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HIV in the WHO African Region Progress towards achieving Universal Access to priority health sector interventions: 2013 UPDATE

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HIV IN THE WHO AFRICAN REGION Progress towards achieving Universal Access to priority health sector interventions

2013 UPDATE

HIV in the WHO African Region Progress towards achieving Universal Access to priority health sector interventions

2013 UPDATE

WORLD HEALTH ORGANIZATION Regional Office for Africa Brazzaville • 2013

AFRO Library Cataloguing-in-Publication Data HIV in the WHO African Region Progress towards achieving Universal Access to priority health sector interventions 2013 UPDATE 1. Acquired immunodeficiency syndrome – epidemiology – therapy - prevention and control 2. HIV infections – epidemiology – therapy – prevention and control 3. Health services accessibility 4. Anti-HIV Agents 5. Disease transmission, vertical – prevention and control I. World Health Organization. Regional Office for Africa ISBN : 978 929 023 243 8 (NLM Classification: WC 503.2)

Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Library, WHO Regional Office for Africa, P.O. Box 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507; E-mail: afrobooks@afro. who.int). Requests for permission to reproduce or translate this publication, whether for sale or for non-commercial distribution, should be sent to the same address. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Office for Africa be liable for damages arising from its use. Designed in the WHO Regional Office for Africa, in Congo Brazzaville and Printed in South Africa

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CONTENTS FOREWORD ACKNOWLEDGEMENTS Abbreviations and acronyms EXECUTIVE SUMMARY 1 2 INTRODUCTION 1.1 Background 1.2 Focus of the report 1.3 Data sources 1.4 Structure of the report

v vii viii ix 1 1 2 2 3

Epidemiological situation of HIV in the WHO African Region

7 7 8 13 23 34 37 38

2.1 Introduction 2.2 Implementation of HIV surveillance systems in the WHO African Region 2.3 Trends in HIV prevalence in adults 2.4 Young people aged 15- 24 years 2.5 HIV prevalence among key populations 2.6 Sexually Transmitted Infections (STIs) 2.7 Challenges and the way forward 3 HIV testing and counselling 3.1 Introduction 3.2 Uptake of HIV testing and counselling 3.3 Coverage of HIV testing and counselling services 3.4 Trends in the coverage of HIV testing and counselling services 3.5 Expanding HIV testing and counselling through novel mechanisms and approaches 3.6 Serodiscordant couples and HIV testing and counselling 3.7 Challenges and the way forward

43 43 44 46 51 52 54 54

HIV in the WHO African Region Progress towards achieving

Maximizing the contribution of the health sector 57 57 58 58 59 64 68 68 4.1 Introduction 4.2 Policies and programmes 4.3 HIV prevention among young people 4.4 HIV prevention among key populations 4.5 Voluntary medical male circumcision (VMMC) 4.6 Blood safety 4.7 Challenges and the way forward

in HIV prevention

HIV prevention and treatment among women and children

73 73 75 76 79 80 81 85 86

5.1 Introduction 5.2 HIV testing and counselling among pregnant women 5.3 Providing antiretroviral medicine to pregnant women living with HIV for preventing mother to child transmission of HIV 5.4 Reduction in AIDS related maternal deaths 5.5 Early Infant diagnosis for HIV 5.6 Antiretroviral treatment for HIV positive-children 5.7 Unmet need for family planning 5.8 Challenges and the way forward

Scaling up treatment and care for people living with HIV 6.1 Introduction 6.2 Coverage of antiretroviral therapy among people living with HIV 6.3 Availability of anti-retroviral therapy facilities 6.4 Retention of people living with HIV on antiretroviral therapy 6.5 TB/HIV collaborative activities 6.6 Surveillance and monitoring of HIV Drug Resistance (HIVDR) 6.7 Impact of antiretroviral therapy 6.8 Challenges and the way forward

89 89 90 92 93 95 97 100 101

Looking forward

105 109 109 110

Annexes Annex 1: ART facilities in the WHO African Region Annex 2: Selected indicators in TB-HIV collaborative activities, WHO African Region, 2001-2012

Universal Access to priority health sector interventions 2013 UPDATE

FOREWORD This report is being released by the WHO Regional Office for Africa on the occasion of World AIDS Day 2013. It provides updated information, at regional and sub-regional level, and in some countries, on the epidemiological situation of HIV and progress made so far towards achieving Universal Access to HIV prevention, treatment, care and support in the WHO African Region. The report shows that remarkable progress has been made in expanding and scaling up health sector HIV prevention, treatment, care and support interventions and services in the past years. Countries in the African Region are on the right track “to have halted by 2015 and begun to reverse the spread of HIV/AIDS”. HIV prevalence among ANC attendees in the region has declined from 9.5% in 2000 to 3.5% in 2011/2012. Indeed, HIV prevalence among ANC attendees has declined in more than half of the countries in the region and for many others prevalence rates are stabilising or beginning to decline. However, on the whole, HIV prevalence rates remain unacceptably high, especially in southern and eastern Africa. Progress has also been made towards the elimination of mother to child transmission of HIV. Coverage rates for HIV testing and counselling among pregnant women have increased and uptake of ARV for PMTCT has improved substantially with 63% of pregnant women living with HIV having received ARV for PMTCT in the region in 2012, an increase from 34% in 2009. The report also highlights the progress made in the scaling-up of life-saving and infection-prevention HIV treatment, with a total of 7,524,000 people in need receiving antiretroviral therapy by the end of December 2012, an increase of more than 90% from December 2009. These achievements have all been possible through the collective efforts of many partners led by African governments. There has been significant financial investment in the HIV/AIDS response by governments and partners. Drugs and commodities have been made more accessible in all countries, innovative ways of delivering services have been expanded, activism has promoted visibility of the HIV/AIDS epidemic and especially people living with HIV have been at the forefront of the response.

HIV in the WHO African Region Progress towards achieving

The report also highlights challenges in the current HIV response that need to be addressed. New HIV infections are still occurring at unacceptably high rates. Most people in the region are unaware of their HIV status. Access to HIV prevention and treatment interventions and services still remains inadequate, especially for vulnerable and key popu-lations. A significant proportion of people still drop out of care and many national HIV

programmes in the region are heavily dependent on international financial resources. I would like to use this occasion to call on all governments to commit more resources and work closely with all stakeholders to intensify efforts towards attaining the set goals and targets agreed upon in national, regional and international declarations and commitments.

Dr Luis Gomes Sambo WHO Regional Director for Africa

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ACKNOWLEDGEMENTS The contributions of the following individuals who assisted in the development, review, editing, design and lay-out of this publication are gratefully acknowledged. The principal authors of the report were: Godwill Asiimwe-Okiror, Frank Lule, Isseu Toure, Buhle Ncube, Innocent Nuwagira, Nirina Razakasoa, Boniface Ekoue Kinvi, Jesus-Maria Garcia Calleja, Michel Beusenberg. Assimawe Pana and Emil Asamoah-Odei. Michel Gershy-Damet, Kouadio Yeboue, Patrick Kombate, Lori Newman, Chika Hayashi, Lisa Nelson, Awandha Mamahit, and Nathan Shaffer. The design and layout for the report was done by Assamala Amoi-Seminet and Phyllis Jiri of the World Health Organization Regional Office for Africa.

Finally, the efforts of Emil Asamoah-Odei, Francis Kasolo, Tegest Ketsela Mengestu and Nirina Rakazasoa are acknowledged The report was reviewed by the following: for their guidance and coordination in Etienne Minkoulou, Daniel Kibuga, Morkor the development and publication of the Newman-Owiredu, Andre Loua, Guy- report.

