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James Mcintyre & Glenda Gray James McIntyre & Glenda Gray Thirty years of AIDS July 3, 1981 A generation in the shadow of AIDS... AIDS in South Africa First South African publication: 1983: • two cases in homosexual men, • both died in 1982 AIDS in South Africa September 1986: “The present status of AIDS cases in the RSA is: (i) South African residents – 30 cases comprised of: homosexual/bisexual men (26), heterosexual (I), blood transfusion AIDS (I), and haemophiliacs (2); all these are white males;” R Sher, SAMJ, 1986 Thirty years of AIDS “.. has a new microbe arisen like a phoenix from the cauldron of evolution and flourished here and now because of the special social and sexual circumstances of the times?” Ruben Sher, SAMJ 1986 HIV in Soweto HIV at Baragwanath Maternity Hospital South Africa National Survey, 1990 to 2007 2008 - HIV prevalence among ANC attendees 35 35 30 PHRU Soweto PMTCT 30 service, 1987 25 25 20 20 15 15 10 10 5 5 0 0 19 19 19 19 19 19 19 20 20 20 20 19 19 19 19 19 20 20 20 20 87 89 91 93 95 97 99 01 03 05 07 90 92 94 96 98 00 02 04 06 Prevalence (%) Source: 1] PHRU, 2] SA Dept. of Health, 2008 Prevalence (%) 100 fold increase: from 1 in 300 to 1 in 3 over 20 years Setting the scene: ten years ago in 2002 • 1 in 5 South Africans estimated to be HIV infected • 1 million women give birth in SA • There is no uniform access to VCT • There is no uniform access to HIV related information during antenatal care • There is no access to ARV to prevent MTCT • There is no access to ARV in the public sector to treat HIV infection Sarafina II and Virodene "It has little more to say about the HIV virus than it's great fun to sleep with lots of partners and then you get Aids and then you die and go to heaven". Anonymous health worker, 1995 "The rationale of the MCC should be questioned. I surmise that the council is driven by other interests than concern for proper control of medicines". Kgalema Motlanthe, ANC Secretary General, Press conference , 6 March, 1998 accusing the MCC of ulterior motives in banning trials of Virodene Prevention of mother-to-child transmission Trends in reduction of MTCT: results over time 1994 1998 2000 2004: HAART ACTG Bangkok 076 AP/IP ZDV PHPT PHPT-2 ZDV ZDV + NVP 1998 35 HAART Abidjan AP/IP ZDV 2002 30 1999 Transmission (%) Transmission DITRAME +1 PETRA 25 ZDV + NVP AZT/3TC 20 1999 2003: 15 HIVNET 012 DITRAME +1.1 sdNVP ZDV/3TC+ NVP 10 5 0 3 4 5 6 7 8 9 0 1 2 3 4 5 6 9 9 9 9 9 9 9 0 0 0 0 0 0 0 9 9 9 9 9 9 9 0 0 0 0 0 0 0 1 1 1 1 1 1 1 2 2 2 2 2 2 2 USA & Europe Thailand Africa PHRU research contributions In search of a future…… The Soweto PMTCT Programme • First sub district wide PMTCT programme in the country – as a partnership between PHRU and Gauteng Health, established in 2000, ahead of the first government “pilot sites, grew out of the PHRU PMTCT research site, extending across Soweto in 2001 - 2002 • Initial support from Elizabeth Glaser Pediatric AIDS Foundation, French government Fonds de solidarité thérapeutique internional (FSTI) • From 2003, funding moved to direct funding from USAID to PHRU, and then moved to Anova from 2009 • Acknowledged as a leading flagship PMTCT programme in Africa MTCT at Chris Hani Baragwanath and Soweto • Antenatal VCT service since 1987 at CHBH • MTCT Research from 1993 • Phase 1 – Phase III trials * breastfeeding & HIV * PETRA * Emivirine phase I * SAINT * AI455-094: ddi/d4T/ddi+d4T * PEP (NVP vs ZDV) • Postpartum VCT for women who have not had access to antenatal testing now in place MTCT at Chris Hani Baragwanath and Soweto • NVP implementation programme at CHBH from July 2000 • Zola and Lillian Ngoyi Clinics added October 2000 and January 2001 • Additional 11 Soweto Community Health Centres added February 2002 Funded: EGPAF, FSTI, USAID, Gauteng Department of Health A unique focus on community and psycho-social support From the start of the services at Baragwanath, close links