Swaziland HIV Estimates and Projections

Transcription

1 Swaziland HIV Estimates and Projections Workshop Report Mountain Inn Hotel - Mbabane Swaziland On 8-10 October 2007 Prepared by: Sanelisiwe Tsela (NERCHA) Helen Atieno Odido (UNAIDS)

2 Workshop and Report Preparation The HIV Estimations and Projections workshop was a collaborative effort between NERCHA, the Ministry of Health and Social Welfare (MOH&SW) UNAIDS and USG,. The workshop was facilitated by Eleanor Gouws (UNAIDS), Ray Shiraishi (CDC/USG) and Sadhna Patel (USG/CDC) and was officially opened by NERCHA Director, Derek von Wissell. Planning and technical support for the workshop was provided by Sanelisiwe Tsela (NERCHA), Helen Odido (UNAIDS), George Bicego (USG) and Sibongile Mndzebele (MOH&SW). The report was prepared by Helen Atieno Odido and Sanelisiwe Tsela, with contributions from Eleanor Gouws, Ray Shiraishi, Sadhna Patel and George Bicego. Swaziland HIV Estimates and Projections Report, December

3 Acknowledgements The National Emergency Response Council on HIV and AIDS (NERCHA) would like to express profound gratitude to UNAIDS and CDC/USG for providing the technical support that made this very important exercise a reality. We would especially like to thank the Ministry of Health and Social Welfare (MOH&SW) and other partners including CSO, HAPAC, PSI, UNICEF, WHO, MRDYA SWANNEPHA and EGPAF for this collaborative effort and for their invaluable participation. We believe that the outputs of this workshop will assist the country in making data driven decisions and subsequently strengthen the response to HIV in the country. Derek von Wissell NERCHA Director Swaziland HIV Estimates and Projections Report, December

4 Abbreviations and Acronyms AIDS ANC ART CDC EPP HIV M&E MoH&SW NERCHA SDHS SNAP UN UNAIDS Acquired Immune Deficiency Syndrome Antenatal Care Antiretroviral Therapy Centers for Diseases Control Estimation and Projection Package Human Immunodeficiency Virus Monitoring and Evaluation Ministry of Health and Social Welfare National Emergency Response Council on HIV and AIDS Swaziland Demographic Health Survey Swaziland National AIDS Programme United Nations Joint United Nations Programme on HIV/AIDS Swaziland HIV Estimates and Projections Report, December

5 Table of Contents Workshop and report preparations 1 Acknowledgments 2 Abbreviations and Acronyms 3 Table of contents 5 1. INTRODUCTION 1.1 Overview of the HIV Epidemic in Swaziland Rationale for the Estimation and Projections Workshop Workshop s Objectives Scope of work and deliverables Outputs of the workshop 9 2. RESULTS 2.1 Estimation and Projection Package (EPP) Spectrum. Estimating the demographic impact of HIV Measuring prevalence among age group as a proxy for incidence Measuring Prevalence among as a Proxy for Incidence Output from Regression Analysis 18 Appendices 19 List of Participants 21 Swaziland HIV Estimates and Projections Report, December

6 1. INTRODUCTION 1.1 Overview of the HIV Epidemic in Swaziland Swaziland is one of the countries worst affected by the HIV epidemic in the world. Since 1992, the government has been conducting antenatal clinic (ANC) sentinel surveillance, HIV increased dramatically from 3.9% to a high of 42.6% in In 2006, ANC-based prevalence estimates showed a decline to 39.2%. Most affected by HIV are pregnant women aged years, with HIV prevalence of 56.3% in 2004 and 48.9% in 2006, followed by those aged (prevalence of 41% in 2004 and 48.9% in 2006). In the country conducted its first Demographic and Health Survey (DHS), including HIV testing at national level. The preliminary results confirmed that Swaziland was in a crisis as the HIV prevalence in the population of women and men aged was estimated at 26% 1. According to the SDHS, women aged are more likely to be HIV positive than men in the same age group (31 percent and 20 percent, respectively). The findings indicate that the age patterns of HIV infection differ for women and men. HIV prevalence is higher among women than men in age categories younger than 35, while it is higher among men in the age categories 35 years and older (Figure 2). In 2006, HIV prevalence peaked at 49 percent among women in the age group 25-29, while among men, the infection rate was at its highest level among those in the year age category (45 percent). Interestingly, HIV prevalence continues to be moderately high among both women and men in the age category 50 and older; for example, around one-quarter of women and men age were infected while 7 percent of women and 13 percent of men age 60 and older were infected with HIV in Figure 1: HIV Prevalence among Population Age 2 and Older by Age and Sex Female Male Levels of HIV among pregnant women attending ANC have been uniformly high in all four regions in the country, with the worst affected region in 2006 being Shiselweni (41.5%). Manzini region has all along been the worst hit but started showing some stabilization in the 2004 ANC survey. The sharp increase in Shiselweni in the recent years has probably been 1 Preliminary findings of the Swaziland Demographic and Health Survey (SDHS 2007), and the 10 th Round of the National HIV Serosurveillance in Women attending ANC, STI Clients and TB Patients at Health Facilities in Swaziland, Survey Report, Swaziland HIV Estimates and Projections Report, December