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HIV in the WHO African Region Progress towards achieving

Abbreviations AFRO AIDS AIS ANC ART ARVs BSS CDC WHO Regional Office for Africa Acquired Immunodeficiency Syndrome AIDS Indicator Survey Ante-natal Clinic Antiretroviral Therapy Antiretrovirals Behavioural Surveillance Surveys

& acronyms MTCT Mother to Child Transmission

PEPFAR President’s Emergency Plan for AIDS Relief PITC PLHIV Provider Initiated Testing and Counselling People Living with HIV

PMTCT Prevention of Mother to Child Transmission

PWID People WHO Inject Drugs Centres for Disease Control and SADC Southern Africa Development Prevention Community CPT Cotrimoxazole Preventive Therapy SSA Sub-Saharan Africa DHS Demographic and Health Survey STIs Sexually Transmitted Infections DHS+ Demographic and Health Survey TB Tuberculosis plus HIV Testing UA Universal Access DRC Democratic Republic of Congo UN United Nations EMTCT Elimination of Mother to Child UNAIDS Joint United Nations Programme Transmission on AIDS EID Early Infant Diagnosis UNGASS United Nations General Assembly GARPR Global AIDS Response Progress Special Session Reporting UNFPA United Nations Population Fund GFATM Global Fund to fight AIDS, UNICEF United Nations Children’s Fund Tuberculosis and Malaria HIV HTC IBBS MC MDGs MSM Human Immunodeficiency Virus HIV Testing and Counselling Integrated Biological and Behavioural Survey Male Circumcision Millennium Development Goals Men who have Sex with Men UNODC United Nations Office on Drug and Crime USAID VCT VMMC WHO United States Agency for International Development Voluntary Counselling and Testing Voluntary Medical Male Circumcision World Health Organization

Universal Access to priority health sector interventions 2013 UPDATE

EXECUTIVE SUMMARY An updated ‘HIV/AIDS: Strategy for the African Region’ was adopted by the WHO Regional Committee for Africa during its sixty-second session held in November 2012. The strategy provides directions for implementing, in the WHO African Region, the ‘WHO Global context of the HIV epidemic in the region. These include HIV testing and counselling, selected health sector HIV interventions: among key populations, the youth, male circumcision, management of STIs, blood safety, preventing mother to child transmission (PMTCT), providing antiretroviral therapy and TB/HIV collaborative services. The report also provides trends in HIV prevalence and sexual behaviours among young people aged 15-24 years. Epidemiological situation

Health Sector Strategy on HIV/AIDS 2011-2015’

which was adopted by the World Health Assembly in May 2011. The set targets in the regional strategy are; to reduce the proportion of infected young people aged 15-24 years by 50%, reduce new HIV infections in children by 90% with special emphasis on those aged below two years, reduce HIV related deaths by 25% and HIV related tuberculosis deaths by 50%, compared with the 2004 baseline by 2015 (3). The targets, which are in line with the global targets, are based on the 2009 baseline data. This report “HIV in the WHO African Region; Progress towards achieving Universal Access to priority health sector interventions, 2013 Update” provides updated information, at regional and subregional level, and in some countries on the epidemiological situation of HIV and progress made so far towards achieving Universal Access to HIV prevention, treatment, care and support in the WHO African Region mainly using data from 2007 to 2012. The interventions and services assessed are those that are relevant to the epidemiological and social

Current data on HIV prevalence and trends in the WHO African Region show that countries in the region are on the right track “to have halted by 2015 and begun to reverse the spread of HIV/AIDS”. HIV prevalence among ANC attendees in the region has declined from 9.5% in 2000 to 3.5% in 2011/2012. Indeed, HIV prevalence among ANC attendees has declined in more than half of the countries in the region and for many others prevalence rates are stabilising or beginning to decline. However, on the whole, HIV prevalence rates remain unacceptably high, especially in southern and eastern Africa. Population based HIV prevalence data continue to indicate that more women than men are infected with HIV with the largest disparities being seen in the 15-24 year age group.

HIV in the WHO African Region Progress towards achieving

HIV surveillance systems have generally improved over time with many countries conducting national population based surveys to complement HIV sentinel surveillance among pregnant women attending antenatal care. More countries have expanded their ANC sentinel HIV surveillance to improve rural and urban representation However, the conduct of ANC-based HIV sentinel surveillance in the last few years has become inconsistent in several countries and in most countries HIV surveillance in key populations and STI surveillance are inadequate. The available data show that key populations continue to have consistently higher HIV prevalence rates than those in the general population and among ANC attendees. HIV testing and counselling

the less educated, the less wealthy and men are less likely to be tested and counselled for HIV. All people including those in rural areas, adolescents and key populations should be motivated to test and know their HIV serostatus through the use of multiple models and approaches. Maximizing the contribution of the health sector in HIV prevention

The adoption of a policy of providerinitiated testing and counselling (PITC) coupled with decentralization and integration of HIV testing and services into other health programmes and the adoption of community-based approaches for HIV testing and counselling have played a key role in increasing the availability and uptake of HIV testing and counselling services. The number of people aged 15 years and above who received an HIV test and were counselled increased from 23,424,868 in 2007 to 44,997,719 in 2010 in the WHO African Region, an increase of more than 90%. Despite this progress, the majority of people in the WHO African Region do not know their HIV serostatus. Adolescents, rural residents,

A review of the 2012 country Global Aids Response Progress reports showed that countries in the WHO African Region have HIV prevention programmes that target young people. Steadily but slowly young people are adopting safer sexual behaviours and their level of comprehensive knowledge of HIV is increasing. However, the level of comprehensive knowledge of HIV remains relatively low. Early sexual debut, multiple sexual partners and premarital sex are common, and condoms are not always used during higher risk sex and premarital sex. Active engagement of young people in the design, planning, implementation, monitoring and evaluation of age appropriate youth-friendly HIV services should be encouraged at all levels in the national HIV/AIDS response. A systematic review of studies conducted between 2000 and 2011 among sex workers that reported having interventions for reducing HIV transmission among sex workers concluded that there was “virtually no country in the WHO African Region providing interventions for sex workers on an adequate scale and intensity.” The same is true for other key populations. Structural and legal barriers

Universal Access to priority health sector interventions 2013 UPDATE

make it difficult for key populations to access HIV prevention, treatment, care and support services. These barriers need to be identified and addressed in the national HIV response. As a result of strong leadership, commitment and good planning, progress has been made in the 14 priority countries in the WHO African Region implementing voluntary medical male circumcision (VMMC) programmes. A total of 1,710,531 VMMCs were performed in 2012 in the 14 priority countries, more than double the number (884,283) in 2011. Kenya and Ethiopia have so far reached coverage of about 60% of the 80% target required for a public health impact on HIV incidence. However, there is low uptake of VMMC services, especially among men aged 25-49 years, and coverage in several countries remains low. Countries will need to sustain and improve on the achievements made so far, including intensifying efforts to mobilize communities and to raise the level of awareness of the public health benefits of VMMC. Progress has been made with regards to blood safety in the region. However, only 45% of the total blood requirements is currently being met. Countries need to further increase investments in blood safety programmes. HIV prevention and treatment among women and children

Region since 2009. Coverage rates for HIV testing and counselling among pregnant women increased from 38% in 2009 to 50% in 2012. The uptake of ARV for PMTCT has improved substantially with 63% of pregnant women living with HIV in the region receiving ARVs in 2012, an increase from 34% in 2009. In addition, the coverage of antiretroviral therapy among HIV infected children is steadily improving, but remains low with only 33% receiving ARVs in 2012. Similarly, early diagnosis of HIV among exposed infants remains low in most of the countries in the region. The low virological testing rates among exposed infants coupled with loss-to-follow up of exposed infants may largely explain the low ART coverage among children. Big countries in the region such as the Democratic Republic of Congo, Ethiopia and Nigeria which contribute the highest number of pregnant women living with HIV have been facing challenges in providing PMTCT services and will need to step up their efforts. This will require more investment in the programming of PMTCT interventions especially financial and human resources, more training and capacity building for health providers, task shifting policies and other measures to address the human resource challenges, strengthened laboratory capacity, further integration of PMTCT services in other related health programmes and further decentralization of services.

Considerable progress has been made towards the elimination of mother to child transmission of HIV in the WHO African

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Scaling up treatment and care for people living with HIV

The scaling-up of life-saving and infection -prevention HIV treatment in the WHO African Region constitutes one of the great public health achievements during the past decade. By the end of December 2012, a total of 7,524,000 (68%) people in need of ARVs were receiving antiretroviral therapy, an increase of more than 90% from 3,192,000 in December 2009. The achievements are a reflection of strong political commitment, community mobilization, technical innovation, and increasing domestic and international funding. The main factors driving the increase in access to ART include the steep rise in the numbers of facilities providing ART services, expansion of access to ART beyond hospitals by decentralizing ART services to primary health care facilities and rural areas, adoption of task-shifting policies, capacity building, and domestic and international funding. Improved access to antiretroviral therapy is already beginning to increase life expectancy in some countries. Despite the dramatic gains, about 32% of eligible people living with HIV and in need are not receiving antiretroviral medicines and in several countries the pace of progress is slow. Nigeria with the second highest number of people living within the WHO African Region had an ART coverage of 36% in 2012, and similarly Democratic Republic of Congo also with a high number of people living with HIV had coverage of 38% in 2012. Men are less likely to be on antiretroviral medicines than women.

