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HIV and AIDS Research in South Africa Prof Anthony D MBewu BA MBBS FRCP MD FMASSAf

HIV and AIDS Research in South Africa Prof Anthony D MBewu BA MBBS FRCP MD FMASSAf President The Medical Research Council Presentation to the Parliamentary Portfolio Committee

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HIV and AIDS Research in South Africa Prof Anthony D MBewu BA MBBS FRCP MD FMASSAf

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  1. HIV and AIDS Research in South Africa Prof Anthony D MBewu BA MBBS FRCP MD FMASSAf President The Medical Research Council Presentation to the Parliamentary Portfolio Committee on Science and Technology 29 August, 2006 http://www.mrc.ac.za

  2. Mandate of the MRC MRC Mandate Statutory Council - 37 years old, Act 58 of 1991 ‘the objects of the MRC are, through research, development and technology transfer, to promote the improvement of the health and quality of life of the population of the Republic, and to perform such functions as may be assigned to the MRC by or under this Act’. MRC Vision : ‘building a healthy nation through research’ MRC Mission : ‘to improve the nation’s health and quality of life through promoting and conducting relevant and responsive health research’

  3. 35% 30% Males 25% Females 20% Percentage 15% 10% 5% 0% 0-4 5-9 85+ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 75-79 80-84 10-14 65-69 70-74 Age group HIV prevalence levels by sex and age group in 2005

  4. Causes of Death in 2004 in South Africa Statistics South Africa 2005

  5. Top 10 causes of death, South Africa 2000National Burden of Disease Study, Total deaths 556 585 Source: Bradshaw et al., 2003

  6. HIV PREVENTION • Behavioural – ABC (Abstinence, Be faithful, Condomise) • Other technologies Barrier Methods Male and Female Condoms Management of STIs ARV for Prevention Other Prevention Technologies Vaccines Vaginal Diaphragms Male Circumcision PREP Vaginal Microbicides

  7. Objectives of the MRC HIV and AIDS Research Lead Programme • Coordination of MRC HIV AIDS research : 80 researchers in 10 research units; R 160 million p.a. • ensure correct prioritisation of research • avoid unnecessary duplication of research efforts • guide strategic fit of international research collaborations • facilitate translation of research results into policy

  8. Subthemes of the MRC HIV and AIDS Research Lead Programme • Behavioural Interventions • Epidemiological Studies • Clinical • Health Systems; Poverty; Intersectoral Interventions • Prevention of Mother to Child Transmission • Natural products and nutrition for immunemodulation • Vaccine development : SAAVI • Prevention technologies : vaginal microbicides • Bioinformatics and telehealth education • Novel Therapies : Biotechnology • Human development and Community Involvement • Evidence-based Medicine • Research Translation

  9. 1. Behavioural Intervention Sexually-related behaviours that result in exposure to the HIV virus are the main fuel for the epidemic in Africa : - unprotected sexual intercourse - multiple sexual partners - sexual intercourse during bouts of STI - late healthcare seeking behaviour These sexual behaviours are moulded by : • psychosocial determinants - such as self efficacy • environmental determinants - such as condom disposal • social determinants – such as the power relations between men and women and • economic determinants – such as poverty Consequently, any effective and sustainable programme of interventions to halt the HIV and AIDS epidemic is bound to be centred upon behavioural change With widespread awareness of AIDS, young South Africans seem to be taking steps to limit their exposure to the HIV (SADHS 1997; YRBS 2002; RHRU 2002; Antenatal Clinic Survey 2005)

  10. 2. Epidemiological Studies • Antenatal Clinic Survey 2005 : 5.54 million estimated to be HIV • positive (11.6%) in population of 47 866 984 • ASSA 2000 estimate 599 298 need treatment for AIDS according to SA • guidelines – 225 775 already on treatment (37%) • ASSA 2000 model : estimate 354 379 AIDS-related deaths in 2006 • Incidence (new infection rate) seems to be declining (521 607 in 2006, • 2% reduction over 2005 : ASSA) ; whilst deaths increasing • Life expectancy at birth was falling (50.7 in 2006) but may have increased • in past year due to 220 000 on treatment (Stats SA)

  11. 3. Clinical Research Antiretroviral therapy • Patients on comprehensive treatment including ARVs in Africa live for years with reduced episodes of opportunistic infection • South Africa has the largest Comprehensive Treatment Plan in the world with hundreds of thousands screened; and over 138 336 on treatment (total 220 000 on treatment of estimated 599 298 requiring treatment - ASSA). In 231 public health facilities. MRC chaired the Taskteam that wrote the Plan. • Monitoring and evaluation : quality of life, lifespan, side-effects • Treatment during acute infection? SPARTAC • Initiating antituberculous therapy? • Interaction with traditional medicines? • Fixed Dose Combinations • New therapeutic agents Cotrimoxazole • 30% reduction in death; 34% reduction in hospital admissions Multivitamins • 29% reduction in progression to Stage IV or death Traditional Medicines • Efficacy • Safety • Interactions with ARVs Opportunistic Infections

