NAC ZAMBIA GOVERNMENT OF ZAMBIA NATIONAL AIDS COUNCIL Policy Overview and Status of the AIDS Epidemic in Zambia Dr Ben Chirwa Director General National HIV/AIDS/STI/TB Council Contents 1. 1. Status of of the Epidemic 2. 2. Blind Spots 3. 3. Policy/strategy 4. 4. Achievements 5. 5. Way Forward
1. Status of the Epidemic HIV Prevalence 1.3% drop between 2001 and 2007 from 16% to 14.3% (DHS 2001 and 2007) Location: Urban = 20%: Rural = 10.3% Gender: Female = 16%: Male = 12%
Prevalence in Zambia by Province 2001/2 2007 Source: ZDHS 2007 01 8.3 07 6.8 01 11.2 07 13.3 01 9.2 07 6.9 01 19.9 07 17.0 01 13.7 07 10.3 01 15.3 07 17.5 01 13.1 07 15.2 07 20.8 01 22.0 01 17.6 07 14.5 01 = year 2001/2 07 = year 2007 Comparison HIV Prevalence by Province for 2001/2 and 2007 Changes in Provincial HIV Prevalence between 2001/2 and 2007 ZDHS Results HIV Prevalence 25.0% 20.0% 15.0% 10.0% 22.0% 20.8% 19.9% 17.5% 17.0% 15.3% 15.2% 13.1% 17.6% 14.5% 13.2% 11.2% 13.7% 10.3% 9.2% 8.3% 6.9% 6.8% 5.0% 0.0% Lusaka Central C/belt Western Southern Luapula Eastern N/western Northern 2001 2 22.0% 15.3% 19.9% 13.1% 17.6% 11.2% 13.7% 9.2% 8.3% 2007 20.8% 17.5% 17.0% 15.2% 14.5% 13.2% 10.3% 6.9% 6.8% Central: Increased 15.3% to 17.5% Western: Increased 13.1% to 15.2% Luapula: Increased 11.2% to 13.2% REMAINING SIX Provinces = Decreased Highest: Lusaka = 22% (2002)/ 20.8% (2007) Lowest: Northern = 8.3% (2002)/ 6.8% (2007) 6
Trend of HIV Prevalence Among Youths from 1994 to 2006 showed decline Based Axis Title Trend ANC Sentine Surviellance HIV Prevalence 1994 2006 21.0% 20.0% 20.0% 19.1% 19.0% 19.0% 18.6% 18.0% 17.0% 16.7% 16.0% 15.0% 1994 1998 2002 2004 2006 HIV Prevalence 20.0% 18.6% 19.1% 19.0% 16.7% HSS Report 2006 Percentage of Youth Infected Trends in HIV infection among youths 15 24 from 1994 to 2006 25.0% 21.9% 20.7% 20.0% 19.2% 18.1% 15.5% 15.0% 18.8% 16.4% 16.6% 15.9% 10.0% 14.1% 12.9% 12.6% 11.7% 10.9% 5.0% 8.7% 0.0% 1994 1998 2002 2004 2006 15 19 14.1% 10.9% 12.6% 11.7% 8.7% 20 24 21.9% 20.7% 19.2% 18.1% 15.5% 15 24 18.8% 16.6% 16.4% 15.9% 12.9% 7 There is increase in HIV prevalence in some sites- HIV % prevalence by year of ANC SS survey, 7 sentinel sites, Zambia, 1993-2006 Kalabo Macha Chelstone Chilenje Kalingalinga Matero Nchelenge Mean Rate 40 HIV Prevalence in Survey Sites 35 30 25 20 15 10 5 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Status of the Epidemic Total population 15 years and older 1400000 1200000 1000000 800000 600000 400000 200000 0 Total population Total new infections Total deaths Year HIV Incidence in Zambia
HIV Incidence in Zambia HIV incidence rate reduces, the absolute number of new infections increases due to the increase in population size The estimated number of annual new infections in the adult population aged 15-49 years in 2007 and 2008 was 79,755 and 80,442, respectively. The number of annual new HIV infections among adults aged 15-49 years was estimated to have peaked in 1991 at 107,645. The lowest number of new infections among adults 15 years and older was 62,422 in 1997. The increase in the number of new cases after 1997 could be due to the increasing population size Estimates HIV Incidence trend in Zambia 4.5 Percentage of annual new infections 4 3.5 3 2.5 2 1.5 1 0.5 0 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 Year Males Females Total
HIV incidence Figure Regression of HIV incidence among adults by year of end of observation of cohort in different districts in Zambia 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 y = 0.1529x + 314.53 R² = 0.0618 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Source: USBUCEN HIV Global HIV database End year of cohort 2. Blind Spots
Several blind spots which may contribute to another wave of increase exist!!!!!!!! MSM study of N= 3,000 in four cities and two districts in Southern, Lusaka, Copperbelt and Luapula ANAL Practice in different subpop Kaizar P. Zulu etal, 2004
STI syndromes by Gender based on DHS 2007 7 6 5 % prevalence 4 3 Total 15-49 2 1 0 STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/sore or ulcer STI Bad smelling/ abnormal genital discharge Genital sore/ulcer STI/genital discharge/sore or ulcer ZDHS 2007 Females Reporting STI syndromes Males LOW RATES OF MALE CIRCUMCISION Research shows major benefit to males Only 13% of men circumcised, despite general openness to the practice significant provincial differences HIV prevalence in circumcised men is slightly lower Self-reported male circumcision is not always accurate Barriers exist in non-circumcising communities
Percentage of men 15 49 who report having been circumcised Male Circumcision Central Copperbelt Eastern Luapula Lusaka Northern North Western Southern Western TOTAL MOBILITY & MIGRATION: Being away from home increases risk of for all in stable employment including Government staff More nights away can increase risk for the traveller and/or those who stay home, esp for women Mobile workers and migrants form sexual networks with women who sell sex Large mobile groups in Zambia include truck drivers, sex workers (incl informal), fishermen/women and fish traders, seasonal agricultural workers, cross border traders, miners, uniformed services personnel, prisoners, and refugees.