In 2011, men comprised only 36% of the people receiving ART but constituted 44% of the people eligible for ART. Retention of people in the HIV treatment cascade is a challenge at each step in the cascade. Attrition rates are relatively high, and are mainly due to loss-tofollow up. Good progress is being made in the implementation of TB/HIV collaborative activities. Coverage of antiretroviral therapy among people with TB/HIV increased from 37% in 2009 to 57% in 2012, and 74% of TB patients knew their HIV serostatus, up from 69% in 2011. Eighty percent of people with TB and HIV are receiving cotrimoxazole prophylaxis. However, there is low coverage of isoniazid preventive therapy among people living with HIV and screening for TB among people living with HIV is relatively low. Maintaining the quality of HIV treatment and care services and retention of people on ART in the HIV treatment cascade are key in ensuring greater benefits of antiretroviral therapy and to minimize emergence of HIV drug resistance. Greater investments in health systems strengthening will be required to address the implications of implementing the 2013 WHO guidelines on antiretroviral treatment in order to achieve universal access and maximize the impact of ART in the region. Looking forward

Countries in the WHO African Region have made significant progress in expanding and scaling up health sector HIV prevention, treatment, care and

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support interventions and services in the past years. This has resulted in declines in new HIV infections and AIDS related deaths. However there is the need to intensify efforts in order to meet the 2015 regional targets as set out in the Regional HIV/AIDS Strategy.

treating and preventing HIV Infections; Recommendations for a Public Health Approach- Implications for the African Region” - which was adopted by African Ministers of Health in September 2013, provides the policy framework for countries in the WHO African Region to scale-up their national response to HIV/ The WHO Regional Committee Resolution AIDS in order to attain the 2015 HIV - “The WHO Consolidated Guidelines targets and move towards an “AIDSon the Use of Antiretroviral Drugs for Free Generation”.

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Universal Access to priority health sector interventions 2013 UPDATE

HIV in the WHO African Region Progress towards achieving

1. Introduction 1.1 Background The global community, including Member States of the World Health Organization (WHO) African Region, committed itself to achieving Universal Access (UA) to HIV prevention, treatment and care services by 2015 in the 2011 United Nations (UN) Political Declaration on HIV/ AIDS (1). This was a follow-up to the 2006 UN Political Declaration on HIV and AIDS to rapidly scale up access to HIV prevention, care, treatment and support (2). An updated “HIV/AIDS: Strategy for the African Region” was adopted by the WHO Regional Committee for Africa during its sixty-second session held in November 2012 (3). The updated HIV/AIDS Strategy provides directions for implementing, in the WHO African Region, the ‘WHO Global Health Sector Strategy on HIV/ AIDS 2011-2015’ which was adopted by the World Health Assembly in May 2011 (4). The Regional Strategy takes into account the regional specificities and context and defines the health sector’s contribution to the multisectoral response to HIV/AIDS in the region for the period 2012-2015 (3). reduce new HIV infections in children by 90% with special emphasis on those aged below two years, reduce HIV related deaths by 25% and HIV related tuberculosis deaths by 50%, compared with the 2004 baseline by 2015 (3). The targets, which are line with the global targets, are based on the 2009 baseline data. Substantial progress has been made in the WHO African Region in expanding access to interventions and services for HIV prevention, treatment, care and support since the launch of the WHO led “3 by 5” initiative in 2003 (5) Overall there was a decline of 38.5% in new infections between 2001 and 2012 (6). There was a decline of 38% in new HIV infections among children between 2009 and 2012 in the 21 Global Plan Priority countries for the elimination of mother-to-child transmission in the region (7). These gains are in line with the MDG-6 target “Have halted by 2015 and begun to reverse the spread of HIV/ AIDS”. AIDS related deaths have also significantly reduced by 20% between 2001 and 2012 in the region with eleven countries reporting declines ranging from 24% to 73% (6).

The set targets in the 2013 ‘HIV/AIDS: Strategy for the WHO African Region’ Despite these gains, Sub-Saharan Africa are; to reduce the proportion of infected (SSA), which has only 12% of the global young people aged 15-24 years by 50%, population, remains the region most Universal Access to priority health sector interventions 2013 UPDATE

severely affected by HIV/AIDS. At the end of 2012, there were 25.5 million people living with HIV in SSA, accounting for more than two-thirds (71%) of the total global HIV infections. The number of people living with HIV continues to increase largely due to improved access to antiretroviral treatment (people infected with HIV are living longer largely due to receiving life-saving antiretroviral drugs), but also due to new HIV infections. An estimated 1.6 million people were newly infected with HIV in SSA in 2012 (6). This report “HIV in the WHO African Region; Progress towards achieving Universal Access to priority health sector interventions, 2013 Update” is a followup to the first report “HIV in the WHO African Region Progress towards achieving Universal Access to priority health sector interventions 2011 update” that was published in 2011 (8). The report provides an update on the empirical data generated by HIV surveillance systems and programmes on the delivery of HIV prevention, treatment, care and support services in the WHO African Region. The production of this report reflects one of WHO’s core function of monitoring the health situation and assessing heath trends and is in line with the strategic directions for achieving sustainable health development in the WHO African Region 2010-2015 (9). 1.2 Focus of the report

far towards achieving Universal Access to HIV prevention, treatment, care and support in the WHO African Region, mainly using data from 2007 to 2012. The interventions and services assessed are those that are relevant to the epidemiological and social context of the HIV epidemic in the region. These include HIV testing and counselling, selected health sector HIV interventions among key populations, the youth, male circumcision, management of STIs and blood safety, preventing mother to child transmission (PMTCT), providing antiretroviral treatment and TB/HIV collaborative services. The report also provides trends in HIV prevalence and sexual behaviours among young people aged 15-24 years. The report is targeted at all in-country stakeholders, including Ministries of Health, National AIDS Councils/Commissions, and Civil Society, and at donors and International Development Partners, including United Nations Agencies. It can be used as a tool for advocacy and resource mobilization and for encouraging countries to consolidate the progress so far made, and to intensify efforts towards attaining the regional and country goals and targets, including regional and international commitments. 1.3 Data sources

This report provides updated information, at regional and sub-regional level, and in some countries, on the epidemiological situation of HIV and progress made so

The data used in describing the epidemiological situation of HIV in the region are mainly based on the most recent reports of HIV surveillance systems in the African Region primarily for the period

HIV in the WHO African Region Progress towards achieving

2007 to Response for 2012 indicators

2012, country Global AIDS Progress Reports (GARPR) and the MEASURE HIV/AIDS database.

The data used in monitoring progress in the health sector interventions are mainly from the WHO/AFRO Regional HIV/AIDS database, WHO, UNAIDS and UNICEF publications, the WHO Global Health Observatory database, 2012 country GARPR reports, published scientific articles, the websites of UN agencies and other international organizations working on HIV/ AIDS in Sub-Saharan Africa.

Western Africa Sub region: Algeria, Benin, Burkina Faso, Cape Verde, Cote d’Ivoire, The Gambia, Ghana, Guinea, GuineaBissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone and Togo. This report does not include data on South Sudan that only joined the WHO African Region in May 2013. 1.4 Structure of the report

Countries in the WHO African Region have been grouped according to the geographical distribution of countries used by the WHO Regional Office for Africa (AFRO). The same categorization was used in the last report produced in 2011. This allows for comparisons and assessment of the changes since then. Chapter 2 provides an update of the The countries in the sub regions are as HIV epidemiological situation and trends follows: based mainly on an analysis of data Eastern African subregion: Eritrea, Ethiopia, generated by HIV surveillance systems Kenya, Rwanda, Seychelles, Uganda and in the WHO African Region. United Republic of Tanzania Chapter 3 presents the progress made Southern Africa sub region: Botswana, in improving availability and uptake of Comoros, Lesotho, Madagascar, Malawi, HIV testing and counselling services in Mauritius, Moza-mbique, Namibia, South the WHO African Region. Africa, Swaziland, Zambia and Zimbabwe. Chapter 4 describes the progress made Central Africa Sub region: Angola, Burundi, in scaling up selected health interventions Cameroon, Central African Republic, Chad, for HIV prevention in the WHO African Congo, Democratic Republic of Congo, Region. Equatorial Guinea, Gabon, and Sao Tome and Principe.

The report is structured as follows: Chapter 1 presents background information and outlines the focus of the report, the data sources and methods used to collect data that describe the HIV epidemiological situation, and to monitor progress towards Universal Access to health sector HIV prevention, treatment, care and support interventions and services in the WHO African Region.

Universal Access to priority health sector interventions 2013 UPDATE

Chapter 5 presents progress made in scaling up HIV prevention and treatment services for eliminating HIV infection in children and keeping their mothers alive in the WHO African Region. Chapter 6 presents progress towards scaling up HIV treatment and care for

people living with HIV in the WHO African Region, implementation of TB/HIV collaborative activities and monitoring of HIV drug resistance (HIVDR). Chapter 7 presents the way forward.