  12. Health Systems; Poverty; and Intersectoral Interventions In South Africa, infant mortality of 45.4 per 1000 relates to diseases such as gastroenteritis, respiratory infection – many of these being HIV positive infants - “Good Start” – PMCT Cohort and Infant Feeding Study ‘To prevent most of these unnecessary deaths could cost over R5 billion annually in terms of investment in housing, education, clean water, health clinics, healthworker training, nutritional supplements etc’ (MBewu et al 2000) Impact of AIDS on the economy : reduction of GDP growth by 0.4% in 2010 ? (Bureau for Economic Research, Univ of Stellenbosch)

  13. 5.Prevention of maternal-to-child transmission of HIV • The chances of an HIV positive mother transmitting the virus to the child during vaginal delivery is 21 - 43% • Nevirapine monotherapy reduces vertical transmission by 48% (95% CI 17% to 60%)

  14. 6. Natural Products and Nutrition for Immunemodulation • 80% of South Africans use Traditional Medicines • MRC animal toxicity studies; Phase I studies • Fawzi NEJM 2003 : multivitamins - 29% reduction in progression to Stage IV or death • Comprehensive Plan includes nutritional supplementation and multivitamins for both those with AIDS and those who are HIV positive

  15. 7. South African AIDS Vaccine Initiative • The most impressive HIV vaccine development programme in the developing world • Progress • Completed two Phase I clinical trials • Phase I trial with South African designed vaccine in 2006 • Phase II trial later this year • Phase III clinical trails within the next few years • Expected Outputs • effective, affordable locally relevant HIV vaccine • scientists plus the infrastructure of a sustainable vaccine biotechnology industry in South Africa.

  16. 8. Prevention Technologies : Microbicides, Circumcision • High number of HIV infections among women worldwide • Need for technologies to prevent sexual transmission of HIV • Male condoms – women not able to negotiate use with male • partners • A women-controlled method applied before sex that could kill, • neutralize, or block HIV and other sexually transmitted infections • Female condoms – costly and require a certain level of skill and • acceptance by male partners • Circumcision : ?60% reduction in HIV transmission

  17. CARRAGUARD CELLULOSE SULFATE 2% & 0.5% PRO2000 BUFFERGEL & 0.5% PRO2000 C31G (SAVVY) PHASE IIB/III MICROBICIDE TRIALS: GLOBALLY    Burkina Faso Nigeria   Cameroon Ghana  Uganda Benin Kenya  India Tanzania   Malawi  Zambia    Zimbabwe    Philadelphia, USA South Africa   

  18. PHASE IIB/III MICROBICIDE TRIALS: SOUTH AFRICA Johannesburg: RHRU Pretoria: MEDUNSA Cape Town: UCT Mtubatuba: Africa Centre Durban/Hlabisa: MRC Durban/Vulindlela: CAPRISA  Pretoria  Johannesburg   Hlabisa Mtubatuba    Durban  CARRAGUARD CELLULOSE SULFATE 2% & 0.5% PRO2000 BUFFERGEL & 0.5% PRO2000    Cape Town

  19. 9. Novel Therapies : Biotechnology • Fusion inhibitors – NCEs, natural products • ‘Bystander effect’ • Immunemodulators : African Traditional Medicines • Adjunctive therapies

  20. Human development and Community Involvement People/Organizations – directly/indirectly affected and participating in the research process e.g: • Individual/Partners/Family • Community Structures (NGOs/CBOs) • Service Providers • Stakeholders/Government Officials

  21. 11. Evidence-based Medicine • Treatment & prevention of oral candidiasis in HIV-infected adults & children • Balanced diet to reduce morbidity & mortality in HIV-infected adults • Micro-nutrient supplementation to reduce morbidity & mortality in HIV-infected • children and adults • Male circumcision for preventing transmission of HIV in heterosexual men • Behavioural interventions for reducing HIV risk and infection in employees in • occupational settings • Cotrimoxazole for prophylaxis of opportunistic infections in adults and children • Stavudine, Lamivudine & Nevirapine for reducing morbidity and mortality in HIV- • infected adults

  22. CONCLUSION Successful Prevention Strategy TREATMENT/ ARV/STI/ ANTIVIRAL BARRIER METHODS Leadership & scaling up oftreatment/prevention efforts BEHAVIOURAL MODIFICATION Community involvement MICROBICIDES & VACCINES MALE CIRCUMCISION Enhanced by synergistic use of social, behavioural, biomedical and barrier methods

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