Mbulawa Mugabe - UNAIDS
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Title: Overview of the HIV Epidemic in Eastern and Southern Africa: Are we on track to achieve the HLM 2015 targets? Implications for CSO mobilisation & Capacity Building"

Title: Overview of the HIV Epidemic in Eastern and Southern Africa: Are we on track to achieve the HLM 2015 targets? Implications for CSO mobilisation & Capacity Building"

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  • Key Messages: There is a paucity of data on VAW in the region and GBV prevalence studies have only started being conducted. Only three countries in the region have conducted these and they are: Botswana, South Africa and ?? The GARPAR indicator for this HLM target is linked to Intimate Partner Violence which has been shown to link directly with Increased risk of HIV among women and girls, hence indicators selected above;
  • Key Messages: Key HLM target speaks about eliminating stigma and Discrimination. The GARPAR indicator is predicated on a stigma index. However, more than half of the countries in the region (actually 11 countries) have not conducted a stigma index and therefore do not have any measurement of stigma; There is no link between where countries have conducted stigma indices and a favourable legal environment. This shows that measuring levels of stigma in and of itself is not adequate if recommendations to reduce stigma and life punitive laws are not followed through on. Countries like Ethiopia, KenyaTanzania, and Zambia have conducted stigma indices but have very unfavourable legislative environments Upto half (9 countries) of the countries in the region have laws that criminalise HIV transmission (Angola, Kenya, Lesotho, Mozambique, Zimbabwe Zambia and a proposed bill in Uganda); With the exception of Rwanda and South Africa, all countries in the ESA region criminalise same sex relationships; With the exception of four countries: Ethiopia, Malawi and Namibia, all other countries in the region criminalise sex work There are three countries in the region (Angola, Lesotho and Uganda) where the scorecard above suggests that not much progress is being made with this HLM target Every country in the region has punitive laws pertaining to the use of certain narcotics.
  • Key Messages: 1) With the exception of two countries (Comoros and Mauritius), all countries in the ESA region have no entry, stay or residence restrictions for PLHIV


  • 1. Overview of the HIV Epidemic in Eastern andSouthern Africa:Are we on track to achieve the HLM 2015targets? Implications for CSO mobilisation &Capacity Building"Dr. Mbulawa Mugabe, Deputy Director,UNAIDS Regional Support Team for Eastern and Southern Africa
  • 2. 34 million people living with HIV, 2011
  • 3. 2015 targets in the UN Political Declaration 2011 1 2 3 4 5Halve sexual Halve infections Eliminate new HIV 15 million Halve tuberculosistransmission among injecting infections among people on HIV deaths among drug users children and halve treatment people living with AIDS-related HIV maternal deaths 6 7 8 9 10Close the global Eliminate gender Eliminate stigma Eliminate Eliminate parallelresource gap and inequalities and and discrimination travel related systems, for strongerachieve annual sexual violence restrictions integrationinvestment of and increaseUS$ 22-24 bn capacities of women and girls
  • 4. Reduce sexual transmission of HIV by 50%• In 2011, there were approximately 2.2 million new infections in adults globally; 1 million of them were in ESA.• Decline in New Infections from 2001 to 2011: – 7 countries in ESA achieved over 50% – 4 countries achieved 26-49% – 2 countries achieved 10-25% – 3 countries remained stable – 1 country showed an increase• All countries need to achieve 50% decline from 2009 to 2015
  • 5. % Change in Incidence 2001 – 2009 % Change in Country 2001 Prevalence 2001 Incidence 2011 Prevalence 2011 Incidence Incidence 2001-11Malawi 13.8 1.74 10.0 0.49 -72Botswana 27.0 3.48 23.4 1.00 -71Namibia 15.5 2.39 13.4 0.77 -68Eritrea 1.1 0.08 0.6 0.03 -67Zambia 14.4 1.89 12.5 0.80 -58Rwanda 4.1 0.31 2.9 0.15 -53Zimbabwe 25.0 2.11 14.9 1.05 -50South Africa 15.9 2.42 17.3 1.43 -41Swaziland 22.2 4.11 26.0 2.60 -37Kenya 8.5 0.66 6.2 0.45 -32Mozambique 9.7 1.63 11.3 1.13 -31Sudan South 2.6 0.41 3.1 0.33 -21Angola 1.7 0.26 2.1 0.21 -19Lesotho 23.4 2.67 23.3 2.47 -7Tanzania 7.2 0.62 5.8 0.59 -5Madagascar 0.3 0.04 0.3 0.04 10Uganda 6.9 0.69 7.2 0.84 21Comoros na na na na ndMauritius na na na na ndEthiopia na na na na ndSeychelles na na na na nd Source: UNAIDS Estimate 2012
