HIV Situation and What Next in Uganda Dr. Ario Alex Riolexus STD/AIDS Control Programme Ministry of Health February 2013 Ministry of Health

Introduction Uganda has experienced a severe HIV/AIDS epidemic over the last three decades Significant strides in addressing the problem have been made with some achievements in containing the spread. However, recent data indicate some reversals in previous gains with evidence of substantial new infections, increasing HIV prevalence, and deterioration in some behavioral indicators. Epidemiological Surveillance has been an integral component of HIV/AIDS programmes- gathering data to guide programme design and implementation. n Ministry of Health

Sources of Data on the Magnitude and Dynamics of HIV/AIDS National HIV Sentinel surveillance system of Ministry of Health Periodic National HIV/AIDS serological surveys Demographic and Health surveys have a module on HIV/AIDS Public Health Evaluation – special studies Longitudinal studies that survey populations in selected areas e.g.. Rakai project and MRC project in Masaka and Sembabule Other facility based and population based surveys and Research programmes Mathematical Modeling and Projections Ministry of Health

The Uganda AIDS Indicator Survey Previous National Population-Based Serological Surveys were conducted in 1988 & 2004-05 The 2011 UAIS was conducted to update HIV/AIDS indicators, provide data on new indicators e.g. CD4 T-cell counts as well as trends for several programme indicators

Trends of HIV Sero-prevalence among Urban Antenatal sites 1989 -2010

HIV Estimates Parameter No % No. of HIV Infected People: Total   Total 1,390,732 Males 625,521 45 Females 765,210 55 Adults 15 yrs+ 1,201,841 86 Children 0 – 14 yrs 188,891 14 No. of New HIV Infection 2011 145,294 68,097 47% 77,197 53% 124,659 86% 20,635 14% No. of AIDS Deaths 62,365 30,124 48 32,241 52 Ministry of Health

HIV among different groups; including MARPs in Uganda

Comprehensive Knowledge of HIV & AIDS Percent of women and men age 15-49 who say that: *Comprehensive knowledge means knowing that the risk of getting HIV can be reduced by using condoms and limiting sex to one uninfected partner, knowing that a healthy looking person can have HIV, and rejecting the two most common local misconceptions about HIV prevention and transmission.

Trends in Comprehensive Knowledge of HIV Percent of women and men age 15-49 with comprehensive knowledge* of HIV *Comprehensive knowledge means knowing that the risk of getting HIV can be reduced by using condoms and limiting sex to one uninfected partner, knowing that a healthy looking person can have HIV, and rejecting the two most common local misconceptions about HIV prevention and transmission.

Trends in Knowledge of Prevention of Mother-to-Child Transmission Percent of women and men age 15-49 who know that HIV can be transmitted by breastfeeding and that the risk of MTCT can be reduced by the mother taking drugs during pregnancy

Age at First Sex and at First Marriage Median age at first marriage and first sexual intercourse for women and men age 25-49 The interval between age at first sex and marriage is about 1 yr for women and 5 yrs for men Men therefore have a longer period to engage in pre-marital sex And when girls decide to marry, they are likely to marry young men who have been involved in premarital sex

Multiple Sexual Partners Among women and men age 15-49 who had 2+ sexual partners in the past 12 months, percent who: Percent of women and men age 15-49 who had sex in the past 12 months: Among women and men age 15-49 who have ever had sexual intercourse

Trends in Multiple Sexual Partners Among women and men age 15-49 who had sex in the past 12 months, percent who had 2+ partners in the past 12 months

Extra marital Sex Percent that extra Marital Sex Condom Use at last extra-marital Sex

Payment for Sex and Alcohol use During Sex 2% of all men age 15-49 report paying for sexual intercourse in the last 12 months. Among those who reported paying for sexual intercourse in the past 12 months, 49% reported using a condom at last paid sexual intercourse. Among women and men age 15-49 who had sexual intercourse in the past 12 months, 24% of women and 25% of men report that either they or their partner drank alcohol. 18% of women and 17% report they either they or their partner was drunk.

Condom Use at First Sex by Residence Among women and men age 15-24 who have ever had sex, percent who used a condom at first sex

Trends in Premarital Sex Percent of never-married women and men age 15-24 who had sexual intercourse in the last 12 months

Premarital Sex and Condom Use Among never-married women and men age 15-24 who had sexual intercourse in the past 12 months, percent who : Percent of never-married women and men age 15-24 who:

Trends in Condom Use at Last Sex Among Never-Married Youth Among never-married women and men age 15-24 who had sexual intercourse in the last 12 months, percent who used a condom at last sex

Cross Generational Sex: 15 – 19 Yr old girls Among women age 15-19 who had sexual intercourse in the past 12 months, 13% had sexual intercourse with a man 10+ years older.

