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The evolving HIV epidemic in South Africa. Salim S. Abdool Karim, MBChB, PhD and Quarraisha Abdool Karim, PhD. The authors.

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The evolving HIV

epidemic in South Africa

Salim S. Abdool Karim, MBChB, PhD

and

Quarraisha Abdool Karim, PhD


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.


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.


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


  • 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.


    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


    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


  • 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.


    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


    Age and gender distribution of HIV infection

    in South Africa

    10

    Male

    JUN/JUL 1992

    Female

    8

    6

    Prevalence (%)

    4

    2

    0

    <9

    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


    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


    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


    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.


    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


    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


    40

    1999

    2000

    2001

    30

    Prevalence (%)

    20

    10

    0

    Gauteng

    Limpopo

    Free State

    East Cape

    North West

    Mpumalanga

    Western Cape

    Northern Cape

    KwaZulu- Natal

    Province

    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


    Tuberculosis caseload and antenatal HIV prevalence

    in Hlabisa district

    Source: Hlabisa Hospital Records


    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


    350

    300

    250

    200

    PERCENTAGE OF 1985-1990 AVERAGE

    150

    100

    50

    0

    15-19

    20-24

    25-29

    30-34

    35-39

    40-44

    45-49

    50-54

    55-59

    60-64

    65-69

    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


    Age specific mortality rate

    1985 baseline for women

    3.500

    3.000

    2.500

    1994

    1996

    2.000

    1997/8

    Ratio

    1998/99

    1.500

    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


    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


    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


    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


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