HIV in the WHO African Region Progress towards achieving

ReferenceS 1. United Nations. United Nations General Assembly Resolution 65/277. Political Declaration on HIV and AIDS 2011. www.unaids.org/en/aboutunaids/ unitednationsdeclarationandgoals/2011Highlevelme etingonaids, accessed 13 September 2013 2. United Nations. United Nations General Assembly Resolution 60/262 Political Declaration on HIV/ AIDS 2006. www.unaids.org/en/aboutunaids/united nationsdeclarationandgoals/2006politicaldeclaration onhivaids, accessed 13 September 2013 3. WHO/AFRO. HIV/AIDS: Strategy for the WHO African Region. 2013. WHO/AFRO, Brazzaville. 4. WHO. Global health sector strategy on HIV/AIDS 2011-2015. 2011. WHO, Geneva. 5. WHO and UNAIDS. ‘3 by 5’ Progress report December 2004. 2004. WHO Geneva 6. UNAIDS. Global Report UNAIDS Report on the global AIDS epidemic 2013. 2013. UNAIDS, Geneva. 7. UNAIDS. 2013 Progress Report on the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. June 2013. UNAIDS, Geneva. 8. WHO/AFRO. HIV in the WHO African Region Progress towards achieving Universal Access to priority health sector interventions 2011 Update. 2011. WHO/AFRO, Brazzaville. 9. WHO/AFRO. Achieving sustainable Health Development in the African Region Strategic Directions for WHO 2010-2015. 2010. WHO/ AFRO, Brazzaville. 10. WHO and UNAIDS. ‘3by5’ Progress Report December 2004. 2004. WHO, Geneva

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HIV in the WHO African Region Progress towards achieving

2. Epidemiological situation of HIV in the WHO African Region Key messages

• HIV prevalence among ANC attendees • HIV prevalence rates are much higher has declined in more than half of the in urban areas than in rural areas in countries in the WHO African Region most countries. However, the gap is and for many others, HIV prevalence narrow in most of the countries in rates are stabilizing or beginning to southern Africa. decline. • Key populations continue to consistently • The HIV epidemic in the WHO have much higher HIV prevalence rates African Region is diverse and has than the general population and ANC wide variations across sub-regions and attendees between countries with southern Africa surveillance systems have remaining the most disproportionately • HIV improved over time with many affected subregion by the epidemic. countries conducting population based • HIV prevalence rates are much higher HIV serosurveys and behavioural in women than men with the largest surveillance to complement ANC based disparities being seen in the 15-24 HIV sentinel surveillance. year age group.

2.1

Introduction

With more than two-thirds (71%) of the total number of people living with HIV in the world, Sub-Saharan Africa remains the region most affected by the HIV/AIDS epidemic. As at the end of 2012, an estimated 25.5 million people were living with HIV in the region, an increase from the previous years as more people are living longer as a result of receiving lifesaving antiretroviral therapy but also due to new infections (1). There has been a decline of 38.5% in new HIV infections between 2001 and 2012 in Sub-Saharan Africa (1). HIV prevalence data among ANC attendees 7

and from national population based surveys conducted in the WHO African Region confirm that prevalence rates have declined or stabilized in most of the countries (2). However, HIV continues to spread in the region, with 1.6 million new infections in 2012 (1). At the global level, young people aged 15-24 years accounted for 42% of new infections, with nearly 80% of them living in Sub-Saharan Africa (3) This chapter presents an update on the magnitude and trends in HIV prevalence in countries and sub-regions in the WHO African region since the last report “HIV

Universal Access to priority health sector interventions 2013 UPDATE

in the WHO African Region Progress towards achieving Universal Access to priority health sector interventions: 2011 update” was published in 2011(2). It is mainly based on empirical data generated by HIV surveillance systems in the region for the period 2007 to 2012. For trend analysis in HIV prevalence rates, the data presented goes back to 2001. The chapter also presents HIV prevalence and trends in sexual behaviours among young people aged 15-24 years.

2.2.1 HIV surveillance among pregnant women

Sentinel HIV surveillance among ANC attendees has been the main source of information on trends in HIV prevalence in Sub-Saharan Africa. The data generated have also been utilized to produce national HIV/AIDS estimates.

In the early phases of the establishment of HIV surveillance systems, antenatal clinic sites were selected mostly in urban areas and in sites with high HIV prevalence. 2.2 Implementation of HIV Over time, HIV sentinel surveillance surveillance systems in the WHO systems have evolved to include more African Region rural sites, thus increasing geographical With the support of WHO and other and rural-urban representation (5). development partners almost all the countries in the WHO African Region Countries in the WHO African Region are implementing second generation HIV conduct HIV surveillance among ANC surveillance systems. Second generation attendees once a year or every two years surveillance systems monitor trends in HIV depending on the national HIV sentinel infection and trends in sexual behaviours surveillance guidelines/protocol. This is in and attempt to capture the diversity of accordance with the WHO guidelines on the HIV epidemic in different areas and conducting HIV sentinel surveillance among ANC attendees (6). South Africa uses populations within countries (4). probability proportional to size to enrol Second generation HIV surveillance ANC attendees for HIV surveillance. This systems include surveillance of HIV approach produces a more representative among pregnant women attending sample of ANC attendees but requires selected antenatal care clinics (ANC), substantial resources, which is a challenge population-based HIV serosurveys and to most of the countries in the region. gathering behavioural data mainly from Twenty-six out of the 47 countries in the Demographic and Health surveys (DHS), WHO African Region conducted a round AIDS Indicator Surveys (AIS), Integrated of sentinel surveillance among ANC Biological and Behavioural. Surveys (IBBS) attendees in the period 2010 to 2012 and Behavioural Surveillance Surveys and an additional 8 countries had a last (BSS). Additional data are drawn from round of ANC surveillance in 2009. A STI surveillance among ANC attendees, number of countries are not conducting HIV surveillance among key populations ANC surveillance regularly (Table 2.1). and special studies.

HIV in the WHO African Region Progress towards achieving

Table 2.1: Last round of HIV sentinel surveillance among ANC attendees by country and subregion, WHO African Region, most recent year Sub region Country Botswana Comoros* Lesotho Madagascar* Malawi Mauritius Mozambique Namibia South Africa Swaziland Zambia Zimbabwe Eritrea Ethiopia Kenya Rwanda Seychelles Uganda United Republic of Tanzania Angola Burundi Cameroon Central Africa Republic Chad Congo Democratic Republic of Congo Equatorial Guinea Gabon Sao Tome and Principe Algeria Benin Burkina Faso Cape Verde* Cote d’Ivoire Gambia Ghana Guinea Guinea Bissau Liberia Mali Mauritania Niger* Nigeria Senegal Sierra Leone Togo 2007 2007 2007 2007 2007 2007

2008 2008 2008 2008 2008

2009 2009 2009 2009 2009 2009 2009 2009 2009

2010 2010 2010 2010 2010 2010 2010 2010 2010 2010 2010

2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011

2012 2012 2012

Southern Africa

Eastern Africa

Central Africa

Western Africa

Sources: GARPR country reports 2012, Country ANC HIV surveillance reports in selected countries and WHO/AFRO surveillance updates 2003, 2005 and 2007 *: Comoros, Cape Verde, Madagascar and Niger have not conducted any ANC surveillance round in the period 2007 to 2012

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2.2.2 Population based surveys

surveys are not appropriate for estimating prevalence levels in countries with such Population based surveys provide useful epidemics; they tend to underestimate information on HIV prevalence data in the HIV prevalence (7) men, women (non-pregnant and pregnant women) and in people not using health Monitoring of sexual behaviours using facilities. Fifty-seven national population behavioural surveys is vital in increasing based surveys were conducted in 30 understanding of the factors driving the countries in the WHO African Region HIV epidemic. It helps to explain the between 2001 and 2012 of which 22 patterns and trends in HIV infection. DHS incorporated HIV testing (Table 2.2). and AIS are the main sources of data on Countries that conducted repeat surveys behaviours in the WHO African Region. where HIV testing was incorporated were Other sources of behavioural data in the able to monitor HIV prevalence trends region include Multiple Indicator Cluster in the general population. Countries that Surveys (MICs), Behavioural Surveillance did not include HIV testing were able Surveys (BSS) and Integrated Biological to assess trends in sexual behaviours. Behavioural Surveys (IBBS) conducted These surveys are usually conducted mainly among the youth and special once every five years. However, due groups. Additional sexual behavioural data to the distribution of HIV infection in has been generated by special studies concentrated epidemics, sampling from including cohort studies conducted in a households may not represent high risk number of countries in the region. mobile populations. Thus population based

HIV in the WHO African Region Progress towards achieving

Table 2.2: Implementation of population based surveys, WHO African Region, most recent year Sub region Country Lesotho Malawi Mozambique Year of survey 2004 2009 2004 2010 2009 20012002 2004 2007 Swaziland 20062007 20012002 20052006 20102011 2002 20042005 2012 2005 2011 2003 20082009 2012 Eastern Africa Rwanda 2005 2010 2004 Uganda 2007 2011 United Republic of Tanzania Burundi Cameroon Central Africa Congo DRC Gabon Sao Tome and Principe 2003 2006 2012 2002 2010 2004 2011 2007 2009 2007 2012 20082009 Type of survey DHS+ DHS+ DHS+ DHS+ AIS DHS+ DHS DHS DHS+ Young adult survey DHS+ DHS+ HIV/AIDS HIV/AIDS DHS DHS+ DHS+ DHS+ DHS+ AIS DHS+ DHS+ HIV/AIDS DHS AIS AIS AIS/MIS AIDS/Malaria survey HIV/AIDS DHS+ DHS+ DHS+ DHS+ AIS DHS DHS+ DHS+ Study population women 15-49, men 15-59 Women 15-49, men 15-59 Women 15-49, men 15-59 Women 15-49 , men 15-59 Women 15-49, men 15-59 Women 15-49, men 15-59 Women and men 15-49 years Women 15-49, men 15-59 Women 15-49, men 15-59 Women and men 15-29 Women 15-49, men 15-59 Women 15-49, men 15-59 2years and above 2 years and above Women Women Women Women 15-49,men 15-59 15-49, men 15-59 15-49, men 15-59 15-49, men 15-59