Trends in Prior HIV Testing Percentage of women and men age 15-49 who have ever been tested for HIV and received the results 92% of women and 91% of men age 15-49 know where to get an HIV test. Currently, two-thirds (66%) of women report ever being tested for HIV and received their results, a marked increase from 13% in 2004-05. HIV testing among men has increase four-fold, from 11% in 2004-05 to 45% in 2011. Overall, 72% of pregnant women reported prior testing and receiving their results during antenatal care.

HIV Testing During Pregnancy Among women who gave birth in the two years before the survey, 72% were tested for HIV during antenatal care and received the results.

HIV prevalence by self-reported prior HIV testing Self-reported HIV status from testing prior to the survey Women Men Total % +   Previously tested, received results 9.7 7.8 9.0 Positive 95.6 88.6 93.4 Negative 4.3 3.5 4.0 Other  11.5 (21.1) 15.1 Did not receive results 9.6 7.9 9.1 Not previously tested 5.2 4.6 4.8 Total 15-49 8.3 6.1 7.3

Trends in HIV Prevalence Percent HIV-positive Overall, HIV prevalence among women and men age 15-49 has increased from 6.4% in the 2004—05 UAIS to 7.3% in the 2011 UAIS. It is important to remember that an increase in HIV prevalence is not necessarily a sign of ineffective HIV prevention programs; an increase in HIV prevalence could be a result of an increase in the uptake of antiretroviral (ARV) medication, resulting in more people with HIV living longer.

HIV Prevalence by Age Age Percent HIV positive Women become infected at younger ages than men. Prevalence for both women and men increases with age until it peaks at age 35-39 for women (12.1%) and at age 40-44 for men (11.3%). Age

HIV Prevalence by Region West Nile 4.9% Mid Northern 8.3% Uganda 7.3% North East 5.3% Kampala 7.1% Percent HIV-positive women and men age 15-49 who are HIV-positive Central 2 9.0% Mid Western 8.2% Mid Eastern 4.1% HIV prevalence ranges from a low of 4.1% in Mid Eastern region to a high of 10.6% in Central 1 region. East Central 5.8% South Western 8.0% Central 1 10.6%

HIV Prevalence by Region 2004-5 Vs 2011 Uganda 7.3% West Nile 4.9% Mid Northern 8.3% North East 5.3% Kampala 7.1% Percent HIV-positive women and men age 15-49 who are HIV-positive Central 2 9.0% Mid Western 8.2% Mid Eastern 4.1% HIV prevalence ranges from a low of 4.1% in Mid Eastern region to a high of 10.6% in Central 1 region. East Central 5.8% South Western 8.0% Central 1 10.6%

HIV Prevalence by Education Percent HIV-positive

HIV Prevalence by Wealth Quintile Percent HIV-positive Poorest Richest

HIV Prevalence by Marital Status Percent HIV-positive HIV prevalence is highest among those who are widowed. HIV prevalence is also high among divorced and separated men and women. Women and men who have never been married are least likely to be HIV-positive. Figures in parentheses are based on 25-49 unweighted cases.

Discordance among Couples Among couples where both partners were tested, percent distribution by discordance Among couples where both partners were tested for HIV, 6% were discordant, which means one partner is HIV-positive and the other is not.

Discordance Among Couples

HIV Prevalence by Circumcision and Age Percent HIV positive Age

HIV Prevalence by Sexually Transmitted Infections Among women and men age 15-49 who ever had sexual intercourse and who were tested for HIV, percent HIV-positive

HIV Prevalence among Youth Percent of women and men age 15-24 HIV-positive Overall, 3.7% of young women and men age 15-24 are HIV-positive. HIV prevalence among young women is markedly higher than among young men, except for youth age 15-17 where there is nearly no difference in HIV prevalence between women and men.

Trends in HIV Prevalence among Youth Percent HIV-positive women and men age 15-24

HIV Prevalence among Children Percent of children under age five who are HIV-positive 0.7% of Uganda children under age five are HIV-positive. There is no variation in HIV prevalence among children by gender or urban-rural residence.

