS 2012. Together we will end AIDS
Total annual resources for AIDS in low and middle income countries
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110
2
4
6
8
10
12
14
16
18
Domestic (public and private) International
US
D (
Bil
lio
ns
)
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Scale-up of HIV counselling & testing in selected countries, 2007 vs 2011
Source: www.unaids.org
Zimbabwe Lesotho Swaziland Rwanda Botswana0
10
20
30
40
50
60
70
2007 2011
Pro
po
rtio
n o
f ad
ult
s w
ho
rec
eive
d
HIV
co
un
sell
ing
an
d t
esti
ng
(%
)
4 fold ↑
6 fold ↑2.5 fold ↑ 3.5 fold ↑
50% ↑
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Annual number of voluntary medical male circumcisions, 2009–2012
18
Number of male circumcisions
Source: UNAIDS Global Report 2013
1 800 000
1 600 000
1 400 000
1 200 000
1 000 000
800 000
600 000
400 000
200 000
02009 2012
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Condom use among MSM in selected countries, 2007 vs 2011
Source: www.unaids.org
0
20
40
60
80
1002007 2011
Co
nd
om
use
at
last
sex
am
on
g
MS
M (
%)
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Needle exchange programs in selected countries, 2010 vs 2012
Source: UNAIDS Global report 2013
Indonesia Afghanistan Viet Nam Tajikistan Mauritius Belarus0
50
100
150
200
250
2010 2012
Nu
mb
er
of
sy
rin
ge
s d
istr
ibu
ted
pe
r p
ers
on
wh
o in
jec
ts d
rug
s
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Increasing antiretroviral therapy coverage by region
% ART coverage
% of people eligible who are receiving ART (based on 2010 WHO guidelines)
Source: UNAIDS Global report 2013
100
80
60
40
20
0
Number of people receiving ART increased from ~2 million in 2005 to ~13 million in 2013
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Despite impressive progress, the spread of HIV has yet to be controlled!
In 2013, there were:
Source: UNAIDS Global Report 2014
1.5 million HIV deaths
35 million living with HIV
2.1 million new infections
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Source: UNAIDS Global Report 2014
2 out of 3 new HIV infections
are in sub-Saharan Africa
1 out of 3 new HIV
infections are in youth(15-24yr)
6,000 new HIV
infections each day
2013 Global HIV epidemic at a glance
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Rank Country% of people with HIV in the world
1 South Africa 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%
10 Malawi 3%
Remaining countries 39%
South Africa
Nigeria
India
Kenya
Mozambique
Uganda
Tanzania
Zimbabwe
USA
Zambia
Remaining countries
Top 10 countries: People living with HIV
61%
Zambia
Source: UNAIDS Global Report 2014
33%
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Zambia
Top 20 countries: People living with HIVSouth Africa
NigeriaIndia
KenyaMozambique
14.7 million = 42%
6. 7. 8. 9. 10.
11. 12. 13. 14. 15.
16. 17. 18. 19. 20.
21.5 million = 61%
25.6 million = 73%
28 million = 80%
1. 2. 3. 4. 5.
UgandaTanzania
ZimbabweUSA
Zambia
MalawiChina
EthiopiaRussiaBrazil
IndonesiaCameroonD.R.Congo
ThailandCote d’Ivoire
Source: UNAIDS Global Report 2014
Top 20 for new HIV infections differs
only by 2 countries
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3 Key Challenges1. 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
34 years on: AIDS is still far from over
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ART scale-up: Health systems challenges in sub-Saharan African ART Programs:
Source: Global AIDS report, 2014, UNIADS
0% 20% 40% 60% 80% 100%
29%
39%
45%
100%
People covered People no longer covered
People (≥15 years) living with HIV (PLWH)
PLWH who know their HIV status (HIV Testing)
PLWH receiving ART (ART initiated in Eligibles)
PLWH with supressed viral load(Retained in care/good adherence)
100%
45%
39%
29%
HIV status, Retention in care & Adherence
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Sub-Saharan Africa’s disproportionate burden in the global HIV epidemicThe HIV burden in sub-Saharan Africa in 2013:
25 million living with HIV, 1.5 million new infections, 1.1 million deaths
Sources: UNAIDS Global Report 2014 & Kaiser Foundation Report, 2013
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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
Source: WHO TB Report 2013
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MSM bear disproportionate burden of the HIV epidemic
Source: Beyrer et al, The Lancet, 2012
0
5
10
15
20HIV prevalence in all adults HIV prevalence in MSM
Perc
enta
ge
1220%
1490% 980% 1027%
330%
358%
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HIV prevalence in MSM in
Africa
HIV prevalencein MSM:
Range:
6% in Egypt
to
31% in Cape Town
Source: Griensven et al. Current Opinion in HIV and AIDS 2009
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HIV prevalence among people who inject drugs
Source: Mumtaz GR et al. PLoS Medicine; 2014
2005 2006 2008 20110
5
10
15
20
25
30
HIV
pre
vale
nce
(%
)
Pakistan
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Global HIV prevalence among adult women sex workers, 2013
Source: Beyrer, et al, The Lancet, 2014.
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Age Group (Years)
HIV Prevalence(N=1029)
≤16 8.4%
17-18 18.6%
19-20 25.4%
21-22 32.8%
23-24 44.8%
HIV prevalence in young pregnant women in rural
South Africa (2009-2012)
Source: Abdool Karim Q, 2014
9.1 per 100 women-yrs (95% CI: 7 - 12)
Source: Abdool Karim Q et al, Science 2010
HIV incidence in 18-35 year women in this community:
9.1%
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Age Group (years)
HIV Prevalence (2010)% (95% Confidence Interval)
Male (n=1252)
15 1.0 (0.0 - 2.2)
16-17 1.1 (0.2 - 2.0)
18-19 1.5 (0 - 3.7)
≥20 1.8 (0 - 3.9)
Female (n= 1423)
2.6 (1.2 - 4.0)
6.1 (2.6 - 9.6)
13.6 (9.0 - 18.1)
24.7 (6.3 - 43.1)
HIV prevalence in school boys & girls in rural South Africa (Grades 9 & 10)
Source: Abdool Karim Q, et al Sex Transm Infect 2014
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Phylogenetic analysis to identify HIV transmission networks in rural SA schools
F21-B = Female, 21 years, from School BM20-C = Male, 20 years, from School CGreen colour = line linking cluster in map
F21-A + F16-A
F18-A + M21-C
M13-A + M18-C
F16-E +
F18-E
F17-B + M20-C
F14-C + community person
School A
School B
School C
School E
School D
Source: Kharsany et al. AIDS Research & Human Retroviruses 2014
Main Road
Gag gene (p17p24 fragment) sequences from 118 learners (88F & 30M) and 135 community sequences
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Stigma: Major impediment to HIV prevention and treatment
Source: UNAIDS Together we will end AIDS 2012
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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 Source: Cremin I. et al. AIDS 2013
Status quo
+ 100% ART at CD4 200
+ Circumcision
+ Early ART
+ PrEP
Is HIV epidemic control achievable?Without a vaccine or cure?
Yes, HIV epidemic control is achievable!However, a vaccine or cure is essential for elimination
www.aids2014.orgSource: Kiragu K. UNAIDS 2013
37-40% reduction between 2009 & 2012 Only slightly off-track for 2015 target
There is already a Global Planfor the elimination of new HIV infections
in children by 2015 !
Next: Epidemic control in all age groups
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http://aidsvu.org/treatment-sites-or-care-services/hiv-testing-site-locator/
Know your local epidemic! Know your Hotspots & Key Populations
What will it take to reach epidemic control?
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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
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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
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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