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22nd International Conference on AIDS and STIs in Africa,

Rainbow Towers, Harare, Zimbabwe

08 December 2023

Finding the missing targets: what more to do for HIV, Tuberculosis, STIs and Hepatitis?

Quarraisha Abdool Karim, PhD

Associate Scientific Director: CAPRISA

Professor in Clinical Epidemiology, Columbia University

Pro Vice-Chancellor (African Health): University of KwaZulu-Natal

President: The World Academy of Sciences

UNAIDS Special Ambassador: Adolescents and HIV

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Overview

  • Pathway to epidemic control or eradication

​

  • Measurable Goals

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  • Targets = Goals?

​

  • Closing gaps
    • Diagnostic, Treatment and Prevention Technologies
    • Human Rights Framework – leadership, inclusivity and structural inequalities
    • UHC and delivery systems

​

  • Conclusion

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Infectious Diseases�Good, available diagnostics

Effective Treatment 

Effective Cure

Effective Prevention  

Effective Vaccine

​

​

Effective service delivery systems

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Access

(Political will, policy, social mobilisation/global solidarity;

Affordability) 

​

Human rights approaches that address inequalities

​

​

​

​

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Low Endemicity

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Control

​

Elimination/

Eradication

​

​

Treatment & Prevention Technologies

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Infectious Diseases

Effective Treatment 

Effective Cure

Effective Prevention

Effective Vaccine

HIV, TB, STIs,

HBV, HCV

HIV, TB, STIs, HBV, HCV

HIV, TB, STIs

HBV, HCV

​

​

Effective UHC

Access for All/leave no one behind

HIV, TB, STIs, HBV

HCV

​

Access

(Political will, policy, social mobilisation/global solidarity; Affordability)

Nothing for us without us  

HIV, TB, STIs, HBV, HCV

​

​

Low Endemicity

HIV, TB, STIs

Control

HIV, TB, STIs

​

Elimination/

Eradication

HBV, HCV

​

HIV, TB, STIs, HBV, HCV

Treatment & Prevention Technologies

​

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Diagnostics, Prevention and Treatment essential - Combinations of strategies & testing appropriate to the situation – no one size fits all!

Testing: Value of a rapid point of care diagnostics

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TB Treatment – 60 years for new drugs

Short Description of the process

Start: Apr 20YY

Short Description of the process

Short description of the milestone

Start: may 20YY

Short description of the milestone

Start: jun 20YY

Short description of the group item

Start: dec 20YY

Short description of the process

Start: nov 20YY

2018

CDC recommends 3HP treatment if latent TB infection

Short description of the launch

Start: apr 20YY

1920

BCG vaccine against TB developed

1921

BCG vaccine against TB first medically used

2016

WHO END STRATEGY IMPLEMENTED

2012

FDA approves new medicine for treatment of multi-drug-resistant TB

2019

FDA approves new treatment for highly drug-resistant forms of TB

TB vaccine unveiled by scientists

1952

First oral mycobacterial drug developed

1882

Dr Robert Koch identifies causative agent of TB

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Overview

  • Pathway to epidemic control or eradication

​

  • Measurable Goals
  • Targets = Goals?

​

  • Closing gaps
    • Diagnostic, Treatment and Prevention Technologies
    • Human Rights Framework – leadership, inclusivity and structural inequalities
    • UHC and delivery systems

​

  • Conclusion

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UN 2030 Goals – HIV, TB, STIs, HBV, HCV �

HIV :

  • Zero new infections
  • Zero AIDS related threats
  • Zero Stigma and discrimination

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TB:

  • 95 % reduction in incidence (~1.02 million cases)
  • 90 % reduction in TB related deaths (~180,000)
  • 0 % facing TB related social/financial strain

​

STIs:

<150 million new cases of syphilis, gonorrhoea, chlamydia and trichomoniasis

  • (90% of girls with full HPV vaccination by 15 years)

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Hepatitis:

  • <170,000 new hepatitis B infections per year
  • <350,000 new hepatitis C infections per year
  • <310,000 deaths from HBV
  • <140,000 deaths from HCV

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2020 vs 2025 Targets – HIV, TB, STIs, HBV, HCV �

HIV : 2022: Globally 1,3 million New infections

(2025: <370,000)

SSA: 660,000 new infections

2022: Globally 630,000 AIDS-related deaths (2025: <250,000)

SSA: 380,000 deaths

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TB: 2022: 8.7 % reduction in incidence rates

(2025: 50 % reduction )

2022: 19 % reduction in TB related deaths

(2025: 75 % reduction)

2022: 49 % reduction in financial strain

(2025: 0 % )

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STIs: 2020: 374 million new cases of syphilis, gonorrhoea, chlamydia and trichomoniasis (15-49 years old)

(2025: <300 million )

2020: 15 % of girls vaccinated for HPV (15 years)

(2025: 50 %)

Hepatitis B and C:

2020: 1.5 million new HBV infections

( 2025 : 850, 000 )

2020: 1.57 million new HCV infections

(2025: 1 million )

2020: 820,000 HBV deaths

(2025: 530,000 HBV deaths)

2020: 290,00 deaths from HCV

(2025: 240,000 deaths from HCV)

​

​

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“Know your epidemic - Know your response”�Centrality of scientific evidence in the response

  • Data-driven plan for the response

HIV hotspots

Report

Covid-19 epidemic in South Africa

Hlabisa district, KwaZulu-Natal Tanser et al

IJE; 2009

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Progress with 90-90-90 &with recent developments in simplifying HIV treatment – impact on incidence rates?

New drugs with better safety profiles

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Tenofovir

Alafenamide

Simplified Regimens using Dual-Therapy

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Dolutegravir–based dual therapy

Long-acting monthly

dual injectable

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Cabotegravir + Rilpivirine

(Cabenuva)

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Source: UNAIDS 2021

  • Good global progress: 84-87-91

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  • 14 countries across 3 regions achieved the 73% target by 2020

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  • Uneven progress (2 regions <60%)
  • North Africa & Middle East: 36% → 73%
  • Eastern Europe & Central Asia: : 50% → 73%

Global HIV strategy built on TasP – 2025 target: 95-95-95

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Overview

  • Pathway to epidemic control or eradication

​

  • Measurable Goals

​

  • Targets = Goals?

​

  • Closing gaps
    • Diagnostic, Treatment and Prevention Technologies
    • Human Rights Framework – leadership, inclusivity and structural inequalities
    • UHC and delivery systems

​

  • Conclusion

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Infectious Diseases

Effective Treatment 

Effective Cure

Effective Prevention

Effective Vaccine

HIV, TB, STIs,

HBV, HCV

HIV, TB, STIs, HBV, HCV

HIV, TB, STIs

HBV, HCV

​

​

Effective UHC

Access for All/leave no one behind

HIV, TB, STIs, HBV

HCV

​

Access

(Political will, policy, social mobilisation/global solidarity; Affordability)

Nothing for us without us  

HIV, TB, STIs, HBV, HCV

​

​

Low Endemicity

HIV, TB, STIs

Control

HIV, TB, STIs

​

Elimination/

Eradication

HBV, HCV

​

HIV, TB, STIs, HBV, HCV

Treatment & Prevention Technologies

​

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Challenges in meeting targets in SSA

HIV

    • Access & Uptake of testing services
    • Stigma, Discrimination and Gender-based Violence
    • Having other STIs or STDs that increase HIV risk
    • Challenges achieving and sustaining viral suppression
    • Poor uptake and persistent use of PrEP
    • Patchy access to information; and available prevention and treatment treatments
    • Primary prevention efforts limited
    • Delays in access to PrEP choices
    • No Vaccine or Cure