7 triggered by the recent industrialization and increased mobility in the region. National HIV prevalence among antenatal clinic attendees over time is shown in Figure 2. Figure 2: HIV Prevalence among antenatal clinic attendees in Swaziland (Sentinel surveillance report, 2006, MOH&SW) prevalence (%) In order to manage the HIV epidemic in the country, the government formed the National Emergency Response Council to HIV and AIDS (NERCHA), with the mandate to coordinate the HIV multisectoral response. The Ministry of Health and Social Welfare formed the Swaziland National AIDS Program (SNAP), which leads the health sector response to HIV. Also in place is a national multisectoral HIV and AIDS M&E Framework which spells out the goals, objectives, indicators, data sources and reporting arrangements required for monitoring HIV prevalence as well as Swaziland s programmatic response. The country has been able to intensify the comprehensive HIV prevention, care and treatment efforts guided by the second national multisectoral HIV and AIDS strategic plan According to the SDHS, the percentage of the adult population who had been tested for HIV and knew their results in 2006 was 22% for women and 9% for men. The Ministry of Health has embarked on scaling up HIV Testing and counselling services at all health facilities in an effort to increase the number of people that know their status. Other efforts to increase access to services include the introduction of the utilization of mobile outreach services in the workplace, and including the rural communities in the provider initiated approach to HIV testing and counselling. In addition, the Swazi government with support from Global Fund has made significant progress in the past three years in making antiretroviral therapy (ART) accessible to those in need. 1.2 Rationale for the Estimation and Projections Workshop As a result of the recent increase in treatment access in the country which has slowed the progression from HIV to AIDS and death for many individuals, data on HIV prevalence alone is no longer sufficient to track HIV infection rates and ensure that programmatic response efforts are appropriately targeted. To address the need for information to ensure effective targeting of HIV programmes the UNAIDS has been publishing global estimates on a number of HIV indicators since In March 2007, a team comprised of two national staff based at NERCHA and the UNAIDS M&E advisor attended an estimates and projections workshop organized by the UNAIDS/WHO working group on Global HIV/AIDS and STI Surveillance in Pretoria, South Africa. During the workshop, the Swaziland team together with other regional counterparts were trained on the UNAIDS estimation methodology, including Spectrum and EPP, and proceeded to generate estimates of HIV prevalence and the demographic impact of HIV, treatment needs and coverage estimates using the revised Spectrum model. At the time, the Swaziland HIV Estimates and Projections Report, December

8 country had not released the preliminary HIV prevalence results from its first DHS which are needed for calibration of national, rural and urban HIV prevalence estimates. In June 2007, the Ministry of Economic Planning and Development released the preliminary findings of the first Swaziland Demographic and Health Survey (SDHS ). With the release of the SDHS estimates of national HIV prevalence it was an opportune moment for the country, supported by technical experts from UNAIDS/Geneva and CDC/Atlanta, to undertake the necessary analysis and modelling to make available more reliable estimates of HIV prevalence, the demographic impact of the epidemic, and ART needs and service coverage. These data are valuable for planning, budgeting, and forecasting as well as for monitoring and evaluation of the response. The UNAIDS/CDC team facilitated a three-day orientation and training workshop on Spectrum and EPP aimed at national staff from NERCHA and MOH&SW, UN and civil society partners, and in particular those staff who are mandated to manage and provide data regularly. 1.3 Workshop objectives 1. To review the country s HIV prevalence data (including data from ANC and DHS), enter data, by site for urban and rural areas, into EPP and calibrate the prevalence curves using the latest DHS estimates of prevalence 2. To generate uncertainty bounds on the national curve in EPP; read the national prevalence curve into Spectrum and estimate the demographic impact of HIV 3. To generate estimates on ART needs and coverage as required for various national and UNGASS indicators 4. To assess the trends of prevalence among young women (age years) attending antenatal clinics using regression analysis 5. To organize a consensus building meeting to agree on assumptions, the process and outcomes of Spectrum and EPP with the NERCHA, MOH&SW, civil society, the UN and other relevant partners. 1.4 Scope of work and deliverables 1. To generate new curves for national, urban and rural HIV prevalence trends 2. To agree on the national HIV prevalence for 2006, with uncertainty bounds 3. To assess demographic impact of HIV in terms of numbers infected, prevalence, incidence and AIDS-related deaths 4. To assess the potential impact of treatment on prevalence and AIDS deaths 5. To revise estimates for the following national and UNGASS indicators: Number of Orphans (double and single) No of people in need of ART by sex No of people receiving ART (1 st and 2 nd line by age and sex) Number of children needing treatment Number of children receiving cotrimoxazole Number of new infections by sex Number of mothers needing PMTCT 6. To perform regression analysis on the prevalence data among young women aged years attending antenatal clinics from to assess the trends in prevalence. 7. To enhance understanding of EPP and Spectrum and build in-country capacity in using these methodologies to make national estimates of HIV and its impact. Swaziland HIV Estimates and Projections Report, December

