High incidence of HIV in young women despite high ART coverage and viral

load suppression

Results from a population-based survey in KwaZulu-Natal, South Africa

Helena HuergaMSF-OCB Operational Research Day 2014

Background

• South Africa highest number of people with HIV and

on ART in the world

• MSF working in South Africa since >10 years

• Kwazulu-Natal (KZN): project “Bending the Curves”

– Aim to reduce HIV/TB incidence and morbi-mortality

– Gradually implemented since 2011

BackgroundGood understanding of HIV epidemic in a community

essential to define strategies of intervention

HIV+ at health facilities (partial view of community)

HIV surveys in population (overall view of community)

Objectives

Primary: To assess ART coverage

Secondary: – To estimate HIV incidence & prevalence

– To assess viral load suppression

– To assess HIV testing coverage and access to HIV care & ART

– To assess access to PMTCT and male circumcision coverage

Methods• Design: cross-sectional study

• Population:– Aged 15-59 years – Living in Mbongolwane / Eshowe

• Survey area:– Pop: 115,000 hab.– Rural, urban and farms– 2 hospitals & 10 ART clinics

• MSF project:– HIV testing in community– Linkage to care

– Support to MOH on ART – Early ART <500CD4– PMTCT B+– Male circumcision

StudyProcedures

Interview head of household

Interview eligible individuals

Household questionnaire

Individual questionnaire

duel HIV test

Discordant Not done

Negative Positive

Blood collection (phlebotomy)

Laboratory tests - GCVL Durban

3 tubes 3 tubes 1 tube

ELISA HIV test

Positive Negative

CD4 count DBS cards Viral load Genotyping Storage

NAAT for acute infection

Interview HIV positive / Test not done

Questionnaire HIV care & ART

Incidence testing - Biorad - LAg

ARV levels

- NICD Joburg

- Groote Schuur Cape Town

Plasma separation

HIV rapid test (finger prick)

Results: who participated?

Women, n (%) 3518 62.3

Age, median years (IQR) 26 19-40

Never married, n (%) 4234 75.0

Secondary education, n (%) 2806 49.7

Rural area, n (%) 4711 83.4

Student/unemployed, n (%) 4146 73.4

Moved residency, n (%) 761 13.5

Table: Participants’ socio-demographic characteristics

2377 HH visited –> 6688 individual eligible –> 5649 (84.5%) included

HIV prevalence: How many were HIV-positive?

Overall: 25.2% (95%CI: 23.6-26.9)

Women age 30-39: 56%

- Women: 30.9% (95%CI: 29.0-32.9)

- Men: 15.9% (95%CI: 14.0-18.0)

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-590

5

10

15

20

25

30

35

40

45

50

WomenMen

Age group

%

HIV incidence: How many new infections per year?

Women Men Total

/100 PY (95%CI) /100 PY (95%CI) /100 PY (95%CI)

15-29 years 3.2 (1.4-4.9) 1.0 (0.0-1.9) 2.1 (1.1-3.2)

30-59 years 0.1 (0.0-1.7) 0.2 (0.0-2.0) 0.1 (0.0-1.4)

Overall 2.0 (0.7-3.2) 0.8 (0.0-1.6) 1.4 (0.6-2.3)

PY: person-year

ART coverage: How many in need of treatment were on ART?

Overall: 75.0% (95%CI: 72.0-77.8)

Women age 20-24: 42%

- Women: 78.5% (95%CI: 75.8-81.0)- Men: 63.9% (95%CI: 56.7-70.5)

89% successfully treated with ART (VL<1000 copies/ml)

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59

0

20

40

60

80

100

120

140

No ARTART

Num

ber o

f ART

elig

ible

CD4

<350

; PM

TCT

B

When did they start ART?

8,3

12,5

16,7

25,5

37,1

0

5

10

15

20

25

30

35

40

Before 2006 2006-2007 2008-2009 2010-2011 2012-2013

%

Year of ART initiation

• Time since ART initiated: 31.0 m (IQR: 12.4-61.0)• Year range ART initiated: 1992-2013

Start MSF project

HIV testing: who tested where?HIV testing: 81.4% (95%CI: 79.8-82.9)

- Women: 88.4% (95%CI: 86.8-89.9) - Men: 69.8% (95%CI: 67.2-72.4)

Time since test: 6 months (IQR: 3-16)

Number of tests: 3 times (IQR: 2-4)

78.6%

2.0%

18.9%0.6%

Place of HIV test overall

Public sectorPrivate sectorMSFOther

Public sector

94.7%1.9%3.3% 0.1%

Individuals aware of HIV status

Public sector

Who was already aware of their HIV infection?

Awareness: 75.2% (95%CI:72.9-77.4)

Women & men 20 -24 y: 43.1% &

83.3%- Women: 77.7% (95%CI: 75.1-80.1)

- Men: 67.3% (95%CI: 62.0-72.1)

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

Wom

en

Men

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59

0

50

100

150

200

250

Not awareAware

Num

ber o

f HIV

pos

itive

Cascade of care

0

10

20

30

40

50

60

70

80

90

100

74.8%

65.4%57.1%

52.1% 49.3%

% o

f all

HIV

posi

tive

Of all HIV positive, 49% had no detectable virus, and hence were not transmitting HIV.

Discussion• KZN survey:

– ART coverage and VL suppression relatively good

– Overall moderate incidence in a high HIV prevalence area

– High incidence in young women

– Impact on the HIV epidemic but gaps in cascade of care

• Limitations: cross-sectional design in mobile population

• Strengths: survey in population, inclusion rate

Discussion• Recommendations:

– Maintain quality and go further to enlarge eligibility criteria

– Develop strategies to test, link and treat young people 20-30y

– Include interventions for prevention focused on young women

• Implications on the operations:

– HIV population based surveys are critical to define strategies

– Change orientation of MSF intervention in KZN after survey?

Mbongolwane & Eshowe study participants and communities

South Africa survey team Malika Bouhenia Radoslav Antonov Nomsa Nzama Godwin Dube Field teams

MSF South Africa Gilles Van Cutsem Ruggero Guilliani Mathew Reid Emilie Venables Emilie Wang

NICD Johannesburg Adrian Puren

University of Cape Town Jennifer Norman

SACEMA Stellenbosch Alex Welte

Global Laboratory Durban Madurai Lorna Bronwyn Pitam Collin Pillay

AcknowledgementsMSF SAMU South Africa Tom Ellman Eric Goemare Emmanuel Fajardo Carole Metcalf

MSF Brussels Marc Biot

Epicentre Paris Jihane Ben Farhat David Maman Serge Balandine Jean-François Etard