Zambia Southern Africa

Zimbabwe

South Africa Eritrea Ethiopia

Kenya

Women 15-49,men 15-59 Children 18 monts14 years, Women and men 15-64 Women 15-49, men 15-59 Women 15-49, men 15-59 0-4 years, women 15-49, men 15-59 Women 15-49, men 15-59 0-14 years, women 15-49, men 1559 0-4 years, 15-49 women and men Women 15-49 , men 15-49 Women 15-49, men 15-59 Women Women Women Women Women Women Women Women and men 12 years and above 15-49, men 15-59 15-49, Men 15-59 15-49, men 15-59 15-49, men 15-59 15-49, men 15-59 15-49, men 15-59 15-49, men 15-59

Women 15-49, men 15-59

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Cont’d: Table 2.2: Implementation of population based surveys, WHO African Region,

most recent year

Sub region

Country Benin Burkina Faso Cape Verde Cote d’Ivoire Ghana

Year of survey 2006 2012 2003 2010 2012 2005 20112012 2003 2008 2005 2007 2001 2006 2002 2006 2002 2008 2011 2005

Type of survey DHS DHS DHS+ DHS+ DHS AIS DHS+ DHS+ DHS DHS+ DHS+ DHS+ DHS+ HIV/AIDS DHS+ HIV/AIDS DHS+ DHS DHS+ DHS+

Study population Women 15-49, men 15-49 Women 15-49, men 15-59 Women 15-49, men 5-49 Women 15-49, men 15-49 Women 15-49, men 15-49 Women 15-49, men 15-49 Women 15-49, men 15-59 Women 15-49, men 15-59 Women 15-49, men 15-59 Women 15-49, men 15-59 Women 15-49, men 15-59 Women Women Women Women 15-49, men 15-59 15-49, men 15-59 and men 15-49 15-49, men 15-59

Western Africa

Guinea Liberia Mali Niger

Women and men 12-49 Women 15-49, men 15-59 Women 15-49, men 15-59 Women 15-49, men 15-59 Women 15-49,men 15-59

Sierra Leone

Senegal

20102011

Sources: Country DHS reports, MEASURE HIV/AIDS indicators survey database, Stavetieg, S., et al.’Demographic Patterns of HIV testing uptake in Sub Saharan Africa DHS comparative reports 30.2013

2.2.3 HIV surveillance among key populations

Key populations are those whose sexual behaviours make them vulnerable or who have a higher risk of acquiring HIV infection. Studies among key populations have tended to utilize convenient sampling methods. Peer referral and venue based sampling approaches are mainly used to access key populations in venues/ locations that are frequented by them. Key populations are enrolled into studies mainly using social networks (8). Female sex workers are the key populations most often monitored by HIV surveillance systems in the region. A recent review

conducted in the African Region found that 26 countries conducted biological and behavioural surveillance surveys (IBBS) and or Beha-vioural Surveillance Surveys (BSS) that included HIV testing among sex workers, eighteen countries conducted surveys among Men who have Sex with Men (MSM) and 9 countries among People Who Inject Drugs (PWID) in the period 2008-2012 (8). Other key populations that have been studied in the region include STI patients, migrants, truck drivers, the military, prisoners, cross border traders, fishermen, miners and bridging populations mainly clients of sex workers (9).

HIV in the WHO African Region Progress towards achieving

The challenge in conducting HIV surveillance among key populations is the lack of a sampling frame that identifies the “members” of these populations. Thus, data from key populations cannot be generalised to a country (8). Difficulties ranging from criminalization to social structural barriers including stigmatization and discrimination make it difficult to access key populations. 2.2.4 STI surveillance

attendees in the period 2007-2012 and population based HIV serosurveys conducted between 2008 and 2012 are presented below. Where necessary, data from earlier periods have been included to show trends. 2.3.1 HIV prevalence among pregnant women aged 15-49 years attending antenatal clinics

Prevalence/incidence of STIs is an important indicator for risk behaviours. They provide early warning signs for action in the National HIV and AIDS response. Syphilis testing among ANC attendees is supposed to be a routine practice in all countries in the WHO African Region. However, only a few countries are systematically collecting, analysing and reporting on the results of syphilis testing among ANC attendees. Special studies and research conducted in several countries in the region have been valuable sources of data on STIs. Many countries do include STI case reporting based on syndromes in their health information systems. Differences in syphilis testing strategies, health seeking behaviours, self-medication and the strength of STI programmes need to be taken into account when interpreting trends in STI prevalence. 2.3 Trends in HIV prevalence in adults in the WHO African Region

Data on HIV prevalence among ANC attendees continue to indicate that the WHO African Region does not have a ‘one African epidemic’. There is a marked diversity in HIV prevalence rates between countries and between sub regions (Table 2.3). The median HIV prevalence among ANC attendees aged 15-49 years in the 26 countries that conducted a round of ANC HIV surveillance in the period 2010 to 2012 was 3.5%. This varied from < 1% in Mauritius, Eritrea, Senegal, Seychelles and Sao Tome and Principe to 41.1% in Swaziland. HIV prevalence rates among ANC attendees in southern Africa were much higher than HIV rates in other sub regions in 2010-2012. ANC attendees in southern Africa had a median HIV prevalence of 26.5% followed by eastern Africa with a rate of 4.4% and then central Africa with median HIV prevalence of 3.5%. Western Africa had the lowest median HIV prevalence (2.1%) in 2010-2012.

In southern Africa, HIV prevalence rates HIV prevalence and trends in the among ANC attendees ranged from < 1% WHO African Region using data from in Mauritius to 41.1% in Swaziland. In HIV sentinel surveillance among ANC

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eastern Africa, prevalence ranged from < 1% in Eritrea to 7.1% in Uganda (2007) while for central Africa, rates ranged from < 1% in Sao Tome and Principe

to 7.8% in Cameroon. In western Africa, the rates ranged from < 1% in Algeria, Mauritania and Senegal to 5.8% in Guinea Bissau.

Table 2.3: Median HIV prevalence (%) among pregnant women aged 15-49 years attending antenatal care in selected countries in the WHO African Region, most recent year Subregion Botswana Lesotho Malawi Mauritius Southern Africa Mozambique Namibia South Africa Swaziland Zambia Zimbabwe Eritrea Ethiopia Kenya Eastern Africa Seychelles Rwanda Uganda Tanzania Angola Burundi Cameroon Central African Republic Chad DR Congo Equatorial Guinea Gabon Sao Tome and Principe Algeria Benin Burkina Faso Cote d’Ivoire Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Nigeria Senegal Sierra Leone Togo

Country

Year 2011 2011 2010 2010 2009 2010 2011 2010 2007 2009 2011 2009 2010 2012 2007 2007 2011 2009 2007 2012 2011 2010 2011 2008 2009 2011 2007 2010 2010 2008 2011 2011 2008 2009 2011 2009 2009 2010 2011 2010 2010

HIV prevalence 30.4 24.3 10.6 0.48 13.9 18.8 29.5 41.1 14.3 16.1 0.8 3 6.2 0.6 3.7 7.1 5.1 2.8 2.8 7.8 4.8 3.4 3.5 10 5.2 0.5 0.09 1.7 1.6 4.5 1.7 2.1 2.5 5.8 2.6 3.3 0.48 4.1 0.95 2.2 3.5

Central Africa

Western Africa

Sources: Country GARPR reports 2012, Country ANC HIV surveillance reports of selected countries WHO/AFRO HIV/AIDS database 14

HIV in the WHO African Region Progress towards achieving

Trends in HIV prevalence among pregnant women (ANC attendees) aged 15-49 years

rate among ANC attendees aged 15-49 years declined from 9.5% in 1999-2000 to 3.4% in 2007-2008 and to 3.5% in More than 50% of the countries in the 2010-2012 in the WHO African Region. WHO African Region have registered declining HIV prevalence rates among In southern Africa, HIV prevalence rates ANC attendees (aged 15-49 years), among ANC attendees have declined and for many others, HIV prevalence is considerably in Botswana, Malawi, Zambia either stabilising or beginning to decline. and Zimbabwe. Prevalence rates are However, HIV prevalence is slowly on stabilizing or even beginning to decline the rise in Mauritius and Uganda. In in Namibia and South Africa. In Lesotho, Uganda, the rise is after a phase of Swaziland, Mozambique and Madagascar declining HIV prevalence rates followed prevalence rates are stabilising (Figure by a phase of stabilisation for some 2.1). years. Overall, the median HIV prevalence Figure 2.1: Trends in median HIV prevalence (%) among ANC attendees aged 15-49 years in selected countries in southern Africa, WHO African Region, 2001-2012 Swaziland Namibia 45 40

Botswana Zimbabwe

South Africa Malawi

Lesotho Mozambique

Median Median HIV Prevalence (%)

35 30 25 20 15 10 5 0 2001 2002 2003 2004 2005 2006 Year 2007 2008 2009 2010 2011

Sources: Country GARPR reports 2012 and ANC HIV surveillance reports in selected countries

In eastern Africa, HIV prevalence rates among ANC attendees have declined in Eritrea, Ethiopia, Kenya, Rwanda and the United Republic of Tanzania (Figure 2.2). However, in Uganda, HIV prevalence

rates dropped from 22% in 1991 to 5% in 2002 and gradually increased to 7.1% in 2007. HIV prevalence in Seychelles remained < 1% between 2005 and 2012.

