Ministry of Health

HIV Situation and What Next in Uganda

Dr. Ario Alex RiolexusSTD/AIDS Control Programme

Ministry of HealthFebruary 2013

Ministry of Health

Introduction

Uganda has experienced a severe HIV/AIDS epidemic over the last three decades

Significant strides in addressing the problem have been made with some achievements in containing the spread.

However, recent data indicate some reversals in previous gains with evidence of substantial new infections, increasing HIV prevalence, and deterioration in some behavioral indicators.

Epidemiological Surveillance has been an integral component of HIV/AIDS programmes- gathering data to guide programme design and implementation.

n

Ministry of Health

Sources of Data on the Magnitude and Dynamics of HIV/AIDS

National HIV Sentinel surveillance system of Ministry of Health

Periodic National HIV/AIDS serological surveys Demographic and Health surveys have a module on

HIV/AIDS Public Health Evaluation – special studies Longitudinal studies that survey populations in selected

areas e.g.. Rakai project and MRC project in Masaka and Sembabule

Other facility based and population based surveys and Research programmes

Mathematical Modeling and Projections

The Uganda AIDS Indicator Survey

Previous National Population-Based Serological Surveys were conducted in 1988 & 2004-05

The 2011 UAIS was conducted to update HIV/AIDS indicators, provide data on new indicators e.g. CD4 T-cell counts as well as trends for several programme indicators

Trends of HIV Sero-prevalence among Urban Antenatal sites 1989 -2010

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Pre

vale

nce

(%)

Year

Nsambya Rubaga Mbarara Jinja Tororo Mbale Lacor

HIV EstimatesParameter No %No. of HIV Infected People:

Total 1,390,732 Males 625,521 45Females 765,210 55Adults 15 yrs+ 1,201,841 86Children 0 – 14 yrs 188,891 14

No. of New HIV Infection 2011 Total 145,294  

Males 68,097 47%Females 77,197 53%Adults 15 yrs+ 124,659 86%Children 0 – 14 yrs 20,635 14%

No. of AIDS Deaths Total 62,365

Males 30,124 48Females 32,241 52Ministry of Health

HIV among different groups; including MARPs in Uganda

22

17.415.5

6.8

33

18

7.4

13.7

0.6

6.4

0

5

10

15

20

25

30

35

HIV

pre

vale

nce

F is hers(L VB Cs tudy)

F is hers(Wakis odis trict)

F is hers(Mukonodis trict)

P lantations urvey

F emales ex

workers

P artnersof F S W

B odabodariders

MS M Univers itys tudents

UH S B S2004-5

Comprehensive Knowledge of HIV & AIDSPercent of women and men age 15-49 who say that:

*Comprehensive knowledge means knowing that the risk of getting HIV can be reduced by using condoms and limiting sex to one uninfected partner, knowing that a healthy looking person can have HIV, and rejecting the two most common local misconceptions about HIV prevention and transmission.

Trends in Comprehensive Knowledge of HIV

*Comprehensive knowledge means knowing that the risk of getting HIV can be reduced by using condoms and limiting sex to one uninfected partner, knowing that a healthy looking person can have HIV, and rejecting the two most common local misconceptions about HIV prevention and transmission.

Percent of women and men age 15-49 with comprehensive knowledge* of HIV

Trends in Knowledge of Prevention of Mother-to-Child Transmission

Percent of women and men age 15-49 who know that HIV can be transmitted by breastfeeding and that the risk of MTCT can be reduced by the mother taking drugs during pregnancy

Age at First Sex and at First Marriage

Median age at first marriage and first sexual intercourse for women and men age 25-49

The interval between age at first sex and marriage is about 1 yr for women and 5 yrs for men

Men therefore have a longer period to engage in pre-marital sex

And when girls decide to marry, they are likely to marry young men who have been involved in premarital sex

Multiple Sexual Partners

Percent of women and men age 15-49 who had

sex in the past 12 months:

Among women and men age 15-49 who had 2+

sexual partners in the past 12 months, percent who:

Among women and men age 15-49 who have ever

had sexual intercourse

Trends in Multiple Sexual Partners

Among women and men age 15-49 who had sex in the past 12 months, percent who had 2+ partners in the past 12 months

Extra marital Sex

Percent that extra Marital Sex Condom Use at last extra-marital Sex

Trends in Premarital Sex

Percent of never-married women and men age 15-24 who had sexual intercourse in the last 12 months

Premarital Sex and Condom Use

Percent of never-married women and men age 15-24 who:

Among never-married women and men age 15-24

who had sexual intercourse in the past 12 months, percent

who :

Trends in Condom Use at Last Sex Among Never-Married Youth

Among never-married women and men age 15-24 who had sexual intercourse in the last 12 months, percent who used a condom at last sex

Trends in Prior HIV TestingPercentage of women and men age 15-49 who have ever been tested for HIV and received the results

Women Men

13 11

2521

66

45

2004-05 UAIS 2006 UDHS 2011 UAIS 92% of women and 91% of men age 15-49

know where to get an HIV

test.

HIV Testing During Pregnancy

Among women who gave birth in the two

years before the survey, 72% were tested for HIV during antenatal care and received the

results.

Trends in HIV Prevalence

Percent HIV-positive

HIV Prevalence by Age

Age

Perc

en

t H

IV

posi

tive

Percent HIV-positive women and men age 15-49 who are HIV-positive

HIV Prevalence by Region

West Nile4.9%

Mid Northern

8.3% North East5.3%

Mid Eastern4.1%

EastCentral5.8%

Central 29.0%

Central 110.6%

SouthWestern

8.0%

MidWestern

8.2%

Kampala7.1%

Uganda7.3%

Percent HIV-positive women and men age 15-49 who are HIV-positive

HIV Prevalence by Region 2004-5 Vs 2011

West Nile4.9%

Mid Northern8.3%

North East5.3%

Mid Eastern4.1%

EastCentral

5.8%

Central 29.0%

Central 110.6%

SouthWestern

8.0%

MidWestern

8.2%

Kampala7.1%

Uganda7.3%

HIV Prevalence by EducationPercent HIV-positive

HIV Prevalence by Wealth Quintile

Percent HIV-positive

Poorest Richest

HIV Prevalence by Marital StatusPercent HIV-positive

Figures in parentheses are based on 25-49 unweighted cases.

Discordance among Couples

Among couples where both partners were tested, percent distribution by discordance

Discordance Among Couples

Concordant Positive

35%Discordant

Partnerships65%

Among HIV affected couples, 65% are sero-discordant,or 65% of HIV-infected married individualshave negative Partners !!

HIV Prevalence by Circumcision and Age

Age

Perc

en

t H

IV

posi

tive

HIV Prevalence by Sexually Transmitted Infections

Among women and men age 15-49 who ever had sexual intercourse and who were tested for HIV, percent HIV-positive

HIV Prevalence among Youth

Percent of women and men age 15-24 HIV-positive

Trends in HIV Prevalence among Youth

Percent HIV-positive women and men age 15-24

HIV Prevalence among ChildrenPercent of children under age five who are HIV-positive

Summary-1 HIV prevalence high at 7.3 % with regional

heterogeneity

Higher prevalence amongst MARPs and women

New infections increasing (124,000 in 2009, 130,000 in 2010, 145,000 in 2011)

Summary-2 Stable and low prevalence amongst children

and lower youth groups respectively

Age at 1st sexual debut high

HIV transmission is still predominantly heterosexual – 78%, MTCT – 19%, 1-3% others

Summary-3 Comprehensive knowledge low

The lower HIV prevalence among circumcised respondents compared to uncircumcised

Multiple sexual partnership and extramarital sex high – amongst men

Condom use low and going down

Summary-4 Alcohol and commercial sex playing a

significant contribution to HIV transmission

HIV testing increasing especially amongst women and in ANC clinics

Wealth and low education a risk factor in women

Summary-5 Married and widowed more infected.

