Know Your epidemic: The value of population-based household surveys Eva Kiwango Senior Strategic Information Advisor United Nations Joint Programme on HIV/AIDS (UNAIDS)

Presentation Outline 1.Information and epidemiological insights provided by population based surveys for high transmission geographies and priority populations; 2.UNAIDS Fast Track Targets 3.Highlight future directions and additional information that is derived from population-based surveys in order to measure critical HIV program outcomes and impacts. 4.Summary key points

Determination of progress towards National Strategic Plan, MDGs, and the UN political declaration of commitments’ HLM targets. 1 Halve sexual transmission 2 Halve infections among PWID 3 Eliminate new HIV infections among children and halve AIDS-related maternal deaths 4 15 million people on HIV treatment 5 Halve TB deaths among people living with HIV 10 Eliminate parallel systems, for stronger integration 9 Eliminate travel related restrictions 8 Eliminate stigma and discrimination 7 Eliminate gender inequalities and sexual violence and increase capacities of women and girls 6 Close the global resource gap and achieve annual investment of US$ 22B-24B

Number of prevalence surveys Information and epidemiological insights: HIV prevalence by sex and age Source: P. Ghys, M. Mahy, T. Rehle CROI 2014 Source: HSRC 2012

Information and epidemiological insights: Adjusting estimated prevalence from ANC data

Information and Epidemiological insights: Sub-national HIV Prevalence (Source: HSRC 2012)

Information and Epidemiological insights: Sub-national HIV Prevalence HIV Prevalence among persons aged 15 – 64 years by region (KAIS, 2012)

Information and epidemiological insights: Condom Use at last sex by age groups and sex. South Africa 2002, 2005, 2008 and 2012 (Source: HSRC)

2. UNAIDS Fast Track Targets

Fast-Track action towards achieving the by 2020 The Fast-Track Targets include: 90% of people living with HIV knowing their HIV status. 90% of people who know their status on treatment. 90% of people on treatment with suppressed viral loads. Other targets include – reducing the annual number of new HIV infections to in 2020 and in 2030; and – achieving zero discrimination

The Fast Track targets are firmly based on an approach to leaving no one behind Close the gap between people who have access to HIV prevention, treatment, care and support services and people who are being left behind —young women and adolescent girls, men who have sex with men, migrants, prisoners, sex workers, people who inject drugs. We also need to focus on children and adolescents, who continue to be left behind (UNAIDS GAP report 2012). – AIDS is the leading cause of death among adolescents in Africa. – Children are 37% less likely to have access to treatment than adults.

3. Highlight future directions and additional information that is derived from population- based surveys in order to measure critical HIV program outcomes and impacts.

Future Directions 1. Expanding the age range of the sampled population: Surveys can provide additional information on the HIV epidemiology At the lower end among children (to date few surveys have included children) – South Africa: HIV prevalence among children aged years suggest a reduction in HIV prevalence (PMTCT, children aging out of cohort?) At the higher end among people over 50 years of age. – Important levels of HIV prevalence among 50+

Future Directions 2. National HIV Incidence: The recent development and availability of a reliable HIV incidence assay means that HIV incidence can and should be measured as a routine component of population-based surveys. 3. Immunologic Status (CD4 Cell Count): Measurement of CD4 cell counts in people living with HIV is used to assess the proportion of persons who are eligible for treatment (already on ART as well as not on ART); and Provides information on the population-level reach of the treatment response.

Future Directions 4. ART Coverage: Subnational trends in this measure provide crucial information on progress and gaps, and can inform resource allocation to achieve coverage goals according to epidemic distribution. Obtaining information on the characteristics of persons who do not access care is important for program improvement to more effectively meet the needs of people living with HIV.

Future Directions 5. High transmission geographies and populations: Geographic Location: Sub national HIV prevalence and incidence trends provide crucial information on progress and gaps, and can inform resource allocation to achieve coverage goals according to epidemic distribution. –District –High-Transmission Areas: e.g. informal settlements, truck routes etc. Populations left behind: Obtaining information on the characteristics of persons who do not access care is important for program improvement. – Young women, adolescents, men who have sex with men, prisoners, sex workers, migrants, people who inject drugs.

Future Directions 6. Continuum of Care among People Living with HIV HIV-infected persons aged 15 to 64 years, KAIS 2012

Future Directions 7. Community viral load suppression: Viral Load suppression reflects adherence to HIV treatment and quality of ART programs. These measures inform programs about the population-level suppressive effect of ART and about further HIV transmission potential. Viral suppression among HIV-infected persons aged years on ART, KAIS 2012 Viral suppression among HIV-infected persons aged years, KAIS 2012

Viral load suppression among HIV-infected women and men aged years in HIV discordant relationships, KAIS 2012

4. Summary Key Points 1.A wealth of information and epidemiological insights provided by HIV surveys - understand how much progress has been made and how far HIV programs still have to go to achieve population-level coverage and quality » Fast Track Targets ; » reducing the annual number of new HIV infections; and » achieving zero discrimination 2.Additional information that should be derived from population-based surveys in order to measure critical HIV program outcomes and impacts. » Sub-provincial level estimates of people who are being left behind by geographic area (micro-epidemics) » Continuum of Care among People Living with HIV » Immunologic Status (CD4 Cell Count) » Viral Suppression

Key References 1.CDC (2014): COPFY14 Supplemental Guidance Clarification on Information, Design and Cost Considerations for Population-based Surveys to Measure HIV Outcomes and Impact (draft version) 2.Ghys P D, Mahy M, Rehle T (2014): Know Your Epidemic, Know Your response: Data for Action: Population Surveys: What Do They Show? Presentation at CROI Shisana, O, Rehle, T, Simbayi LC, Zuma, K, Jooste, S, Zungu N, Labadarios, D, Onoya, D et al. (2014) South African National HIV Prevalence, Incidence and Behaviour Survey, Cape Town, HSRC Press. 4.NDOH, CDC and UNAIDS (2014): Mapping HIV micro-epidemics in South Africa: Insights on high transmission geographies and key populations (draft) 5.UNAIDS (2014): UNAIDS Fast Track: Ending the AIDS Epidemic by UNAIDS RST report 7.UNAIDS Global report