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Figure 2.2 Trends in median HIV prevalence (%) among ANC attendees aged 15-49 years in selected countries in eastern Africa, WHO African Region, 2001-2012 Kenya Rwanda 14 12 Median HIV Prevalence (%)

Tanzania Eritrea

Ethiopia Seychelles

Uganda

10 8 6 4 2 0 2001 2002 2003 2004 2005 2006 Year 2007 2008 2009 2010 2011

Sources: Country GARPR reports 2012 and ANC HIV surveillance reports in selected countries

Figure 2.3 shows declining HIV prevalence rates in the Central African Republic, Burundi and Sao Tome and Principe. In the Central African Republic, HIV prevalence decreased from 9.1% in 2006/2007 to 4.8% in 2011. HIV

prevalence has stabilised in Cameroon at around 7.6% between 2009 and 2012 and in the Democratic Republic of Congo at around 3.5% between 2006 and 2011.

Figure 2.3:Trends in median HIV prevalence (%) among ANC attendees aged 15-49 years in selected countries in central Africa, WHO African Region, 2001-2012 Central Africa Republic DRC Sao Tome and Principe 16 14 Median HIV Prevalence (%)

Equatorial Guinea Angola

Cameroon Burundi

12 10 8 6 4 2 0 2001 2002 2003 2004 2005 2006 Year 2007 2008 2009 2010 2011

Sources: Country GARPR reports 2012 and ANC HIV surveillance reports in selected countries 16

HIV in the WHO African Region Progress towards achieving

In Western Africa, declining HIV In eastern Africa, HIV prevalence rates among ANC attendees have declined in Eritrea, Ethiopia, Kenya, Rwanda and the United Republic of Tanzania (Figure

2.2). However, in Uganda, HIV prevalence rates dropped from 22% in 1991 to 5% in 2002 and gradually increased to 7.1% in 2007. HIV prevalence in Seychelles remained < 1% between 2005 and 2012.

Figure 2.4:Trends in median HIV prevalence (%) among ANC attendees aged 15-49 years in selected countries in western Africa, WHO African Region, 2001-2012 Nigeria 7 6 Median HIV Prevalence (%)

Togo

Mali

Ghana

Benin

5 4 3 2 1 0

2001

2002

2003

2004

2005

2006 Year

2007

2008

2009

2010

2011-2012

Sources: Country GARPR reports 2012 and ANC HIV surveillance reports in selected countries

Urban and rural HIV prevalence differences

HIV prevalence rates are generally higher in urban areas than in rural areas in the WHO African Region (Figure 2.5). In Mozambique HIV prevalence was 22.1% in urban areas and 9.5% in rural areas in 2009 and similarly in the Tanzania

mainland, prevalence rates were 7.2% and 4.3% in urban and rural areas respectively in 2011. On the other hand in Namibia and the Democratic Republic of Congo, HIV prevalence among ANC attendees in urban areas and rural areas were close.

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Figure 2.5: Median HIV prevalence (%) among ANC attendees aged 15-49 years in selected countries by area of residence, WHO African Region, most recent year Urban 14 12.9

Rural

Median HIV prevalence (%)

12 10 8 6 4 2 0 Benin Sierra Leone 2010 Central African Republic Malawi Eritrea Democratic Republic of Congo 2011 Tanzania Cameroon 3.4 2.2 1.3 2.5 1 0.3 5.4 3.7 3.7 3.6 4.3 8.8 7.2 8.1

7.4

2012

Sources: Country GARPR reports 2012 and ANC HIV surveillance reports in selected countries

2.3.2 HIV prevalence among the adult population aged 15-49 years: data derived from population based surveys

This section presents HIV prevalence in the general population using data from population based surveys conducted in selected countries in the region in the period 2008-2012. The analysis of HIV prevalence trends utilized data from 2001 to 2012. Data from recent population based surveys conducted in several countries in the region

that incorporated HIV testing continue to show that there are marked variations in HIV prevalence rates among the adult general population (men and women) in the subregions and between countries in the WHO African Region (Table 2.4). These data corroborate the diversity shown by the results from ANC sentinel surveillance. Between 2007 and 2012, HIV prevalence among the adult population aged 1549 years ranged from 0.7% in Senegal (2010/2011) to 22.4% in Lesotho (2009).

HIV in the WHO African Region Progress towards achieving

Table 2.4: HIV prevalence (%) among the general population (women and man) aged 15-49 years by sex in selected countries: data from population-based surveys, most recent year All respondents (men & women ) Subregion Country Year

Women

Men

N Southern Africa

HIV prevalence (%) 22.4 10.6 10.9 … 15.2 1.5 5.6 3 5 7.3 1.4 4.3 3.2 4.1 1 0.7 1.5

HIV prevalence (%)

Lesotho Malawi Mozambique South Africa Swaziland Zimbabwe

2009 2010 2009 2008 2007-2008 2010-2011 2011 2012 2010 2011-2012 2011 2010 2011 2009 2012 2010 2010-2011 2008

10,632 13,588 10,828 … 13,563 27,385 13,720 12,607 17,745 19,556 8,087 13,503 12,110 10,445 14,607 9,430 6,174

7,624 7,091 6,590 …. 7,313 12,581 7,233 6,917 9,756 10,883 4,533 7,221 6,438 5,459 8,293 5,326 3,448

26.7 12.9 13.1 14.1 31 17.7 1.9 6.9 3.7 6 8.3 1.7 5.6 4.1 5.8 1.2 0.8 1.7

3,008 6,497 4,238 … 6,250 12,581 6,487 5,690 7,989 8,673 3,554 6,282 5,671 4,986 6,314 4,104 2,726

18 8.1 9.2 8.4 20 12.3 1 4.4 2.2 4 6.1 1 2.9 2.1 2.2 0.8 0.5 1.2

Eastern Africa

Ethiopia Kenya Rwanda Tanzania Uganda

Central Africa

Burundi Cameroon Congo Gabon

Western Africa

Burkina Faso Senegal Sierra Leone

Sources: MEASUREDHS HIV/AIDS indicator survey database, Country DHS/AIS reports, country GARPR reports 2012, WHO/AFRO database, South Africa national HIV prevalence incidence, behavioural communication survey, 2008

Figure 2.6 shows the variations in HIV prevalence among the general population aged 15-49 years between countries and subregions. Southern Africa and eastern Africa subregions are the worst affected. HIV prevalence rates among the general population aged 15-49 years in southern Africa ranged from 10.6% in Malawi (2010) to 22.4% in Lesotho (2009). In eastern

Africa, prevalence rates ranged from 1.5% in Ethiopia (2011) to 7.3% in Uganda (2011). In Central Africa HIV prevalence rates ranged from 1.4% in Burundi (2010) to 5.2% in Gabon (2012). Western Africa had the lowest HIV prevalence rates from < 1% in Senegal (2010-2011) to 1.5% in Sierra Leone (2008).

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Figure 2.6: HIV prevalence (%) among adult general population aged 15-49 years in selected countries by country and subregion, WHO African Region, most recent year 25 20 HIV Prevalence (%)

22.4

16.9

15 10 5 0 2009 Lesotho

15.2 10.6 7.3 5.6

5 3 1.5 2011

4.3

4.1

3.2 1.4

1.5 2008 Sierra Leonne

0.7

2008 2010-2011 2010 South Zimbabwe Malawi Africa Southern

2011 Uganda

2012 2010-2011 2010 Kenya

2011

2012

2009 Congo

2010 Burundi

2010 2010-2011 Burkina Senegal Faso Western

Tanzania Rwanda Ethiopia Cameroon Gabon Eastern

Central

Sources: MEASUREDHS HIV/AIDS indicator survey database, Country DHS/AIS reports, country GARPR reports 2012, South Africa national HIV prevalence incidence, behavioural communication survey, 2008

Gender differences

Population based data continued to show that women were more likely to be HIV infected than men in almost all the countries with the exception of Niger where the prevalence rates among women and men were almost the same (Table 2.5). The differences

in HIV prevalence rates among women and men vary between countries. In Gabon (2012), women were about 2.5 times more likely to be infected than men while in Congo (2009), Cameroon (2011), Ethiopia (2011) and South Africa (2008) women were about 2 times more likely to be infected than men.