TB

    • Access to health facilities and access to TB diagnostic services
    • Quality of diagnostics
    • Access to effective for treatment
    • Limited treatment success – MDR & XDR TB
    • High mortalty rates and high TB recurrence rates
    • Recent investments in innovation in diagnostic, treatment and vaccine development
    • BCG effective in preventing TB meningitis in children

STIs

    • Limited diagnostic screening
    • High AMR rates
    • Weak national health systems and policy development
    • Lack of accelerated research for prevention technologies
    • Recent investments in innovation in diagnostic, treatment and vaccine development
    • Lack of SRH services that incorporate STI care
    • Limited investments in STI care
    • POC diagnostics

Hepatitis

    • No vaccine or prophylaxis for HCV
    • Poor scale up of HBV vaccines or HCV treatment
    • High costs of HBV vaccines and Finances not being directed to necessary sectors
    • Poor diagnosis leads to increased transmission
    • Increase in PWID and PWUD populations

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Hepatitis B vaccine

  • HBV approved in 1981.
  • South Africa only adopted the vaccine in 1995 (14 years later!!!)
  • The vaccine was introduced in Ethiopia in 2007
  • Coverage rates in Africa remain low despite approval over 40 years ago

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Few countries with Birth dose HBV

Limited programmes in SSA despite the high prevalence of Hepatitis B. Only 7 out of 40 countries from the GAVI alliance have birth dose programmes.

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Consistent Political leadership & Community engagement: �“Do things with people - not on people”

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Challenge of behaviour change

  • Challenge of “Know - Do” gap

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  • Counterproductive scare tactics

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  • Importance of supporting behaviour change

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Striving for Universal Health Care�Access & Integration

Number of people receiving antiretroviral therapy: 2010–2019

AIDS 2000 conference

Galvanised the call for universal access to HIV treatment

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Scale up of oral PrEP and Implementation challenges

Sources: Shaefer R et al. Lancet HIV 2021; 8: e502–10; Irungu EM, Lancet Glob Health 2021; 9: e1730–39; San Francisco Department of Public Health. HIV epidemiology annual report, 2020

  • 70% of all MSM in San Francisco on PrEP in 2020

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  • PrEP scale-up → 43% ↓ in new diagnoses in 3 years

High rates of PrEP uptake in HIV discordant relationships but not in many others

  • High rates of discontinuation:
    • PrEP continuation was 57% at 1 month, 44% at 3 months & 34% at 6 months

PrEP needs to shift from a user-initiated service to a provider-initiated service (like pMTCT)

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Leaving no one behind!

3 Underlying principles:

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  1. Leave no one behind, fight stigma & inequality
  2. Evidence-based strategy
  3. Effective implementation targeted for priority areas

4 Key components:

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  1. Re-commit to TasP, but move beyond 95-95-95
  2. Provider-initiated PrEP
  3. Combination prevention using tools as needed

4. Continue to innovate

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Conclusion

  • In pandemics and epidemics, scientific evidence has importance in decision-making: providing guidance & challenging misinformation

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  • In AIDS, consistent political leadership strengthened responses; scientific evidence provided a path forward, e.g. with ARV treatment

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  • Equitable access is key to ensure everyone is safe and benefits from advances; Investments in research, infrastructure and health care delivery key
  • Important lessons on the costs of incomplete epidemics and pandemics - MDR and XDR TB; COVID-19 VoC, etc

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  • The HIV and Covid-19 pandemics have provided a new lens for the nexus between science, politics and global health as we pursue the path of the sustainable development goals

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A key lesson from HIV: Importance of mutual interdependence & shared responsibility

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  • Global solidarity – essential for access to life-saving medication, e.g. Global Fund & PEPFAR

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  • Shared responsibility: Countries where individuals see caring for fellow citizens as important do better than those where individuals focus on themselves first

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  • No-one is safe until everyone is safe!

“The AIDS movement demonstrates that with a shared vision, shared responsibility and through global solidarity… …we can change the course of history.”

– UNAIDS 2015