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

2. 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

3. 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

4. The Uganda AIDS Indicator Survey
Previous National Population-Based Serological Surveys were conducted in 1988 &
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

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

6. 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

7. HIV among different groups; including MARPs in Uganda

8. Comprehensive Knowledge of HIV & AIDS
Percent of women and men age 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.

9. Trends in Comprehensive Knowledge of HIV
Percent of women and men age 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.

10. Trends in Knowledge of Prevention of Mother-to-Child Transmission
Percent of women and men age 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

11. 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

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

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

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

15. Payment for Sex and Alcohol use During Sex
2% of all men age 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 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.

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

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

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

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

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

21. Trends in Prior HIV Testing
Percentage of women and men age who have ever been tested for HIV and received the results
92% of women and 91% of men age 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 HIV testing among men has increase four-fold, from 11% in to 45% in Overall, 72% of pregnant women reported prior testing and receiving their results during antenatal care.

22. 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.

23. 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

24. Trends in HIV Prevalence
Percent HIV-positive
Overall, HIV prevalence among women and men age 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.

25. 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 for women (12.1%) and at age for men (11.3%).
Age

26. 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 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%

27. 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 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%

28. HIV Prevalence by Education
Percent HIV-positive

29. HIV Prevalence by Wealth Quintile
Percent HIV-positive
Poorest
Richest

30. 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 unweighted cases.

31. 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.

32. Discordance Among Couples

33. HIV Prevalence by Circumcision and Age
Percent HIV positive
Age

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

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

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

37. 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.

38. 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)

39. 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

40. 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

41. 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

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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. Thank You
Ministry of Health