9 1.5 Outputs of the Workshop The Estimation and Projection Package (EPP) 2 has been developed by the UNAIDS Reference Group on Estimates, Modelling and Projections as a tool to assist national programmes in estimating and projecting the course of the HIV epidemic in their countries. EPP provides direct input to Spectrum, which together with population and demographic data, epidemiological assumptions and treatment coverage, produces estimates and projections of HIV incidence, deaths, treatment needs and other AIDS impacts 3. At this workshop, participants applied EPP and Spectrum to data collected in Swaziland. 2 Brown T, Grassly NC, Garnett G, Stanecki K. Improving projections at the country level: the UNAIDS Estimation and Projection Package Sexually Transmitted Infections 2006;82 (suppl_iii): iii34-iii40 3 Stover J, Walker N, Grassly NC, Marston M, Projecting the demographic impact of AIDS and the number of people in need of treatment: updates to the Spectrum projection package. Sexually Transmitted Infections 2006;82 (suppl_3): iii45- iii50. Swaziland HIV Estimates and Projections Report, December

10 2. RESULTS 2.1 The Estimation and Projection Package (EPP) - process to produce HIV prevalence curves a) Data - ANC data were available for each of 4 regions (Hhohho, Manzini, Lubombo, Shiselweni) for every two years between 1992 and DHS prevalence data were available by region, sex and age for In the absence of site-specific historical data, a curve was fitted in EPP to the regional aggregates of ANC prevalence for which complete historical trend data were available - The regional ANC-based prevalence curves were then scaled according to the DHS 2006 prevalence estimates. These were combined to estimate the national prevalence curve - Analysis was performed to establish uncertainty ranges on the prevalence curve. b) EPP outputs (Figure 3 and 4) - Curves fitted to regional data show that the national epidemic is levelling off at around 26% - National prevalence for 2007 was estimated at 26.03% - Uncertainty bounds on the prevalence curve are also shown in figure 4 below - The figure below shows that prevalence in Swaziland is generally high in all four regions, with Hhohho curve showing high trends until Figure 3: Estimated prevalence curves fitted to data from the four regions in Swaziland Swaziland HIV Estimates and Projections Report, December

11 Figure 4: Swaziland national projected curve with uncertainty range 2.2 Spectrum: Estimating the Demographic Impact of HIV Several new assumptions were endorsed by the UNAIDS Reference Group on Estimates, Modelling and Projections at its December 2006 meeting. These assumptions have been built into the 2007 versions of the estimation software tools (EPP 2007 and Spectrum 3) that were used in this Swaziland Estimates and Projections workshop. Spectrum was used to estimate the demographic impact of HIV in Swaziland, using the assumptions and processes outlined below. a) The Process and Epidemiological assumptions in Spectrum - National prevalence curve: Calibrated using the SDHS, generated by EPP analysis was read into SPECTRUM - HIV progression: Net survival of people living with HIV is assumed to be 11 years (instead of previously assumed 9 years) based on available cohort data (paper in press). Waybill survival function assumes that the median time from HIV infection to ART need is 8 years, and median time from ART need to death (in the absence of treatment) is 3 years, totaling 11 years from HIV infection to death in the absence of treatment. Swaziland HIV Estimates and Projections Report, December