Summary-1 HIV prevalence high at 7.3 % with regional heterogeneity Higher prevalence amongst MARPs and women New infections increasing (124,000 in 2009, 130,000 in 2010, 145,000 in 2011)

Summary-2 Stable and low prevalence amongst children and lower youth groups respectively Age at 1st sexual debut high HIV transmission is still predominantly heterosexual – 78%, MTCT – 19%, 1-3% others

Summary-3 Comprehensive knowledge low The lower HIV prevalence among circumcised respondents compared to uncircumcised Multiple sexual partnership and extramarital sex high – amongst men Condom use low and going down

Summary-4 Alcohol and commercial sex playing a significant contribution to HIV transmission HIV testing increasing especially amongst women and in ANC clinics Wealth and low education a risk factor in women

Summary-5 Married and widowed more infected. Discordance high Cross-generational sex on the increase

Why has the Epidemic gone up? 1 Most interventions are on a scale that is insufficient to make significant public health impact. Most HIV prevention interventions are not aligned with sources of new infections. Complacency has led to a reversal of widespread risky sexual behaviour and low levels of comprehensive knowledge about HIV prevention. Ministry of Health

Why has the Epidemic gone up? 2 Socio-economic and structural factors Multiple concurrent partnerships Polygamy MARPs Poverty Lifestyle - Alcohol consumption, phonography, peers etc Urbanization Mobility Discordance Stigma and discrimination Ministry of Health

Why has the Epidemic gone up? 3 Health system weaknesses Leadership Service delivery - Inequitable access to health services etc HRH Diagnostics, Logistics and SCM MIS Financing Ministry of Health

What needs to be done? The Global Trend Treatment 2.0 - 2010 Creating better pills and diagnostics Strengthening community mobilization Stop cost being an obstacle Improve uptake of HIV testing and linkage to care Treatment as Prevention Ministry of Health

What needs to be done? The Global Trend Political declaration 2011 on Targets and Elimination Commitments Reduce sexual transmission of HIV by 50% by 2015 Eliminate new HIV infections among children by 2015 and substantially reduce AIDS-related maternal deaths. Reach 15 million people living with HIV with life saving antiretroviral treatment by 2015. Reduce tuberculosis deaths in people living with HIV by 50 percent by 2015. Towards Zero – Zero New Infections, Zero HIV Related deaths, Zero Discrimination Towards an AIDS Free Generation Ministry of Health

What needs to be done? There is need for effective , comprehensive and intensified evidence informed interventions for long-term sustainability of successful HIV and AIDS programs and averting of rising new infections. Build strong partnerships guided by mutual cooperation and strong country ownership principles Ministry of Health

What needs to be done? Acknowledge that the only one single intervention that would bring down HIV is a vaccine and probably a cure which is still not less than a decade or two away – it’s a longer term trajectory. So in the interim, no one single intervention will do the miracle rather a combination of strategies – Combination Prevention Ministry of Health

What needs to be done? The country has come up with the HIV Prevention Strategy which addresses the epidemic through: increasing adoption of safer sexual behaviours and reducing risk taking behaviours; expanding critical coverage and utilization of biomedical prevention interventions; and creating a sustainable enabling environment that mitigates underlying socio-cultural and other structural drivers of the epidemic. Ministry of Health

What needs to be done? The strategy sets ambitious targets for a combination of HIV prevention interventions which include: evidence informed behavior change interventions, HTC, eMTCT, scaling up ART, SMC, creating condom demand and utilization, targeting high risk populations etc Ministry of Health

What needs to be done? In addition to combination prevention, addressing health system issues is at the forefront – improved coordination and partnerships, leadership, innovative domestic financing, improved and harmonized information systems, HRH, streamlined SCM, diagnostics, effective community structures Ministry of Health

Interventions Promote ABC as the core prevention strategy Create demand and increase availability and utilization of condoms Increase HTC coverage and linkage to care Implement eMTCT plan focusing on all the four prongs including roll out of Option B+ Ministry of Health

Interventions Scale up treatment for PLHIV including children Scale up EID, follow up of babies and mothers and link them to care Treatment as Prevention – Discordance Prompt management of STI and OIs Comprehensively target MARPs Ministry of Health

Interventions Roll out SMC as part of the comprehensive prevention package Strengthen patient monitoring Strengthen surveillance, monitoring and evaluation Set benchmarks that are regularly assessed to assure goals are being met Ministry of Health

In conclusion, We need to: Move our interventions to scale Target source of new infections and drivers of epidemic Design appropriate messaging Propagate a “care continuum” – create demand, test, link to care, treat eligible, retain in care and ensure adherence Ministry of Health

Thank You Ministry of Health