  • 6. Priority Actions: Sexual Transmission• Assist countries identify who is getting infected / who is at risk of infection (KYE/R)• Prioritize relevant, effective, and impactful prevention strategies for different populations (IF)• Advocate for the scale up of Basic High Impact Program Activities: 1. Increase # of people on ARVs (effect on transmission) 2. Scale up male circumcision as a priority 3. Behavior change programmes 4. Programmes for key populations (almost no data for MSM, sex work, IDU in region) 5. Condom promotion & distribution (Condom use at last sex in Lesotho – 34%)• Make smart investments that combine programs with critical enablers to exploit synergies
  • 7. Estimate of Number of Adults 15-49 yrs. VMMC needed to reach 80% coverage / country (PEPFAR Data)
  • 8. Estimate Number of VMMC done / country as of October 2011 (PEPFAR Data)
  • 9. Estimate Number of VMMCs needed to prevent one HIV infection (PEPFAR Data)
  • 10. Reduce HIV transmission among people who inject drugs by 50% Country Number of IDUs with HIV Gender Distribution M/F Kenya 64,500 89/11 South Africa 33,500 73/27 Tanzania 22,000 N/A Mauritius 19,000 N/A Source: compiled from academic sources that are not comparable• Practically no data for IDU (and other key populations) in the region• Country Action: Prioritize collection of data on IDU in the region
  • 11. Eliminate new infections among children and reduce AIDS-related maternal deaths• Global – approximately 330,000 babies were born with HIV in 2011; 55% or 180 000 were in ESA• Nearly 90% of all new HIV infections among children globally occur in 22 countries – 21 of those countries are in Africa, and 14 are in ESA• Global Plan aims to reduce new infections in infants by 90% from 2010 levels, by 2015; requires achieving >90-95% coverage for high quality PMTCT services in priority countries
  • 12. Percentage Coverage of PMTCT Services 2011 (excluding SD Nevirapine) Countries 2 - 49% Countries 50 - 79% Countries >80%• ESA coverage for PMTCT services in 2011 was 72%• PMTCT coverage in five is low
  • 13. Priority Country Actions: Implement the Global Plan on EMTCT1. Frame it – Develop an EMTCT Plan2. Advocate for it – Leadership, communication3. Do it – Implementation (4 prongs)4. Account for it – M&E, shared responsibilityAlmost all countries have developed emtct plans – follow up on implementation;CARMMA is bring launched across countries in the region – follow up on implementation
  • 14. Reach 15 million PLHIV with ART by 2015• # of persons living with HIV in ESA 2011 – 17.1m• # of persons eligible for ART using CD4 350 guidelines – 8.1m• # of persons on ART 2011 – 5.2m (64% coverage)• Unmet need for ART – 2.9m• Epidemiological projections shows that if the 15x15 target is met by 2015, 80% of those in need of ART will be receiving therapy Source: UNAIDS & WHO Estimates, 2010
  • 15. Estimated ART Coverage (CD4<350) 2011 Countries <50% Countries 50 - 79% Countries >80% Source: WHO Data 2012• 5 countries Rwanda, Botswana, Namibia, Swaziland and Zambia have achieved > 80% coverage; consider treatment forprevention
  • 16. Priority Country Actions: 15x15• Increase ART Demand: – Promote testing campaigns for early diagnosis and commencement of therapy – Push for Treatment for Prevention especially in countries that have achieved high ART coverage (e.g. Botswana)• Improve Supply: – simplify the way HIV treatment is currently provided (e.g. fixed dose combination ARVs for children in Uganda; CD4 testing devices at select clinics in Mozambique reduced test time from 27 days to 1 day) – decentralize provision of services (e.g. shift from hospitals to health centers and from clinical officers to nurses in Malawi)• Better Intelligence: – forecasting on medicines and commodities to prevent stock outs
  • 17. Reduce TB deaths in PLHIV by 50% • TB is a leading killer of people living with HIV causing one quarter of all deaths. People living with HIV and infected with TB are 20 - 30 times more likely to develop active TB disease, compared to people without HIV. • In 2010 there were an estimated 1.1 million new cases of HIV- positive new TB cases globally; approximately 60% occurred in ESA • In 2010, about 350 000 people died of HIV-associated TB globally. Almost 250 000 deaths were in ESASource: WHO Report 2011: Global Tuberculosis ControlData for ESA extrapolated
  • 18. HIV Prevalence (Percent Estimate) in New TB Cases, 2009 < 25% 25 – 50% 50 – 83%Source: WHO 2010In South Africa, Lesotho, Swaziland, Namibia, Botswana, Zimbabwe, Zambia, Mozambique, Malawi &Uganda, more than 50% of new TB patients are HIV positive
  • 19. Priority Actions in TB/HIV Epidemics• Ensure that TB burden reduction in people living with HIV is sufficiently addressed in NSPs• Mobilize partners to provide the technical support to countries assisting them to scale-up HIV and TB responses (WHO is lead agency)• Advocate for HIV programmes in countries to effectively implement TB prevention, treatment, care and support (service integration)• Social movement building and activism for PLHIV & TB.