were established with emerging AIDS NGO’s Agreement from hospital management to have NGO’s work together with clinical staff in the antenatal clinic – unheard of at that time! Focus on community education and empowerment Linkages with NGO groups – SELAF, NACOSA and AIDS Consortium Emergence of HIVSA as major community support partner since 2002 Early success in the Soweto PMTCT programme In the original three sites from January to December 2001, 13 313 women were offered pre-test counselling of which 12 200 (91.6%) accepted VCT. Of these, 12 009 (98.4%) were tested, of which 3 741 (31.2%) were HIV positive. The number of women receiving their results was 10 436 (86.9%) with 71.3% (8 560) receiving their results on the same day as testing. Nevirapine was dispensed to 2 924 (78.2%) of the HIV positive women constituting 90.8% of those who received their results. Violari et al, XV International AIDS Conference,2004 Soweto PMTCT Service Jan – December 2001 13313 ANC attendances, 3741 HIV positive (28%) 14000 12000 10000 8000 6000 4000 2000 0 pre test vct test - hivpos NVP Soweto PMTCT Service Jan – December 2002 30064 ANC attendances, 8516 HIV positive (29.2%) Estimated proportion of positive women given Nevirapine: 72% 35000 30000 25000 20000 15000 10000 5000 0 ANC clinic visits Accepting VCT Post-test counselling HIV-positive Given Nevirapine Soweto PMTCT Service Jan – December 2003 29,648 ANC attendances, 8,527 HIV positive (30.2%) Estimated proportion of positive women given Nevirapine: 93% ANC clinic visits 30000 Accepting VCT 25000 Post-test counselling 20000 15000 HIV-positive 10000 Given Nevirapine 5000 0 NVP baby Soweto PMTCT Programme: Major achievements (Jan - Dec 2003) • 99% of the women took part in counselling • Majority of women (90%) in ANC have an HIV result • 92% of positive women received results • 86% of all positives received NVP • 50% of all infants receive NVP PMTCT – Soweto 2006 ANC clinic visits Accepting VCT Post-test counselling 35000 HIV-positive Post-test counselled 30000 9 9 NVP Mom 8 3 2 0 7 NVP baby 1 2 0 25000 0 9 3 3 2 Referred for CD4 test 20000 CD4 test done Received results 15000 CD4 < 200 Received results 10000 9 5 2 9 7 9 8 0 8 4 4 7 4 6 3 1 3 0 3 0 1 8 5000 7 3 9 9 7 4 8 8 6 8 7 7 4 0 5 29.4% women test HIV-positive 14.9% CD4 < 200 AIDS and politics: a new era in South Africa "Shall I repeat garlic, shall I talk about beetroot, shall I talk about lemon... ……these delay the development of HIV to Aids-defining conditions, and that's the truth." Health Minister Manto Tshabalala Msimang, 7 June 2006 “I would thoroughly endorse the role- out of antiretrovirals and any way we can accelerate that, the better” Health Minister Barbara Hogan, 26 September 2008 Back on track.... • South Africa has rapidly scaled up its prevention of mother to child HIV transmission (PMTCT) programmes. • By 2010, PMTCT was offered at 98% of health facilities with virtual universal coverage of mothers booking and delivering in health facilities. • In 2010, early transmission from mother to child was found to be 3.5 percent in South Africa, and only 1.1 percent of 4- to 8-week-old infants in the country were infected with HIV. Soweto: Cumulative PMTCT stats (2000-2011) 350 000 300 000 250 000 200 000 ANC visits 150 000 Women tested 100 000 Positive 50 000 0 2001 2002 2000 2003 2004 2005 2006 2007 2008 2009 2010 2011 Soweto PMTCT: Infections averted (2000 – 2011) 25000 20000 Estimated number of children infected with 15000 no intervention Infections averted 10000 5000 Estimated number of children infected 0 2001 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 With acknowledgements and thanks to all the staff of the Soweto PMTCT programme: clinic staff, PHRU staff, HIVSA staff and Anova staff, and to the Department of Health & donors who have made this possible over the last ten years, and changed the lives of mothers and children in Soweto .
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