12 - HIV age distribution: the sex and age specific distribution of HIV prevalence from the 2006 Swaziland DHS, preliminary report were used (see Table 1). Table 1: Prevalence of HIV by age and sex from the Swaziland DHS, Sex ratio: The female to male HIV prevalence ratio from the SDHS was used. Adult female and male prevalence rates from the SDHS were 31.1% and 19.7% respectively, resulting in a female: male ratio in 2006 of HIV-related reduction in fertility rates: the SPECTRUM default estimates of the ratio of fertility of HIV infected women to the fertility of uninfected women were changed to a ratio of 1.5 among women aged years, and a ratio of 0.95 for all women older than 20 years. Should more reliable Swazi-specific information on the impact of HIV on become available, such data will be used to update the assumptions. - Treatment coverage: Number of adults and children in need of ART who are currently receiving treatment are presented in Table 2, together with national targets for provision of ART by The number of women receiving PMTCT services was to 8221 in It is assumed that the number was scaled up linearly from 2004 to 2006 and then from 2006 to about 12,000 (90%) in Number of HIV positive children receiving cotrimoxozole: the number could not be verified due to the inability of current registers to capture this information. - Number of adults and children in need of treatment: the number were estimated from Spectrum - Duration of breastfeeding is assumed to be between 7 and 17 months. This may be revised following release of final DHS findings and report on early Percent of HIV positive mothers who provide mixed feeding to children: 100% (as compared to exclusive breastfeeding and replacement feeding). b) Demographic inputs and assumptions - Provisional estimates from the national census conducted in Swaziland in 2006 indicate that the national population size in Swaziland is about 950,000 (final numbers as well as population breakdown by age and sex were not available at the time of the workshop). - Recent census data therefore indicate that the Spectrum population projections (based on fertility and mortality assumptions including HIV effects) are probably too high (1.2 million). To produce more accurate estimates of population size life Swaziland HIV Estimates and Projections Report, December

13 expectancies were adjusted downward. Projected life expectancy in the absence of AIDS, needed by Spectrum to produce a base population trend, was thus altered so that it remained stable at 55 for men and 59 for women between 1985 and This resulted in an estimated population size (including the impact of HIV) of about 1.1 million in Population sizes by age and sex in Spectrum will be further adjusted according to the official 2006 census data as soon as these data are officially verified and endorsed. c) Summary of Results Tables 2 and 3 below provide HIV estimates based on the calculations and assumptions stated above. Specific Spectrum Outputs: - Estimated adult (15-49 year) prevalence in 2007 is about 26.1% with an uncertainty range 4 of % as shown in figure 5. - Total number of adults and children living with HIV in 2007:185,005 (with uncertainty range from 176, ,794). - Estimated number of new adult infections in 2007: 12,568 (11,258-13,735) - Estimated total number of adult and child deaths in 2007: 11,545 (9,923-13,123) - Estimated number of adults in need of ART in 2007: 53,721 (44,016-62,099) - Estimated number of children in need of ART in 2007: 4,529 (4,217-4,877) - Estimated number of AIDS orphans in 2007: 54,541 (46,710-63,400) 4 Uncertainty analysis was done in Spectrum using 500 iterations Swaziland HIV Estimates and Projections Report, December

14 Figure 5: Adult HIV prevalence with 95% uncertainty ranges Swaziland HIV Estimates and Projections Report, December

15 Table 2: HIV population, adults, mothers and children needing and receiving ART and/or PMTCT and contrimoxazole YEAR HIV+ Populatio n (Adults15 +) 162, , , , , , , , ,051 HIV + Populatio n (children 0-14) 12,628 14,016 14,887 15,357 15,672 15,876 15,971 15,967 15,897 Adults (15 +) in Need of ART Adults (15 +) Receiving Children in Need of ART Children receiving ART Children needing Cotrimox azole PMTCT (Mothers in need) PMTCT (Mothers receiving) Table 3: Summary data on estimated new infections, orphans, and AIDS deaths from YEAR New Infections (Adults 15+) New Infections (children) AIDS Orphans OVC AIDS Deaths (Adults 15+) AIDS-related Child Deaths