Discordance high

Cross-generational sex on the increase

Why has the Epidemic gone up? 1 Most interventions are on a scale that is

insufficient to make significant public health impact.

Most HIV prevention interventions are not aligned with sources of new infections.

Complacency has led to a reversal of widespread risky sexual behaviour and low levels of comprehensive knowledge about HIV prevention.

Ministry of Health

Why has the Epidemic gone up? 2 Socio-economic and structural factors

Multiple concurrent partnerships Polygamy MARPs Poverty Lifestyle - Alcohol consumption, phonography,

peers etc Urbanization Mobility Discordance Stigma and discrimination

Ministry of Health

Why has the Epidemic gone up? 3 Health system weaknesses

Leadership Service delivery - Inequitable access to health

services etc HRH Diagnostics, Logistics and SCM MIS Financing

Ministry of Health

What needs to be done? The Global Trend

Treatment 2.0 - 2010Creating better pills and diagnosticsStrengthening community

mobilizationStop cost being an obstacleImprove uptake of HIV testing and

linkage to careTreatment as Prevention

Ministry of Health

What needs to be done? The Global Trend

Political declaration 2011 on Targets and Elimination Commitments

Reduce sexual transmission of HIV by 50% by 2015 Eliminate new HIV infections among children by 2015

and substantially reduce AIDS-related maternal deaths.

Reach 15 million people living with HIV with life saving antiretroviral treatment by 2015.

Reduce tuberculosis deaths in people living with HIV by 50 percent by 2015.

Towards Zero – Zero New Infections, Zero HIV Related deaths, Zero Discrimination

Towards an AIDS Free GenerationMinistry of Health

What needs to be done? There is need for effective ,

comprehensive and intensified evidence informed interventions for long-term sustainability of successful HIV and AIDS programs and averting of rising new infections.

Build strong partnerships guided by mutual cooperation and strong country ownership principles

Ministry of Health

What needs to be done? Acknowledge that the only one single

intervention that would bring down HIV is a vaccine and probably a cure which is still not less than a decade or two away – it’s a longer term trajectory. So in the interim, no one single intervention will do the miracle rather a combination of strategies – Combination Prevention

Ministry of Health

What needs to be done? The country has come up with the HIV

Prevention Strategy which addresses the epidemic through: increasing adoption of safer sexual behaviours and reducing risk taking behaviours; expanding critical coverage and utilization of biomedical prevention interventions; and creating a sustainable enabling environment that mitigates underlying socio-cultural and other structural drivers of the epidemic.

Ministry of Health

What needs to be done? The strategy sets ambitious targets for a

combination of HIV prevention interventions which include: evidence informed behavior change interventions, HTC, eMTCT, scaling up ART, SMC, creating condom demand and utilization, targeting high risk populations etc

Ministry of Health

What needs to be done? In addition to combination prevention,

addressing health system issues is at the forefront – improved coordination and partnerships, leadership, innovative domestic financing, improved and harmonized information systems, HRH, streamlined SCM, diagnostics, effective community structures

Ministry of Health

InterventionsPromote ABC as the core

prevention strategyCreate demand and increase

availability and utilization of condoms

Increase HTC coverage and linkage to care

Implement eMTCT plan focusing on all the four prongs including roll out of Option B+

Ministry of Health

InterventionsScale up treatment for PLHIV

including childrenScale up EID, follow up of babies

and mothers and link them to careTreatment as Prevention –

DiscordancePrompt management of STI and OIsComprehensively target MARPs

Ministry of Health

InterventionsRoll out SMC as part of the

comprehensive prevention packageStrengthen patient monitoringStrengthen surveillance,

monitoring and evaluationSet benchmarks that are regularly

assessed to assure goals are being met

Ministry of Health

In conclusion, We need to:

Move our interventions to scale Target source of new infections and drivers of

epidemic Design appropriate messaging Propagate a “care continuum” – create

demand, test, link to care, treat eligible, retain in care and ensure adherence

Ministry of Health

Ministry of Health

THANK YOU