Transcript LESOTHO Analysis of Prevention Response & Modes of

Lesotho
Modes of Transmission
(MoT) Study
Prevention Reference Group Meeting
Stop AIDS! Keep the promise
Outline of Presentation
Introduction
Overview of HIV prevalence in Lesotho
Key MOT Study questions
Components of the MOT study
Methodology employed
Know Your Epidemic (KYE)
Know your response (KYR)
KYE & KYR Synthesis
Key Recommendations
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Introduction
Multi-country study in five countries –
Lesotho, Kenya, Mozambique, Swaziland and
Uganda
Purpose:
To check whether the response matches
the magnitude of the epidemic
To establish where the bulk of HIV
infections will come from in the next year
Study undertaken by NAC, MOHSW and
supported by UNAIDS & World Bank
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Overview of HIV Prevalence in Lesotho (cont.)
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Key questions the MoT study aims to answer
1. Are HIV prevention policies based on the
latest available evidence and global best
practice?
2. Do HIV prevention policies & programs
respond to the key drivers?
3. Is funding for HIV prevention allocated to
where it is most needed?
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Components of the MoT Study:
1.Incidence data
(modelled)
3. Prevention
policies, response
and strategic info
review
“Know your
epidemic”
2. Epidemiological
review
“Know your
response”
4. Review of
resources for
prevention
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Methodology (KYE & KYR)
1.
2.
3.
4.
Incidence modelling: UNAIDS model, prior use in
several countries, 1-day modelling workshop
Epidemiological review: desk review of data (published,
unpublished, national and sub-regional);
Prevention review: checklists for KIs on policy context &
SI, use of programme activity monitoring databases +
structured interviews with HIV implementers for
assessment of HIV activities
Review of prevention resources: Review of NASA
2005/06 - 2007/08 report, focus on prevention spending,
some further analysis
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1.Incidence data
(modelled)
“Know your
epidemic”
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2. Epidemiological
review
PREVALENCE PATTERNS:
Age and sex-related heterogeneity
Women have a higher burden of infection than men
•
Women are 40% more likely to be HIV positive
•
57% of PLHIV are female
“Two peaks” in females, high prevalence in older males
•
Female prevalence rises extremely steeply among young
women and shows a first “peak” among women in their
late 20s and reaches its highest level in women in their
late 30s (fig)
•
Male prevalence peaks at 30-34 years and is higher than
female prevalence for adults in their 40s
•
Trends in ANC clients: drop in young women, rise in older
women
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HIV prevalence patterns (cont.) (2004)
50
40
39
41
40
43
39
34
29
30
25
20
10
0
24
28
17
8
11
Women
Men
2
15-19
20-24
25-29
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30-34
35-39
40-44
Source: LDHS 2004
45-49
Heterogeneity by education status
Probability of being HIV positive decreases
with increasing education (“education is
protective”) *
Education strongly predicts preventive
behaviours like condom use, delayed sexual
debut, HTC uptake and knowledge about
AIDS *
ANC: Prevalence drop in more educated
women
* multivariate analysis by Corno & de Walque 2007
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HIV prevalence
From 2003-2007: Largest HIV prevalence drop in ANC clients with tertiary
education, smallest drop in those with primary education
40
35
30
25
20
15
10
5
0
-4%
-19%
-31%
2003
2005
27
26
Primary
26
32
30
26
High school
Source: MOHSW ANC surveillance 2003, 2005, 2007
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26
24
Tertiary
18
2007
Homogeneity
• All districts, both sexes, and most age groups
had HIV prevalence above 15% in the 2004
DHS (except females 15-19 and males 15-24)
• Women and men in all wealth, education and
migration strata analysed have a HIV
prevalence of at least 15%
• All but one ANC sentinel site reported HIV
prevalence above 15% in 2007
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Applying the UNAIDS Incidence Model

Calcification by main HIV exposure/mode of
transmission eg. MSM; IDU, SW, CSW- Gaps in
most of the data
 Nationally representative data on multiple
partner frequencies: 2004 DHS, 2007 CIET KAP
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Incidence model (using DHS 2004) multiple partners: 21.1%
(M), 7.6%(F)
Risk group
Distribution of new infections (DHS m ultiple partnership data)
Blood transfusions
Medical injections
No risk
One partner last 12
Partners MP
Multiple Partnerships (MP)
Female partners of MSM
MSM
Partners of Clients
Clients
Sex workers
Partners IDU
Injecting Drug Use (IDU)
0.00
0.04
0.00
61.80
15.27
16.49
0.52
3.02
1.75
0.62
0.49
0.00
0.00
0
10
Largest group (0.5 mio)
– 62%.