  • 20. Global Investment of US$22-24b / year in low and middle income countries• By 2010, Africa had mobilised close to US $ 8bn from both International and Domestic Sources• The increase in domestic resources is smaller than that of international resources•Advocate for implementation of the African Union Roadmap
  • 21. Share of care and treatment expenditure originating from international assistance, African countries, 2009–2011 Source: Global AIDS Response Progress Reporting country reports (most recent available).• Most countries in SSA are more than 50% dependent on international sources for treatment;
  • 22. HLM Target 7:Eliminate Gender Inequalities & GBV and Increase Women and Girls’ Capacity to Protect Themselves from HIVCountries % women who think % of men who think Criminalisation of Legislative IPV is justified IPV is justified (2 Marital Rape Environment: Domestic SexualAngola ?? ?? ?? ?? ??Botswana ?? ?? No ?? ??Comoros ?? ?? ?? No YesEritrea 71% ?? ?? ?? ??Ethiopia 81% 52% Yes No NoKenya 53% 44% No Yes YesLesotho 37% Yes No YesMadagascar 32% 30% ?? No YesMalawi 28% 16% ?? ?? ??Mauritius ?? ?? Yes Yes YesMozambique 36% ?? Yes Yes NoNamibia 35% 41% Yes NoRwanda 48% ?? ?? Yes YesSeychelles ?? ?? Yes No NoSouth Africa ?? ?? Yes Yes YesSouth Sudan ?? ?? ?? ?? ??Swaziland 38% 41% ?? No YesTanzania 54% 38% Yes Yes NoUganda 70% 60% No Yes YesZambia 62% 49% Yes Yes YesZimbabwe 49% ?? Yes Yes Yes
  • 23. HLM Target 7:Eliminate Gender inequalities & GBV and increase women and girls’ capacity to protectthemselves from HIVIssues Challenges Opportunities Areas for Scaled up Action1. Eliminate Gender • Prevention: Women & • Treatment is prevention – could • Scaling up theInequality in HIV girls still the majority of reduce HIV infections in women & participation of men inPrevention and Treatment PLHIV & gap not narrowing; progress though limited is being prevention and treatment made with microbicide research programmes • Treatment: Poor men’s • Increasing programmes to health seeking behaviour engagement men – eg: men’s groups, scaling up of MC & couples • Treatment outcomes: counselling Programmes focus on coverage & not outcomes. • Increasing global platforms • Focus on HIV/SRH&R Cervical cancer killing focusing on cervical cancer in particularly for WLHIV WLHIV WLHIV and stronger HIV/SRHR linkages2. Eliminate GBV • Paucity of GBV prevalence • Increasing legislative instruments data to protect women & girls from • Deeply entrenched societal violence; •Scaling up community attitudes towards women • Increasing programmes to engage driven prevention of & girls men & traditional & religious violence initiatives • Weak GBV enforcement leadership in eliminating GBV3. Increase Women’s & • Women’s lower economic • Free education, increased • Sustain gains in girlsgirls capacity to protect empowerment heightens women’s participation in decision education and ecothemselves from HIV vulnerability; making & expansion in micro- empowerment of women credit facilities • Sexuality education still a • Scaling up advocacy with challenge & levels of • Increased advocacy in the area of traditional & religious knowledge among young sexuality education leaders & school bodies women still low
  • 24. HL HLM Target 8: Eliminate stigma & discrimination against PLHIV thru laws & policies that protect human rights fundamental freedomsCountries Existence of a National % Reported Stigma by Laws Criminalising HIV Laws Criminalising key Stigma Index PLHIV transmission populations MSM Sex WorkAngola* No N/A Yes Yes YesBotswana No N/A No Yes YesComoros No N.A No Yes YesEritrea No N/A ?? Yes YesEthiopia Yes Indicate the level no Yes NoKenya Yes Indicate the level Yes Yes YesLesotho* No N/A Yes Yes YesMadagascar No N/A Yes No NoMalawi Yes N/A Contradictory Yes NoMauritius On going N/A No Yes YesMozambique No No Yes Yes NoNamibia No No No Yes NoRwanda Yes 20% no No YesSeychelles No N/A no Yes YesSouth Africa On-going N/A no No YesSouth Sudan No No ?? ?? ??Swaziland Yes Indicate the level No Yes YesTanzania Yes Indicate the level Yes Yes YesUganda* No No Proposed in bill Yes YesZambia Yes 36% Yes Yes YesZimbabwe On-going N/A Yes Yes Yes
