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Initially working in HIV prevention, we broadened our focus in response to emerging trends in the HIV field. We now focus on most aspects of HIV-related work – medical prevention technologies (MPTs), structural drivers, improving approaches to care and treatment through health systems strengthening, treatment optimisation and developing models of care for key populations and marginalised groups.
We have responded to emerging trends in the field of HIV.
HIV care and treatment implementation
Although an estimated 6.8 million adults over the age of 15, and 340 000 children were living with HIV in South Africa in 2014 according to UNAIDS , with an adult HIV prevalence of 18.9% in 2014 and an antenatal seroprevalence of 29.5% in 2012, tremendous gains have been made over the past decade in HIV prevention and care. Elimination of mother-to-child transmission (eMTCT) strategies have reduced transmission rates in infants to less than 2.5% at six weeks, HIV counselling and testing (HCT) has become a priority, with increasing numbers of South Africans testing annually.
“It is hard not to call the last decade of antiretroviral (ARV) access anything other than a public health, human rights and political success. South African life expectancy has increased by a decade, almost entirely due to effective HIV treatment. HIV testing and condom usage rates are among the highest in the world, ” Wits RHI’s Professor Francois Venter. However, there are a few areas of care which remain important, including TB co-disease; treatment optimisation, particularly in the face of global economic restrictions and sustainability, and where complex HIV disease including drug resistance is problematic. Wits RHI continues to develop and lead programmes and research in all these areas.
South Africa has the largest ARV programme in the world, with 3.2 million people on treatment in December 2015. However, to meet the 90-90-90 goals, another 3 million people need to be initiated onto treatment and, with WHO test and treat guidelines being implemented in September 2016, treatment optimisation is more important than ever before.
ART is a significant driver of costs for programmes and finding ways to make HIV treatment simpler, more convenient, cost effective, and with the fewest side-effects, is a key component of our work. Wits RHI’s HIV treatment optimisation research agenda explores new and better ARVs and improved dosing and regimens. The D4T stavudine dose-reduction study ended in December 2015, with results due in mid-2016, and new projects aimed at improving first- and second-line regimens are starting soon.
Care and treatment in adolescents
The HIV epidemic continues to take a devastating toll with 2 500 young people newly infected every day. Thanks to the increased availability of antiretroviral treatment and HIV services, increasing numbers of children who acquired HIV perinatally are now reaching adolescence.
Wits RHI works with the NDoH and other key partners to ensure that HIV/AIDS care and treatment services are high quality, cost effective, and reach HIV-positive populations. Our clinicians, public health advisors, and health scientists provide ongoing technical expertise and we identify, evaluate and replicate innovative interventions that are low-cost, high impact approaches to service delivery.
Wits RHI also links HIV services to other healthcare services to strengthen the country’s healthcare system.
Care and treatment in adults
Wits RHI’s research portfolio is contributing to global evidence and cutting-edge research as part of an international response to the HIV epidemic. Despite outstanding achievements in which over 3 million people (December 2015) are accessing ART in South Africa, there are still an estimated one million in need of ART and an additional three million who are in need of care and support services. Increased access to ART and better TB diagnostics has renewed focus on complex case management.
Referral systems are being stressed by the large number of people being screened and initiated on ART, as well as the surge of multi-drug resistant (MDR)/extremely drug resistant (XDR) patients.
Wits RHI offers technical support to the DoH on DR TB and clinical support and mentoring at decentralised DR treatment sites within The City of Johannesburg Region F.
Care and treatment in children
HIV and TB in children remains a challenge. Children have limited options with regards to HIV and TB medication, and disease progression is often different to that of adults. According to the Elizabeth Glaser Pediatric AIDS Foundation, children with HIV are 20 times more likely to contract TB and UNAIDS estimates that 700 children worldwide become infected each day, and that almost half of them will die before their second birthday without ARV therapy.
Diagnosis of infant HIV and subsequent initiation onto ART is thus imperative to prevent disease progression and mortality. This is one of the major objectives of the Wits RHI paediatric team, which is working to strengthen health systems to better identify and care for children living with HIV and TB. Technical assistance, training and mentorship are provided to facilities in the districts where we operate, to increase their capacity to treat HIV-infected children and adolescents holistically.
Wits RHI’s paediatric clinical research team is located at the RHI Shandukani Research Centre in Hillbrow. Shandukani conducts research with the aim of decreasing the mortality and morbidity associated with HIV disease and infectious diseases in children, adolescents and pregnant women.
The team conducts clinical and network trials of new drugs and evaluates treatment regimens to guide the care and management of HIV-positive infants, children, and adolescents, with a particular interest in TB/HIV co-infected children. This is done in partnership with the International Maternal Paediatric Adolescent Aids Clinical Trials Group (IMPAACT). Shandukani provides secondary level and specialised health services for women, adolescents and children, and includes a 24-hour midwife-led obstetric unit.