Table 2.5: HIV prevalence (%) among general population (women and men) aged 15-49 years by sex in selected countries, WHO African Region, most recent year HIV prevalence (%) Subregion Country Year Women Southern Africa Lesotho Malawi Mozambique Swaziland Zambia Zimbabwe Eastern Africa Ethiopia Kenya Rwanda Tanzania 2009 2010 2009 2007-2008 2007 2010-2011 2011 2012 2010 2011-2012 26.7 12.9 13.1 31.1 16.1 17.7 1.9 6.9 3.7 6

Men 18 8.1 9.2 19.7 12.3 12.3 1 4.4 2.2 4

HIV in the WHO African Region Progress towards achieving

Table 2.5: HIV prevalence (%) among general population (women and men) aged 15-49 years by sex in selected countries, WHO African Region, most recent year

HIV prevalence (%) Subregion Country Year Women Central Africa Burundi Cameroon Congo Democratic Republic of Congo Western Africa Benin Cote d’Ivoire Ghana Guinea Liberia Mali Niger Senegal Sierra Leone 2010 2011 2009 2007 2006 2005 2003 2005 2007 2006 2006 2010-2011 2008 1.7 5.6 4.1 1.6 1.2 6.4 2.7 1.9 1.9 1.5 0.7 0.8 1.7

Men 1 2.9 2.1 0.9 0.8 2.9 1.5 0.9 1.2 1 0.8 0.5 1.2

Sources: WHO/AFRO HIV/AIDS database, measuredhs.com HIV/AIDS Indicators survey and DHS/AIDS country reports in selected countries

Figure 2.7: HIV prevalence (%) among adult general population aged 15- 49 years by sex in selected countries in the WHO African Region, most recent year

Women 35 30 Median HIV Prevalence (%) 31.1 26.7

Men

25 20 15 10 5 0 2008 Swaziland 2009 Lesotho 2009 Mozambique 2010 Malawi 2010 Burundi 2010-2011 Zimbabwe 2011 Cameroon 2011-2012 Tanzania 19.7 18 13.1 9.2 12.9 8.1 5.6 1.7 1 2.9 17.7 12.3 6

Sources: MEASUREDHS HIV/AIDS Indicators survey and DHS/AIDS country reports in selected countries

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Figure 2.7 further illustrates the differences in HIV prevalence between women and men in the WHO African Region. In Lesotho (2009), HIV prevalence rates among women and men were 26.7% and 18% respectively while in Kenya (2012), the prevalence rates were 6.9% and 4.4% in women and men respectively. The Urban-Rural Difference

and rural HIV prevalence rates were close in 2012. Secondary analyses of data from DHS conducted in 20 countries in sub-Saharan Africa between 2003 and 2008 showed that the urban poor were more likely to be HIV infected than their urban nonpoor counterparts. However the reverse was true in the rural areas, the nonpoor rural residents were more likely to be infected with HIV than the rural poor residents (11). For example, in Swaziland the non-poor urban residents had an HIV prevalence of 25.4% as compared to 36.5% among the poor urban residents in 2008. In Zambia the non-poor rural residents had an HIV of 11.8% versus 8.8% among the poor rural residents in 2007.

On the whole, HIV prevalence rates are higher in urban than in rural areas (Figure 2.8). The differences between urban and rural areas vary between countries. For example, in 2011 in Ethiopia, the HIV prevalence rate in urban areas was about seven times more than that in rural areas (4.2% versus 0.6%) while in Gabon the urban

Figure 2.8: HIV prevalence (%) among the general population (women and men) aged 15-49 years in selected countries by residence, WHO African Region, most recent year Urban 18 16 16.7 14.6

Rural

Median HIV Prevalence (%)

14 12 10 8 6 4 2 0 2010-2011 Zimbabwe 2011 Uganda 2012 Kenya 2010 Rwanda 2010-2011 Tanzania 2011 Ethiopia 2012 Gabon 2008 Sierra Leone 8.7 7 7.2 5.6 4 2.3 0.6 4.2 4.1 4 2.5 1 7.1 7

Sources: MEASUREDHS HIV/AIDS Indicators survey and DHS/AIDS country reports in selected countries

HIV in the WHO African Region Progress towards achieving

Trends in HIV prevalence among the general population aged 15-49 years

In general, HIV prevalence rates among the general population aged 15-49 years are declining or stabilizing in countries that have had repeat population based surveys (Figure 2.9). In South Africa,

HIV prevalence rates among the general population aged 15-49 years remained almost stable between 2005 and 2008; 16.2 % and 16.9% respectively. In Uganda, there was an increase in the HIV prevalence rate from 6.4% in 2004/05 to 7.3% in 2011.

Figure 2.9:Trends in HIV prevalence (%) among the adult general population (men and women) aged 15- 49 years in selected countries, WHO African Region, 2001-2012 18 16

15.6 14.3 11.8

Median HIV Prevalence (%)

14 12 10 8 6 4 2 0

10.6 7.3 7 5.6

6.4

5 3 3 1.4 1.5

2001-2002

2004-2005

2003-2004

2011-2012

2007

2004

2010

2011

2003

2012

2005

2010

2005

Zambia

Malawi

Uganda

Kenya

Tanzania

Rwanda

Ethiopia

Sources: MEASUREDHS HIV/AIDS Indicators survey and DHS/AIDS country reports in selected countries

2.4 Young people aged 15-24 years

2.4.1 HIV prevalence in young people aged 15-24 years among ANC attendees

This section presents HIV prevalence trends among young people (ANC attendees and young people in the general population) aged 15-24 years. The section also presents trend analyses of comprehensive knowledge of HIV and sexual behaviours among young people.

There were variations in HIV prevalence among young ANC attendees aged 15-24 years between countries and subregions (Figure 2.10). HIV prevalence among ANC attendees aged 15-24 years ranged from 0.3% in Eritrea (2011) to 34% in Swaziland (2011). Southern African countries had the highest HIV prevalence rates.

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2010

Figure 2.10: HIV prevalence (%) among ANC attendees aged 15-24 years in selected countries, WHO African Region, most recent year 40 35 30 25 20 15 10 5 0

Median HIV prevalence (%)

20.5 11.6 4.2 2.6 14.5 8.2 4.2 3.4 0.7 0.3

Burkina Faso

Ethiopia

Malawi

Sierra Leone

Guinea Bissau

South Africa

Swaziland

Zimbabwe

Nigeria

2009

2010

2011

Source: GARPR country reports 2012 and country ANC HIV surveillance reports in selected countries

Trends in HIV prevalence among ANC attendees aged 15-24 years

The general trend is that HIV prevalence rates among young ANC attendees aged 15-24 years are declining (Figure 2.11). For example, in Botswana, HIV prevalence among ANC attendees aged 15-24 years declined by more than 50% from 30.2%

in 2000 to 14.5% in 2011. Similarly in Zimbabwe, HIV prevalence rates among young ANC attendees decreased from 20.8% in 2002 to 11.6% in 2009. In Nigeria, HIV prevalence among young ANC attendees decreased from 5.8% in 2001 to 4.2% in 2010.

Figure2.11:Trends in median HIV prevalence (%) among ANC attendees aged 15-24 years in selected countries, WHO African Region, 2000-2011 Swaziland Nigeria 45 40

Botswana Ethiopia

South Africa Sierra Leone

Zimbabwe

Median HIV Prevalence (%)

35 30 25 20 15 10 5 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year

Source: GARPR country reports 2012 and country ANC HIV surveillance reports in selected countries 24

Botswana

Eritrea

HIV in the WHO African Region Progress towards achieving

HIV prevalence among young people (women and men) aged 15-24 years in the general population

Africa had the highest HIV prevalence rates among young people aged 15-24 years. Population based HIV prevalence data continue to show that females aged 15-24 years were more likely to be infected with HIV than males of the same age (Figure 2.12). For example, in Ethiopia for every young man infected there were 5 young women infected (0.1% versus 0.5%).