  • 25. HLM Target 8: Eliminate stigma & discrimination against PLHIV thru laws & policies that protect human rights fundamental freedomsIssues Challenges Opportunities Areas for Scaled up ActionEliminate Stigma & • More than half the Increased All countries toDiscrimination countries in the region treatment access conduct Stigma Indices have not measured and positive health levels of Stigma outcomes/longivity of life for PLHIV Scale up access to • Where Stigma Index justice programmes reports have been for PLHIV and conducted, undertake concerted recommendations are campaigns with not being implemented community leadersPromote Laws and • There are few countries Increasingly, NSPs Concerted advocacy isPolicies that protect in the region with laws make required to removethe rights and that fully promote and commitments to punitive lawsfundamental protect the rights of rights basedfreedoms of PLHIV PLHIV responses Ensure all NSPs include actions to address the • Technical Capacity to needs of Key address this area is populations & other inadequate vulnerable groups
  • 26. HLM T Target 9: Eliminate HIV-Related Restriction on Entry, Stay and Residence• Only Two Countries in the ESA Region Criminalise stay and entry for PLHIV.• Intensify advocacy for a “final push” for the removal of these restrictionsCountry Criminalisation of Entry for Criminalisation of Stay & PLHIV Residence for PLHIVComoros No YesMauritius No Yes Source: Making the Law work for the HIV Response, July 2010
  • 27. Strengthen integration of the AIDS response in global health and development efforts• Integration means different things to different people; need to use a standardized definition such as the health systems framework based on the 6 WHO building blocks• No indicators yet on how to measure the integration of HIV into the general health and development sphere in a country. No indicators developed for 2012 country reporting.• UNAIDS part of the EU/UNFPA/UNAIDS Collaboration supporting the integration of HIV and SRHR in seven Southern African countries.• UNAIDS Participating in Experts Meeting to develop indicators for Integration of HIV and SRHR at policy and service delivery levels; may shed light on monitoring of this HLM target.
  • 28. 1. Sexual Prevention: Evidence & Prioritisation: Gather more evidence on where infections are coming from and prioritise high impact interventions;2. IDU: Evidence generation, political support & Implementation of harm reduction programmes;3. EMTCT: Familiarise yourselves with your country emtct plans, provide community based monitoring of implementation;4. Treatment: Promote testing (especially of men), advocate for simpler innovations in testing and treatment, treatment is prevention and treatment outcomes not just coverage;5. HIV/TB: Service Integration6. Money: 15% campaign, domestic funding , local manufacture (AU road map7. Gender: Scale up men’s engagement & work with community structures to end GBV8. Stigma & Discrimination: Country Stigma index reports, evidence on key populations and HIV, political support and concerted action of advocacy to remove punitive laws9. Travel, stay and residence: advocacy for removal in 2 countries, monitor others;10. Integration: advocacy for service integration and contribution to indicator exercise