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
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