MODE OF TRANSMISSION MODELLING OF INCIDENCE: Risk g rou p Injecting Drug Use (IDU) Distribution of new infections by mode of exposure in the adult population Blood transfusions Medical injections No risk Low-risk heterosexual Partners CHS Casual heterosexual sex Female partners of MSM MSM Partners of Clients Clients Sex workers Partners IDU 0 5 10 15 20 25 30 35 40 Percent Adult Risk Behavior % of Incidence incidence Injecting Drug Use (IDU) 0 0.00 Partners IDU 0 0.00 Sex workers 557 0.75 Clients 2,997 4.04 Partners of Clients 1,341 1.81 MSM 732 0.99 Female partners of MSM 40 0.05 Casual heterosexual sex 25,222 33.96 Partners CHS 27,500 37.03 Low-risk heterosexual 15,734 21.19 No risk 0 0.00 Medical injections 124 0.17 Blood transfusions 16 0.02 TOTAL ADULT POPULATION 74,263 MOT Report 2008 What does all these data tell us about the epidemic? There is decline in HIV prevalence in general population but increase in absolute number due to successful ART policy There hotspots existing which might contribute to another wave of increase in HIV incidence HIV prevalence is highest among widows and separated in both urban and rural among women HIV prevalence is positively correlated with employment and educational status
What does all these data tell us about the epidemic? HIV prevalence increases among pregnant women with increase in age disparity among partners Overall incidence is also on the decline but increase in absolute numbers due to population increase. Key behavioral indicators supporting this is partner reduction determinants of incidence incidence prevalence Current response: prevention Current response: care and treatment PLHA Source: ASAP Training, 2007 death
ultiple and concurrent sexual partners lack of male circumcision Drivers of Epidemic high alcohol and drug abuse Low Risk Perception low rates of condom use High mobility High STI Risky cultural practices Gender based violence Key Performance Indicators of the Response Zambia ART PMTCT HCT KNOWLEDGE 0% 20% 40% 60% 80% 100% 2005 achievement 2007 achievement 2010 targets
3. Policy/strategy 3 Ones principles application One national AIDS strategic framework 2006-2010 One national coordinating body - the NAC Reports to Cabinet Committee on AIDS Decentralised structures Stakeholders coordination through self-coordinating groups including Cooperating partners One M&E system Multisectoral Response
National Goal, Vision and Mission Scale up prioritized actions Integrated into dev agenda Universal access Coordinated by NAC A nation free from the threat of HIV and AIDS. Halt and begin to revise spread and mitigate impact Multisectoral Response Prevention Response Package CT PTS,MC, BCC, STI, Workplace PMTC, health care settings Blood safety PEP, Injection safety Stigma and Discrimination
Comparison of Distribution of Spending by Category for 2005 and 2006 Comparision of Percentage of Total AIDS Funds Spent on Specific Thematic Area Between 2005 and 2006 Percentage Spent on Thematic Area 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 28.0% Prevention 26.1% 36.1% 52.3% Treatment Care and Support 19.5% Mitigation and Social protection Advocacy and Coordination Mainstreaming and Decentralization Monitoring Evaluation and research 2005 28.0% 36.1% 19.5% 9.5% 1.7% 5.2% 2006 26.1% 52.3% 4.4% 7.4% 1.8% 8.1% 4.4% 9.5% 7.4% 1.7% 1.8% 8.1% 5.2% 4. Achievements
What is working in the Response PMTCT services has reduced transmission rate from mother to children from 30% to 12.4% (SIDA Report) We have 100% blood safety programme but we do not know the transmission rate through blood Peer programmes for young people are effective for promoting sexual debut What is working in the Response There is sustained change in perception through BCC. But messages need to be segregated Condom promotion is effective in casual sex and among most at risk groups but need to look at stable relationships Positive prevention among PLHIV but need to scale interventions on discordant couples
Percentage of donated blood units screened for HIV in a quality assured manner Zambia maintained 100% screening for HIV of all blood units collected in a quality assured manner for both 2006 and 2007 Data does not include blood units collected or screened by the private sector and rural facility blood transfusion practices not linked to the nine national sites. Percentage of women and men with advanced HIV infection receiving antiretroviral therapy ART programe coverage increased from 32.9% in 2006 to 70% June 2009 245,000 total on ART of which 20,000 are children 427 ART sites established nationwide with cover.
Percentage of HIV positive pregnant women who received antiretroviral prophylaxis to reduce the risk of mother to child transmission Increased from 29.7% in 2006 to 50% in June 2009 The number of sites in all 72 districts have increased from 67 in 2005 to 307 in 2006 678 in 2007, and 937, 2009 Percentage estimated HIV positive incident TB cases that received treatment for TB and HIV 39% of co infected cases receive treatment for HIV and TB Approximately 70 percent of people with TB are co infected with HIV
Percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who know their results 15% of women and men aged 15-49 have a received a test in the 12 months and know their results. 85% does not know their status Over 1500 sites established nationwide 5. Way Forward
1. Target specific populations with specific programmes in specific areas Behaviour change communication programme Social and cultural norm strengthening and change communication programme PMTCT programme Counselling and Testing programme Couples The youth Mobile populations MSM Community leaders Elders and advisors in the community All pregnant women and their partners, Couples in urban areas Individuals who request the service 2. Establish AIDS Fund This will sustain current investment by government