Www.monash.ac.za Country to provincial review: Developing an understanding of the North West...

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Country to provincial review: Developing an understanding of the North West response

within the national context: A KYR/KYE perspective

Prof Keitshepile Geoff SetsweNW Business Sector Conference on Health and Wellness

Sun City 6 July 2011

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In this presentation

• Know Your Epidemic (KYE) in SA and North West province• Know Your Response (KYR) in North West

– Antiretroviral treatment coverage– PMTCT– HCT– STI– Male medical circumcision– Blood and blood products– Self-reported behaviours– Sexual debut– Multiple sexual partners– Condom distribution– Factors supporting and hindering HIV prevention in NW

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SOUTH AFRICAN NSP FOR HIV/AIDS 2007 TO 2011

4 KEY PRIORITY AREAS TO RESPOND TO THE EPIDEMIC

PREV

ENTI

ON

TREA

TMEN

T, C

ARE

&

SUPP

ORT

HU

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HTS

& A

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JUST

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MO

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The primary prevention goal of the NSP is to reduce the national HIVincidence rate by 50% by 2011.

A mid-term review (MTR) and a KYE/KYR synthesis were conducted in late 2009 to assess performance in the implementation of the NSP for 2006-2008.

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Epidemiological Review(HSRC)

Prevention policies, response and strategic info

review(HSRC)

Review of resources for

prevention(CEGAA)

“Know your epidemic”

(KYE)

“Know your response”

(KYR)

Components of the HIV Know Your Epidemic, and Know Your Response Synthesis

Incidence data (modelled)

(SACEMA)

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Data collection for KYR in North West: Workshops in the districts and participation levels

District Venue for workshops Participants

Number of participants

Bojanala Rustenburg Civic Centre

Civil and public sectors

35

Dr Kenneth Kaunda PCA offices, Klerksdorp


55

Ruth Mompati Huhudi Community Hall


53

Ngaka Modiri Molema

Scotts Manor Lodge, Lichtenburg


50

Total 193

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National HIV prevalence

• SA has over 5.6 million people living with HIV (PLHIV). Worldwide, one in six PLHIV is in South Africa.

• SA has made significant progress in scaling up some key interventions.

• However, the number of new infections continues to outstrip the number of AIDS-related deaths - an indication that prevention efforts are failing to keep pace with the HIV epidemic.

Source: SANAC (2011) The HIV epidemic in South Africa: What do we know and how has it changed.

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National HIV prevalence

• HIV prevalence has stabilized. In adults aged 15-49 years, the three HSRC surveys estimated HIV prevalence at 15.6% (2002), 16.2% (2005) and 16.9% (2008).

• In ANC clients, HIV prevalence has gradually levelled off - estimates for 2006, 2007, 2008 and 2009 are very similar with 29% sampled ANC clients HIV positive

• Although HIV prevalence is stable, the total number of PLHIV is on a steep increase of approximately 100,000 additional PLHIV each year due to population growth and the effect of ART reducing the mortality rate to below the HIV incidence rate.

Source: SANAC (2011) The HIV epidemic in South Africa: What do we know and how has it changed

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HIV prevalence in 4 health districts of the North West, 2009

Source: Setswe et al (2011) KYR component 3 report: HIV&AIDS policies and programmes in the North West Province

The 2005 national HIV survey among antenatal attendees indicates that 29% of pregnant women in the North West Province were HIV positive

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HIV prevalence among the population aged 2 and older in North West, 2002, 2005, 2008

Sources: Spectrum estimations and mid-year population estimates from www.statssa.gov.za

North West HIV Prevalence among the Population Age 2 and Older

10%11%

11%

0%

2%

4%

6%

8%

10%

12%

2002 2005 2008

Source: South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2008

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10Sources: Estimated population 15-49 years in mid-2008 from SSA website times-series data, HIV prevalence in persons aged 15-49 years in 2008 from Shisana et al. (2009), table 3.10.

