Policy Overview and Status of the AIDS Epidemic in Zambia

Dr Ben ChirwaDirector General

National HIV/AIDS/STI/TB Council

NACZAM B IA

GOVERNMENT OF ZAMBIA NATIONAL AIDS COUNCIL

Contents

1. Status of the Epidemic1. Status of the Epidemic 1. Status of the Epidemic1. Status of the Epidemic

2. Blind Spots2. Blind Spots 2. Blind Spots2. Blind Spots

3. Policy/strategy3. Policy/strategy 3. Policy/strategy3. Policy/strategy

4. Achievements4. Achievements 4. Achievements4. Achievements

5. Way Forward 5. Way Forward 5. Way Forward 5. Way Forward

1. Status of the Epidemic1. Status of the Epidemic1. Status of the Epidemic1. Status of the Epidemic

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%

HIV Prevalence

0720.8

0714.5

0715.2

076.9

0717.5

0713.3

0710.3

01 8.3

0717.0

0113.1

0117.6

0122.0

0115.3

019.2 0119.9

0113.7

07 6.8

0111.2

01 = year 2001/207 = year 2007

Source: ZDHS 2007

Prevalence in Zambia by Province 2001/2 – 2007

6

Comparison HIV Prevalence by Province for 2001/2 and 2007

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Lusaka Central C/belt Western Southern Luapula Eastern N/western Northern2001-2 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%

22.0%

15.3%

19.9%

13.1%

17.6%

11.2%

13.7%

9.2% 8.3%

20.8%

17.5% 17.0%15.2% 14.5%

13.2%

10.3%

6.9% 6.8%

HIV

Pre

vale

nce

Changes in Provincial HIV Prevalence between 2001/2 and 2007 ZDHS Results

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

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)

Highest: Lusaka = 22% (2002)/ 20.8% (2007)Lowest: Northern = 8.3% (2002)/ 6.8% (2007)

7

Trend of HIV Prevalence Among Youths from 1994 to 2006 showed decline Based

Trend of HIV Prevalence Among Youths from 1994 to 2006 showed decline Based

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%

14.1%

10.9%12.6% 11.7%

8.7%

21.9%20.7%

19.2%18.1%

15.5%18.8%

16.6%16.4%

15.9%

12.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Perce

ntag

e of Y

outh

Infe

cted

Trends in HIV infection among youths 15-24 from 1994 to 2006

HSS Report 2006

1994 1998 2002 2004 2006

HIV Prevalence 20.0% 18.6% 19.1% 19.0% 16.7%

20.0%

18.6%

19.1%

19.0%

16.7%

15.0%

16.0%

17.0%

18.0%

19.0%

20.0%

21.0%

Axis T

itle

Trend ANC Sentine Surviellance HIV Prevalence 1994-2006

There is increase in HIV prevalence in some sites-HIV % prevalence by year of ANC SS survey, 7 sentinel

