1. 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

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

3. 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

4. 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

5. 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

6. Rapid transmission of HIV among young women70 60
HIV prevalence % 50
Women 40
Women 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

7. 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
HIV (%)

8. Young women aged between 15-19 who have had sexual intercourse20 40 60 80
Côte d'Ivoire
Ghana
Kenya
Madagascar
Mali
Mozambique
Senegal
Tanzania
Uganda
Zambia
Zimbabwe %
never-married
ever-married
Source: DHS

9. Prevalence of STIs among girls aged 15-1960 50 % 40
Kisumu 30 20
Ndola 10
HSV-2
HIV
Syphilis
Trichomo
Chlamydia
Gonorrheoa

10. HSV-2 prevalence among young people
by number of lifetime partners
100
HSV-2
(%) 80
Women
Men 60 40 20
No. of lifetime partners

11. 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

12. 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

13. 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

14. 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

15. Male partners of young girls are older. Rural Zimbabwe10 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

16. 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

17. 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 fold

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

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. 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

26. HIV prevalence in 15-19-year-old pregnant women, Kampala and Lusaka
Kampala, Uganda
Lusaka, Zambia 30 25 20 15 10 5
% HIV
year