Carael Michel Free University of Brussels UNAIDS IUSSP Seminar: HIV, resurgent infections and population change in Africa What are the priority approaches needed to control the HIV epidemic in Africa? Carael Michel Free University of Brussels UNAIDS

What are the priority approaches needed to control the HIV epidemic in Africa?

The last decade in sub-Saharan Africa… Socio-economic conditions Deteriorating economic conditions and food production Increased indebtedness in 22 out of 48 countries Inadequate spending on health and education; deterioration in girls enrolment in secondary schools Increased insecurity, conflicts and migration

Young women/men (aged 15-24) living with HIV/AIDS, 2001 Europe 118,000 / 395,000 Americas 290,000 / 420,000 Asia & Pacific 1 million / 790,000 Africa 5,7 million / 2,8 million

Concept of Thresholds In simple models (uniform mixing) R0 is the basic reproductive rate  is the transmission probability/partner c is the number of partners/time D is average duration of infectiousness If R0 < 1 epidemic dies out

Rapid transmission of HIV among young women 70 60 HIV prevalence % 50 Women - 15-19 40 Women - 20-24 30 20 10 Kisumu, Kenya, 1997 Lusaka, Zambia, 1995 Mposhi, Zambia, 1996 Ndola, Zambia 1997 Kisesa, Tanzania, 1997 Cotonou, Benin 1997 Masaka, Uganda 1989 Masaka, Uganda 1996 Yaounde, Cameroon 1997 Fort Portal, Uganda 1995 Carletonville, South Africa, 1998 Mutasa district, Zimbabwe, 1998

HIV prevalence among young people A South African mining town by number of lifetime partners A South African mining town 20 40 60 80 100 No. of lifetime partners Women Men 0 1 2 3 4 5 6 7 8 9 10 11 HIV (%)

Young women aged between 15-19 who have had sexual intercourse 20 40 60 80 Côte d'Ivoire Ghana Kenya Madagascar Mali Mozambique Senegal Tanzania Uganda Zambia Zimbabwe % never-married ever-married Source: DHS

Prevalence of STIs among girls aged 15-19 60 50 % 40 Kisumu 30 20 Ndola 10 HSV-2 HIV Syphilis Trichomo Chlamydia Gonorrheoa

HSV-2 prevalence among young people by number of lifetime partners 100 HSV-2 (%) 80 Women Men 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 No. of lifetime partners

Increased HIV sero-conversion is associated with HSV-2 Longitudinal study in rural Tanzania 2.4 16.8 HSV-2 sero-conversion 1.3 6.1 HSV-2 positive at baseline 1 HSV-2 negative Women Odds Ratio Men Odds Ratio Age group 15-24 Source: M.Rodriguez et al. in press

Meta-analysis of the relationship between male circumcision and HIV: strong protective effect .05 .1 .2 .3 .4 .5 1 2 3 4 5 Source:Weiss et al. AIDS, 2001 Adjusted Odds Ratio 12

Early age at first sex leads to increased No. of premarital partners Early age at first sex leads to increased No. of premarital partners. Men No. of premarital partners 6 Lusaka 5 Tanzania 4 Côte d’Ivoire 3 2 1 <15 years 15-19 years 20+ years Age at sexual debut

Odds ratio of male extra marital sexual intercourse in the last year Age at sexual debut Côte d’ivoire Tanzania Lusaka Less than 15 years 1.00 15-19 years old 0.61 0.63 0.97 20-24 years old 0.21 0.38 0.60

Male partners of young girls are older. Rural Zimbabwe 10 8 Age gap with male partner, Years 6 4 2 17 18 19 20 21 22 23 24 Current age of young girls Source: Gregson et al. 2001

HIV spread is more rapid among young female urban poor: a multivariate analysis in Nairobi Slum youth residents initiate sex three years earlier than non-slum residents They have more sexual partnerships They use condoms less often Economic deprivation is the driving force behind HIV Source: Zulu et al, in press

Rapid HIV infection in young women Low socio-economic status, urban poor Large age difference with male partner Loss of virginity Gender inequality Forced sex Asymptomatic/ untreated STI (HSV-2) No or little schooling Early age at first sex Immature genital tract Vulnerability Behavioural factors High susceptibility Single exposure to HIV increased 10-300-fold

From rhetoric to action HIV prevalence in persons 15-24 years old should be reduced 25% by 2005 in the most affected countries UNGASS declaration 2001

Will the next years be different? Improved context for HIV control in young people 29 countries with debt relief plans, with funds earmarked for HIV Increased global funds for HIV-prevention and care Governments committed to spend at least 15% of budget on health and education AIDS as a development and human security issue

Will the next years be different? What must change… Young people’s health has been a low priority due to: Pressure for palliative/curative care in adults High child mortality and morbidity Youth not considered as producers Social denial of young people sexuality

HIV control priorities A youth-serving agenda Reduce early exposure to HIV Reduce susceptibility to HIV transmission Build an empowering environment at community level Reduce inequalities that increase vulnerabilities

A mix of mutually reinforcing approaches Sexual health education Social mobilization Youth-friendly services

Education on sexual health: Lessons learned Community support is the cornerstone of success Support learning with counselling, services & commodities Peer education with gender sensitivity and life-skills Less emphasis on reproduction, more on interpersonal sexual relations Reviews in Zimbabwe, Tanzania, Uganda

Percentage of women age 20-24 who first had sex by age 18, by education Burkina Cameroon CAR Ghana Kenya Mali Niger Tanzania Zimbabwe 100 80 60 40 20 None Prim Sec+ Source: DHS

Youth as a critical population Easier to maintain/change norms and behaviours before patterns are formed Accessible in large numbers through existing institutions Powerful prevention resource in their own right

HIV prevalence in 15-19-year-old pregnant women, Kampala and Lusaka Kampala, Uganda Lusaka, Zambia 30 25 20 15 10 5 % HIV 90 91 92 93 94 95 96 97 98 99 year