FS6%

EC11%

MP10%

LP8%

WC3% NC

1%

KZN33%

GP21%

NW7%

Estimated number of PLHIV aged 15-49 yearsin each province (2008)

7% of PLHIV aged 15-49 years in 2008 were in the North West province

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Summary: HIV&AIDS situation in North West, 2008

• Whole population 13% (of 3.2m)• Antenatal clinic estimate 30%• Adults (ages 20 - 64) 22%• People living with HIV 496,000• New HIV infections (over the year) 43,000• AIDS deaths (over the year) 34,000• Total people in need of ART (mid year) 92,000• Total people accessing ART (mid year) 43,000• Accumulated AIDS deaths 225,000• New infections per day 117• New deaths per day 93

Source: Nicolay N (2008). Summary of provincial HIV and AIDS statistics in South Africa. Metropolitan

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Estimated numbers of adults and children receiving Anti-Retroviral Treatment in South Africa and North

West province, 2006 - 2008• Provision and initiation of patients on the ARV programme in the province

was done at 31 accredited health facilities by the end of 2008.

• In 2008, 80% of adults and children in NW province obtained their ART from the public health service, 14% from disease management programmes (DMP) and 6% from NGOs.

• About 92,000 people were in need of antiretroviral treatment in 2008 with around 47% having taken up treatment.

• 2010/11 in NW: 78,238 before campaign to 127,301 after campaign

Source: Adam and Johnson, 2009.

2006 2007 2008

Total enrolled in South Africa 229 000 371 000 568 000

Number enrolled in North West (NW)

20 500 33 000 46 000

Percentage of national coverage 9.0% 8.9% 8.1%

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PMTCT and child HIV prevalence

• The PMTCT intervention is believed to be the main factor leading to a halving of the HIV prevalence level in children aged 2-14 years between 2002 and 2008.

• By 2008, 95% of public health facilities provided PMTCT services in SA.

• It is plausible that many of the HIV-positive older children identified in the national surveys were infected vertically and 1/3 are slow progressors with median survival of 16 years.

Sources: HSRC survey reports.

Province PHC facilities offering PMTCT

Health facilities offering PMTCT

Facilities offering Dual therapy

North West 307 326 326

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HIV counselling and testing

ProvinceEstimated Population

HCT target population

Number tested for HIV

% of target tested

North West 3,229,078 1,537,093 1,109,242 72

National 48,076,109 22,265,836 10,572,892 47

• North West province performed exceptionally well in HIV testing uptake between 2004 and 2009. • Of the 1.5m HCT target population, 1.1m people (72%) were tested for HIV during this period. This cumulative uptake was the highest of all the nine provinces and exceeded the national average uptake of 47% significantly. • 2010/11 National HCT campaign: NW = 996,220 tested; HIV+ 16.3%

Cumulative HIV testing uptake in the North West province, 2004-2009

Setswe et al (2011) KYR component 3 report: HIV&AIDS policies and programmes in the North West Province

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STI management in NW

• The incidence of STIs in the North West province dropped from 6.3% in 2003/04 to 3.8% in 2006/07 (Monticelli, 2007).

• During the review period, there was appropriate management of STIs in the province.

• There were adequately trained staff who used syndromic management guidelines to offer 100% of STI services in the public sector; this exceeded the NSP target of 60%.

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HIV and male circumcision

• SA and regional evidence that MC is effective in reducing the risk of HIV and other STIs in men, and indirectly HIV prevalence among women in the population.

• MC has broad support by SA men and women

• A shift among young men to getting circumcised in hospital instead of having traditional circumcision, and to doing MC for HIV/STI prevention & hygiene, not tradition.

• Parents of young men may play an important role in getting the young man to go for circumcision.

• During the review period, very little was happening in the North West province to offer medical male circumcision as there was no policy guidance from the national Department of Health or from the South African National AIDS Council (SANAC)


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Blood and blood products

• SA National Blood Service & Western Province Blood Transfusion Service for prevention of HIV transmission through blood

• Rigorous internal quality assurance measures• Inspected by the SA Quality Assurance Systems, other

external quality assurance procedures

• All (100%) of donated blood screened for HIV-1, HIV-2, hepatitis B and C, and syphilis. Since Oct 2005, all donations screened for HIV-1, hepatitis B and C using nucleic acid amplification

• HIV transmission through blood transfusion probably close to zero, unless there are frequent transfusions outside the control of the blood services