Couple discordancy, Low
condom use, ?Secret
partners
Multiple
partner
behaviours:
32%
20
30
40
Percent
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50
60
70
Incidence model (using CIET 2007)
multiple partners: 32% (M), 10%(F)
Risk group
Distribution of new infections (CIET m ultiple partnership data)
Blood transfusions
Medical injections
No risk
One partner last 12 months
Partners MP
Multiple Partnerships (MP)
Female partners of MSM
MSM
Partners of Clients
Clients
Sex workers
Partners IDU
Injecting Drug Use (IDU)
0.00
0.04
0.00
35.15
Only 296,000
individuals –
35%
27.65
31.04
0.50
2.89
1.68
0.59
0.47
0.00
0.00
0
Multiple
partner
behaviours:
59%
10
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20
30
40
Percent
50
60
70
Risk Factors for New Infections
individual level
community level
structural
level
Low male
circumcision
Multiple
concurrent sexual
partners
Inconsistent
condom use
Commercial sex
Social norms
Gender roles &
discrimination
Labour &
migration
Alcohol abuse
Labour &
migration
Sexual &
physical
violence
Income
inequality
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3. Prevention
policies, response
and strategic info
review
“Know your
response”
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4. Review of
resources for
prevention
HIV prevention programmes
•
•
•
•
•
•
•
•
Mass media: 11 programmes: mostly targeting both males and
females of all ages (the ‘general population’); few focus on
specific age groups or target sub-population;
BCC: 23 programmes (15 national); mostly directed at 12-35 old
males and females; some at in-school youth and students; youth
in churches and communities;
Condoms: 9 programmes incl. MOHSW (free distribution) and
PSI (socially marketed condoms);
HTC: MOHSW is the main implementer; key messages relating
to KYS campaign;
PMTCT: provided in all districts in Government and CHAL
facilities;
Male circumcision: services in health facilities & traditional setting
Blood safety: consistently 100% screening
PEP:
services
strengthened,
now available at district-level
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KYR Synthesis
Strong policy environment for HIV prevention, but there is need to
scale-up operationalisation of policy commitments.
Male Circumcision Policy & Strategy to be developed
M&E systems are in place & functional, but there is shortage of data
on high risk sub-populations
Most prevention programmes focus on:
 Interventions affecting Knowledge, Attitudes and Beliefs.
 Risk reduction component (mainly condom distribution)
 Biological/Biomedical Interventions that Reduce HIV Infection and
Transmission Risk (PMTCT,PEP etc.)
 Youth & OVC in & out of school; general population; workplace
 Key Messages - Behaviour change; HTC; life skills; awareness;
ABC; positive living; condom use; sexual violence
 Coverage is often country-wide except for a few programmes
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“Know your
epidemic”
Incidence data
(modelled)
Prevention
policies, response
and strategic info
review
Epidemiological
review
Epidemic
and
Response
Synthesis
“Know your
response”
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and AIDS
Review of
resources for
prevention
1) Are HIV prevention policies based on current best
evidence & practice?
Prevention strategies regarding HCT, PMTCT, treatment
of STIs and blood safety are covered by national policies
and emulate international best practices.
Male circumcision is not addressed by the existing
policies and no MC strategy is available.
The National BCC Strategy has been informed by the
findings of this among other studies conducted in
Lesotho.
Promotion of abstinence and delayed sexual debut in
adolescents needs to take into account societal changes
such as delayed marriage, as well as the “catch-up”
phenomenon.
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2) Do HIV prevention policies & programmes
respond to the key drivers of the epidemic?
Low male circumcision - MC policy and programme yet to
be developed
Multiple and concurrent partnerships - MCPs are highly
prevalent, but not explicitly addressed in communication
programmes
Migration, intimate partner violence & income inequality –
not adequately addressed policy and programmes as
structural drivers by
Prevention activities are not well targeted to priority
populations (discordant couples, migrant couples, out-ofschool youth, sex workers etc.)
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3) Is funding for HIV prevention allocated to where it
is most needed?
According to the NASA 2006/07, only 11% of funding was
spent on HIV prevention
There are great fluctuations in annual spending per
intervention category and ‘communication for social and
behaviour change’ received only 2% of prevention funding
in 2006/07
HCT interventions - received considerable funding
PMTCT - received considerable funding
Expenditure on positive prevention was small, possibly
due to a lack of a clear programme
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Actual Spending based on NSP categories for
2005/06, 2006/07 and 2007/08
100%
90%
80%
22%
16%
35%
Impact Mitigation
70%
60%
50%
38%
57%
31%
Treatment, Care &
Support
Prevention
40%
30%
11%
15%
9%
20%
10%
Mgt,Coordination &
Support
28%
19%
18%
0%
2005/06
2006/07
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2007/08
Key Recommendations
1.
2.
3.
4.
5.
6.
7.
Strengthen the commitment on implementation of existing policies;
Partner reduction as a key element of HIV prevention needs to be
integrated into all relevant prevention strategies and programmes;
Fast-track the process of creating policy framework for a scale-up of
male circumcision (including harnessing traditional sector as
appropriate);
Strengthen research and evaluation along side interventions in
order to understand what works;
Revise content of prevention messages to address underlying social
norms regarding Casual Sex & MCP;
Players at the district level to have a harmonised planning system
which ensures synergy and sustainability of interventions; and
Institutionalise MOT study as a planning tool.
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