16 2.3 Measuring Prevalence among as a Proxy for Incidence One of the UNGASS goals (UNGASS indicator number 22) is to achieve a 25% reduction in HIV prevalence among young people, aged years, in the most affected countries by 2005 and globally by This indicator can be calculated using prevalence data from pregnant women attending antenatal clinics in HIV sentinel surveillance sites in urban and rural areas Measuring Progress towards UNGASS Goals In order to measure progress towards the above UNGASS indicator, a regression analysis can be performed on the HIV prevalence data over time: to determine if there was a change over time, to determine if the change was statistically significant, and to determine the amount of change over time. For this analysis, data over time were used for consistent sites only, i.e. those sites that have consistently recorded HIV prevalence over time, as shown in Figure 9 and 10 for urban and rural sites. A minimum of three data points per site over time are generally required to perform the trend analysis. To assess the trends in HIV prevalence among year old women attending ANCs in Swaziland, site-specific data from 9 urban sites and 8 rural sites collected between 2002 and 2006 (as shown in Table 4) were analysed. Site-level HIV prevalence data were plotted and visual trends were inspected (Figure 9 and 10 below). Table 4: HIV prevalence data for young women (15-24) attending urban and rural antenatal clinics in Swaziland: Site name 2002 N 2004 N 2006 N Urban FLAS HLATHIKHULU KING SOBHUZA MANKAYANE MBABANE PHU NHLANGANO PIGGS PEAK PHU SITEKI VUVULANE Rural DVOKOLWAKO HC DWALENI EMKHUZWENI HC LOMAHASHA LUYENGO MATSANJENI NDZEVANE SITHOBELA Vuvulane not included in analysis

17 60 HIV Prevalence (%) FLAS HLATHIKHULU KING SOBHUZA MANKAYANE MBABANE PHU NHLANGANO PIGGS PEAK PHU SITEKI Year Figure 9: HIV prevalence data by urban antenatal clinic for young women (15-24) in Swaziland, HIV Prevalence (%) DVOKOLWAKO HC DWALENI EMKHUZWENI HC LOMAHASHA LUYENGO MATSANJENI NDZEVANE SITHOBELA Year Figure 10: HIV prevalence data by rural antenatal clinic for young women (15-24) in Swaziland, Swaziland HIV Estimation and Projections Report, December

18 2.3.2 Output from Regression Analysis Regression analysis was performed to assess trends in HIV prevalence among young women (15-24) attending urban and rural antenatal clinics. Results are shown for urban and rural areas in Figures 11 and 12. Key Finding: Predicted HIV prevalence among young people is estimated to have decreased by 17.4% and 13.1% from 2000 to 2005 and by 15.0% and 11.19% from 2002 to 2006 for urban and rural sites, respectively. The results indicate that, despite clear hopeful trends, Swaziland has not yet attained the UNGASS goal of 25% reduction in HIV prevalence among young people aged years by Figures 11: Urban trend with a regression line fitted against HIV prevalence data Figures 12: Rural trend with a regression line fitted against HIV prevalence data Swaziland HIV Estimation and Projections Report, December

19 Appendices Table 13: Summary output for urban regression analysis. Regression Statistics Multiple R R Square Adjusted R Square Standard Error Observations 24 ANOVA df SS MS F Significance F Regression Residual Total Coefficients Standard Error t Stat P-value Lower 95% Upper 95% Intercept X Variable Table 14: Summary output for rural regression analysis. Regression Statistics Multiple R R Square Adjusted R Square Standard Error Observations 24 ANOVA df SS MS F Significance F Regression Residual Total Coefficients Standard Error t Stat P- value Lower 95% Upper 95% Intercept X Variable Swaziland HIV Estimation and Projections Report, December

20 Table 15: Predicted HIV prevalence estimates (pregnant women aged 15-24) based on urban and rural regression analysis. Urban Rural Swaziland HIV Estimation and Projections Report, December

21 List of Participants for the Estimates and Projections Workshop 1. Nhlanhla Nhlabatsi HAPAC 2. Nomsa Mulima MoHSW SNAP M&E 3. Rejoice Nkambule MoHSW SNAP 4. Rachel Masuku Central Statistics Organisation 5. Zodwa Mthethwa UNICEF 6. Richard Walwema MoHSW NRL 7. Faith Dlamini NERCHA 8. George Bicego USG 9. Sibongile Mndzebele MoHSW SNAP M&E 10. Benjamin Gama WHO 11. Edwin Simelane PSI 12. Allen Waligo EGPAF 13. Fortunate Fakudze MoHSW 14. Zanela Simelane MoHSW (Health Statistics Unit) 15. Sanelisiwe Tsela NERCHA 16. Helen Atieno Odido UNAIDS 17. Qhawe Tfwala CSO 18. Mavis Vilane NERCHA 19. Dumisani Sithole MRDYA (Planning Unit) 20. Sibusiso Mngadi NERCHA 21. Richard Phungwayo MoHSW 22. Nozipho Mkhatshwa NERCHA 23. Sarah Tammlumbye SWANNEPHA 24. Futhi Dennis NERCHA Swaziland HIV Estimation and Projections Report, December