sites, Zambia, 1993-2006

0

5

10

15

20

25

30

35

40

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

HIV

Pre

vale

nce in

Su

rvey S

ites

Kalabo Macha Chelstone Chilenje

Kalingalinga Matero Nchelenge Mean Rate

Status of the Epidemic

0

200000

400000

600000

800000

1000000

1200000

1400000

Tota

l po

pu

lati

on

15

ye

ars

an

d o

lde

r

Year

Total population

Total new infections

Total deaths

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

0

0.5

1

1.5

2

2.5

3

3.5

4

4.51

97

0

19

72

19

74

19

76

19

78

19

80

19

82

19

84

19

86

19

88

19

90

19

92

19

94

19

96

19

98

20

00

20

02

20

04

20

06

20

08

20

10

20

12

20

14

Pe

rce

nta

ge o

f a

nn

ua

l ne

w in

fecti

on

s

Year

Males Females Total

Estimates HIV Incidence trend in Zambia

FigureRegression of HIV incidence among adults by year of end of

observation of cohort in different districts in Zambia

y = -0.1529x + 314.53R² = 0.0618

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

HIV

incid

ence

End year of cohortSource: USBUCEN HIV Global HIV database

2. Blind Spots2. Blind Spots 2. Blind Spots2. 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

Kaizar P. Zulu etal, 2004

ANAL Practice in different sub-pop

STI syndromes by Gender based on DHS 2007

0

1

2

3

4

5

6

7

STI Bad smelling/abnormal genital

discharge

Genital sore/ulcer STI/genitaldischarge/sore or

ulcer

STI Bad smelling/abnormal genital

discharge

Genital sore/ulcer STI/genitaldischarge/sore or

ulcer

Females Males

Reporting STI syndromes

% p

reva

lenc

e

Total 15-49

ZDHS 2007

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

• Note that women receive only slight deferred benefit from MC – still need to promote other strategies

Male Circumcision

Central Copperbelt Eastern Luapula Lusaka Northern North-Western

Southern Western TOTAL

Percentage of men 15-49 who report having been circumcised

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.

• Migrant labour is associated with both males and females seeking partners outside marriage and has been a leading factor in the spread of STIs.

MODE OF TRANSMISSION MODELLING OF INCIDENCE:

Distribution of new infections by mode of exposure in the adult population

0 5 10 15 20 25 30 35 40

Injecting Drug Use (IDU)

Partners IDU

Sex workers

Clients

Partners of Clients

MSM

Female partners of MSM

Casual heterosexual sex

Partners CHS

Low-risk heterosexual

No risk

Medical injections

Blood transfusions

Risk

gro

up

Percent

MOT Report 2008

Adult Risk Behavior Incidence

% of 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

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

prevalence

PLHA

incidence

Current response: prevention

determinants ofincidence

Current response: care and treatment

deathSource: ASAP Training, 2007

Drivers of Epidemic

Multiple and concurrent sexual partners

lack of male circumcision

low rates of condom use

high alcohol and drug abuse

Low Risk Perception

High mobility

High STIRisky cultural practicesGender based violence

High STIRisky cultural practicesGender based violence

Key Performance Indicators of the Response

0% 20% 40% 60% 80% 100%

KNOWLEDGE

HCT

PMTCT

ART

Zambia

2005 achievement 2007 achievement 2010 targets

3. Policy/strategy3. Policy/strategy 3. Policy/strategy3. Policy/strategy

‘3 Ones’ principles application

One national AIDS strategic framework 2006-2010

One national coordinating body - the NACReports to Cabinet Committee on AIDSDecentralised structuresStakeholders coordination through self-coordinating groups

including Cooperating partners

One M&E system

Multisectoral ResponseMultisectoral Response

National Goal, Vision and Mission

Universal

access

Halt and begin to revise spread

and mitigate impact

Multisectoral Response

Coordinated by NAC

A nation free from A nation free from the threat of HIV and the threat of HIV and

AIDS.AIDS.

Integrated into

dev agenda

Scale up prioritized actions

Prevention Response

PTS,MC, B

CC, STI,

Wor

kpla

ce

PMTC, health care settin

gs

Package

Blood safety

PEP, Injection safety

Stigma and Discrimination

CT

Comparison of Distribution of Spending by Category for 2005 and 2006

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Prevention Treatment Care and Support

Mitigation and Social

protection

Advocacy and Coordination

Mainstreaming and

Decentralization

Monitoring Evaluation and

research2005 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%

28.0%

36.1%

19.5%

9.5%

1.7%5.2%

26.1%

52.3%

4.4%7.4%

1.8%

8.1%

Perce

ntag

e Spe

nt on

Them

atic A

rea

Comparision of Percentage of Total AIDS Funds Spent on Specific Thematic Area Between 2005 and 2006

4. Achievements4. Achievements 4. Achievements4. 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 anti-retroviral 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 5. Way Forward 5. Way Forward 5. Way Forward

1. Target specific populations with specific programmes in specific areasBehaviour change communication programme

Couples The youthMobile populationsMSM

Social and cultural norm strengthening and change communication programme

Community leadersElders and advisors in the community

PMTCT programme All pregnant women and their partners,

Counselling and Testing programme Couples in urban areasIndividuals who request the service

2. Establish AIDS Fund

• This will sustain current investment by government