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Factors in the sexual transmission of HIV: overview of key indicators (self-reported behaviours)

Sources: HSCR surveys 2002, 2005, 2008

82.7 81.8

17

3.8

69.8 72.875.8 77.1

17.9

2.9

79.8

52.5

78.8 77.6

19.4

3.7

76.868.1

Young men Young women Males Females Males Females

Per

cen

t (%

)

200220052008

"A" Unmarried youth 15-24

who have had sex

"B" 2+ partners in last 12 months, adults

15-49

"C" - Condom use at last sex, adults with 2+ partners in last 12 months

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Sexual debut

• Secular trend towards earlier sexual debut amongst youth - median AFS 20 years for men & women born before 1950, 18 years for those born in 1980s.

• Sex before age 15 has significantly increased in Free State, North West and Mpumalanga between 2002 and 2008

• Young Africans report higher levels of sexual experience than Coloured, White and Indian youth

• Cape Area Panel Study found that girls in lower income households had earlier sexual debut, and that community poverty rates were associated with early sex and higher rates of unprotected sex

• In the Africa Centre study area, the most important and highly significant factor protecting females against first sex before 17th birthday was school attendance.

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Multiple sexual partners

• Frequency of reported multiple partners varies by race , highest in African men

• In 2009 NCS, 16.7% of men and 2.3% of women aged 16-55 reported >1 partner (among those who ever had sex)

• Multiple partner frequency peaks in people in their 20s, but there may be underreporting in older age groups where marriage is more common

• HIV prevalence higher in respondents reporting more sexual partners. Women reporting >1 partner at the time of survey in 2005 were 4.3 times more likely to be HIV+ (p=0.0001).

• Sexual concurrency analysis of NCS 2009 data also suggests higher concurrency rate for African men compared to Coloured, Indian and White men.

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Condom distribution and use in NW

• Young singles (not married/cohabiting) and youth reporting multiple partners are most likely to report using condoms

• More than 30 million male condoms and 500,000 female condoms were distributed in the province in 2008. Apart from public health facilities, condoms were also available to the public at entertainment places, social events and all non-public health facilities.

• The male condom distribution rate in the province remained at

around 6.5 condoms per man per year during the review period, which is substantially below the national average. This is another important HIV prevention activity that required greater managerial attention

• Condoms least likely to be used consistently in partnerships characterised by long term concurrency.

Monticelli, (2007) and Kasienyane R (2009) Budget speech of the Department of Health and Social Development for the financial year 2010/11. North West Provincial Legislature

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Factors supporting HIV prevention in the province

• Strong moral values and community awareness about HIV&AIDS.

• North West has successfully mobilised communities and facilitated partnerships around HIV&AIDS.

• Respondents pointed to a high level of commitment among community members, noting that several NGOs and CBOs have attracted the support of government and the private sector.

• Respondents also highlighted the availability of, for example, VCT and PMTCT.

• Respondents commented on the high level of political commitment to addressing HIV&AIDS both in North West and nationally.


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Factors Hindering HIV Prevention in NW

• According to respondents, North West’s large mining population contributes to the spread of HIV. Mining draws a large migrant population of mostly men who may have families in other provinces, but the miners live in NW and may have other sex partners.

• In addition, gender inequality is rife. Women, including miners’ wives, are unable to protect themselves and negotiate safe sex upon their husbands’ return.

• One respondent noted that stigma and discrimination remain a serious problem in North West.


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Summary – Successes and challenges

Reduction in HIV prevalence among children

due to PMTCT

Reduction in HIV prevalence among youth in

the province

Increased awareness of HIV serostatus – 72%

had been tested in NW in 2009

Reported condom use ↑ from 57% 2002 →

87% 2008

↑ National communication program

SUCCESSESSUCCESSES

Large number of HIV infected individuals

Young women are at ↑ risk of HIV infection

Increase in intergenerational sex

HIV prevention knowledge declined (including in

NW province)

Khomanani campaign on HIV prevention – lowest

reach of all national programs

CHALLENGESCHALLENGES

Source: HSRC Report, 2009

Www.monash.ac.za Country to provincial review: Developing an understanding of the North West...

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