HIV Prevention
HIV prevention is one of the biggest research challenges of our time. The highest burden of the global epidemic is in sub-Saharan Africa where there is a strong feminisation of the epidemic, with women comprising the majority of infected individuals (57%). In South Africa, a disproportionate number of young people infected with HIV are young women and girls between the ages of 15 and 24. They also have the highest prevalence rates in the world.
A major proportion of our HIV research work thus focusses on women, who have borne the brunt of the epidemic due to a complex mix of biological susceptibility, social and economic vulnerability and behavioural factors.
One of the most effective means of controlling the HIV epidemic in South Africa is through the implementation of targeted interventions among those populations most vulnerable to HIV. These key populations have been identified as a priority in the National Strategic Plan on HIV, STIs and TB 2012-2016. Our long history of community engagement has equipped us with a strong understanding of the context that places certain groups at risk and we have undertaken several projects to close this critical gap, driven by a firm belief that equitable and high quality health care services should be available to all.
Wits RHI’s prevention research portfolio includes studies considered among the most important for advancing the field of HIV prevention. Many of these trials focus on assessing ARV-based microbicides and include studies designed to evaluate microbicides along with other promising HIV prevention approaches, such as the daily use of ARVs as pre-exposure prophylaxis (PrEP).
All men and women have the right to quality reproductive health care and access to services such as family planning. In countries where resources are constrained and health systems are overburdened by diseases such as HIV and TB, it remains a challenge to develop reproductive health care strategies that are able to reach populations in need.
Evidence is needed from high quality studies to design and implement these strategies; a gap that Wits RHI is addressing through its research.
Every minute a woman dies from a complication of pregnancy or childbirth.
Some 80 million women each year have unintended or unwanted pregnancies. For too many their only option is abortion in unsafe conditions. Women, especially, need more choice and control over their sexual and reproductive lives.
Since inception, Wits RHI has focused on all aspects of sexual and reproductive health (SRH), including, in the early days, providing data to aid the debate on legalising termination of pregnancy; to actively supporting the conceptualisation, drafting and implementation of contraceptive policy; providing comprehensive training to public health professionals across the country in SRH; and, more recently, providing support to developing approaches to family planning and conception in the context of a generalised HIV epidemic.
We have a robust and expanding portfolio of work in women’s health which spans pre-conception and antenatal care, delivery and infancy. Our studies test new solutions aimed at encouraging women to attend antenatal care early with the benefits of early HIV diagnosis and antiretroviral initiation to prevent HIV transmission to infants, receive quality services and care throughout their pregnancies and deliver healthy babies.
Wits RHI also has a long-standing interest in the interactions between hormonal contraception, HIV and HIV treatment. In 2011, several studies were completed and/or published highlighting the influence of hormonal contraception on HIV transmission, as well as the potential effects of HIV treatment on contraceptive efficacy. Several new projects are also in development aimed at addressing these questions further.
Vaccines are one of the most powerful, cost-effective public health interventions, responsible for saving millions of lives and catalysing economic growth. Yet, in 2013, WHO estimated that a lack of access to established vaccines contributed to approximately two million childhood deaths worldwide.
In South Africa and the African region immunisation programmes do not always achieve the required uptake. The reasons for this are complex and include the inability of communities to access effective vaccines from health services, refusal of individuals and communities to accept vaccines, and the high costs of new vaccines. Reaching the under or unimmunised person and creating community confidence in and demand for vaccines remains an enormous challenge, requiring an interdisciplinary research agenda between the social, behavioural and clinical sciences.
Vaccine preventable diseases (VPDs) are a relatively new, but increasingly important focus area for Wits RHI. We are currently conducting tuberculosis (TB) vaccine studies in infants, and are planning to implement a Respiratory Syncytial Virus (RSV) vaccine trial in pregnant women. Wits RHI has published on human papillomavirus (HPV) vaccine implementation and programme feasibility, and has evaluated the National Department of Health’s national HPV vaccine programme. We are developing an adolescent/pre-adolescent platform for vaccines, and maternal infant pair cohorts.
Wits RHI has also had extensive involvement with international vaccine research partners and global policy. In 2015, we became a lead partner in the African Local Initiative for Vaccinology Expertise (ALIVE); a Wits University project to create a flagship vaccine and immunisation institution. Professor Helen Rees, together with Professor Shabir Madhi of the Respiratory and Meningeal Pathogen Research Unit, is spearheading the initiative, which is supported by a group of eminent South African vaccine researchers and other academics from fields such as implementation science, public health, health economics and social science. ALIVE is being run in conjunction with the National Research Foundation and was launched in May 2016.
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