There were wide variations in HIV prevalence among young people aged 15-24 years in the general population between the subregions and between countries (Figure 2.12). HIV prevalence among young people aged 15-24 years ranged from < 1% in Senegal and Ethiopia to 8.7% in South Africa. In general, countries in southern

Figure 2.12: HIV prevalence (%) among men and women aged 15-24 years in the general population in selected countries by sex, WHO African Region, most recent year

Women 6

Men

Median HIV Prevalence (%)

5.3

5 4 3 2 1 0 2010 Malawi 1.9

4.9

3.1

2.7

2.7 1.2 0.5

2.4 1.5 0.7 0.4 0.5 0.1

2011 Uganda

2011 Cameroon

2010-2011 Tanzania

2009 Congo

2010 Rwanda

2011 Ethiopia

Sources: GARPR country reports 2012 and country DHS/AIS reports in selected countries

2.4.2 Comprehensive knowledge of HIV in young people

Comprehensive knowledge of HIV among young people is defined as the ability to ‘identify two major ways of preventing the sexual transmission of HIV (using condoms and limiting sex to one faithful uninfected partner and rejecting two

most common local misconceptions about HIV transmission and knowing that a health looking person can transmit HIV’ (12). The data available from population based surveys indicate that in general the level of comprehensive knowledge of HIV among young people is relatively low (Figure 2.13).

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Figure 2.13: Proportion (%) of young people aged 15-24 years with comprehensive knowledge of HIV by sex in selected countries, WHO African Region, most recent year

Proportion of people (%) Propor tion of (%) Propor tion ofpeople people (%) Propor ti onof of people (%)(%) Propor ti on of people (%) Propor ti on people (%) Propor ti on of people

27 27 19 27 19 19 29 29 29 29 29 29 29 29 20 33 20 20 33 20 33 33 39 39 35 39 35 39 35 35 44 44 46 4446 44 46 46 58 58 47 58 47 58 Propor ti on of people (%) Proportion of people (%) 47 47

Proportion of people (%) Proportion of people (%) Propor ti onof ofpeople people(%) (%) Propor ti on Propor tion of people

20 0

Propor tipeople on of people (%) Propor tion of (%) Proportion of people (%) Propor tion on of people (%) (%) Propor ti of people Propor ti onof ofpeople people(%) (%) Propor ti on

27 27 35 27 35 35 35

21 21 26 21 26 26 26

2008-2009 Sao Tome and Principe

8 8 22 8

Central

29 29 3429 34 34 34

Sources: MEASUREDHS HIV/AIDS Indicators survey database and country DHS/AIS reports in selected countries

Trends in comprehensive knowledge of HIV

The data available from population based surveys show a modest improvement in the proportions of young people aged 15-24 years (both men and women) with comprehensive knowledge of HIV over

time, with the exception of Congo and Cameroon (Figure 2.14). In Ghana, there was a decline in the proportion of men with comprehensive knowledge of HIV between 2003 and 2008, while there was an increase in women.

21 22 21 33 22 22 33 22 33 33 38 45 38 38 45 38 45 45 45 45 35 45 35 45 35 35 21 26 21 21 26 21 26 2926 29 31 2931 29 31 31

Proportion of people (%)

0 0 0 0 0 0

100100 80 80 64 64 80 80 80 80 80 46 46 45 45 60 43 43 60 100 100 60 8060 80 80 36 36 34 34 60 30 30 60 29 29 60 60 6046 64 60 40 4080 44 44 45 22 22 36 34 80 8 34 34 8 30 29 60 60 20 60 2040 40 29 2930 30 44 40 40 22 45 46 60 40 43 40 40 40 34 8 36 0 0 29 30 40 30 29 34 60 20 20 20 2008-2009 4040 22 4020 44 2008-2009 2010 2010 2012 2011 2009 2012 2011 2009 20 20 20 8 20 34 0 0 29 30 20 202010 2009 Tome 2012 Burundi 2011 Gabon Cameroon Cameroon Congo 40 Tome Burundi Gabon Congo 20 0 SaoSao 20 0 2008 2010-2011 2008 2010-2011 0 00 and 0 00 and Gabon 2009 Cameroon 2005 2004 2011 Burundi Congo 2003 2008 2003 2008 2005 201020 2005 2009 2004 2011 2008 2010-2011 2003 2008 2005 20102003 2008 2005 2010 2009 2004 Principe 2008-2009 2012 2011 2009 2011 Principe 0 Ghana Senegal Ghana 2003 2008 2003 2008Senegal 2005 2011 20100 Congo Cameroon 2011 2005 2009 2004 2011 Congo Cameroon 0 2003 2008 2003 2008 2005 2010- 2011 Ghana Senegal Congo Central Central Western Western Nigeria Ghana Senegal Sao Tome Burundi Gabon CameroonCameroon Congo Central Africa 2011 Ghana Senegal 2008 Nigeria 2010-2011 Congo Cameroon Nigeria Ghana Senegal Central Africa Central Western Central Africa and Western Africa Nigeria Ghana Central Africa WesternAfrica Africa Senegal Principe Ghana SenegalWestern Western Africa Proportion of people (%) Propor tion of people (%) Propor tion of people (%) Propor ti onof ofpeople people(%) (%) Propor ti on 22 22 22

18 tion of people (%) Propor 21 18 Propor tion 18 21 of people (%) 18

Women

Women Men Men Women Women Men Men Women WomenMen Men Men Women Women Men

27 19

33 21 21 33 21 33 33 24 34 24 24 34 24 34 34 34 47 34 34 47 34 47 47 47 55 47 47 55 47 55 55 51 51 54 5154 51 54 54 52 52 46 52 46 52 46 46

100 100 80 80 80 80 100 60 80 80 6080 60 52 47 80 60 60 52 52 6060 47 47 604040 39 39 39 39 39 39 52 47 40 60 29 29 29 29 29 29 40 4040 40 39 39 402020 29 29 20 40 20 2020 20 0 20 0 20 0 00 2004 2009 2003 2009 200520100 2004 2009 2003 2009 200520100 2004 2009 2003 2009 200520102010-2011 2009 2009 2010-2011 2009 2009 0 2006 2011 0 2006 2011 2010-2011 2009 2009 2006 2011 2004 2009 2009 2003 2009 2009 200520102010-2011 Zimbabwe Lesotho Mozambique Mozambique Zimbabwe Lesotho Lesotho Mozambique Zimbabwe 2006 Zimbabwe 2011 Lesotho Mozambique Lesotho Mozambique Zimbabwe Zimbabwe Lesotho Mozambique Zimbabwe Lesotho Mozambique Southern Southern Africa Southern Lesotho Mozambique Southern SouthernAfrica Africa Zimbabwe Southern Southern Southern Africa

100100 80 80 80 80 80 6055 53 55 55 53 53 80 47 60 46 47 60 60 47 60 46 46 40 55 39 39 53 40 39 34 40 40 34 34 60 40 47 46 40 40 40 24 24 2440 39 20 34 40 20 20 24 0 20 20 20 00 2005 2011 2003 20082005 2010 0 0 2005 2011 2003 20082010 2005 2011 2003 2009 2008- 2005 2005 2010 0 2008-2009 2010 2010 2011 2011 2008-2009 2011 2011 2009 2009 2005 20102011 2011 2003 2011 20082005 2010 2008-2009 2008-2009 2010 Rwanda 2011 Uganda Rwanda 2011 Ethiopia Kenya Kenya Rwanda Ethiopia Kenya Ethiopia 2009Uganda Ethiopia Kenya Rwanda Ethiopia Kenya Rwanda Kenya Rwanda Rwanda Uganda Eastern Ethiopia Africa Kenya Uganda Ethiopia Eastern Eastern Ethiopia Kenya Rwanda Eastern EasternAfrica Africa Eastern Eastern Eastern Africa

(%) Proportion of people (%)

100 Women 80

Women Men Women Women Men Men Women Men Women Men Men Women Men

Women

Men

Women 100

Women Men Men Women Women Men WomenWomen Men Women Men Men Women Men

Men

Women Men Men Women Women Men Women Men Men Women Men 100100 Men Women 80 Women Women Men 80 80 100

Western

HIV in the WHO African Region Progress towards achieving

Figure 2.14:Trends (%) in comprehensive knowledge of HIV among young people aged 15-24 years in selected countries by sex, WHO African Region, 2003-2012

Women Proportion of people (%)

Men 58 Proportion of people (%)

80 47 44 46 39 35

Women 80 24 34

Men 47 55 51 54 52 46

27 19

20 0

20 0 2005 2011 2003 20082009 2005 2010

2004

2009

2003

2009

20052006

20102011

29 29

Lesotho

Mozambique Southern Africa

Zimbabwe

Ethiopia

Kenya Eastern Africa

Rwanda

Women Proportion of people (%)

Men Proportion of people (%)

Women 80 38 45

Men

80 60 35 34 26 27 29 22

0 2005 Congo Central Africa 2009 2004 Cameroon 2011

20 0

18 21

2003

2008

2003

2008

21 26

2005

Nigeria

Ghana Western Africa

Senegal

Sources:MEASUREDHS HIV/AIDS Indicators survey database and country DHS/AIS reports in selected countries

2.4.3 Sexual behaviours in young people

Young people aged 15-24 years are asked in behavioural surveys such as DHS and AIS about their sexual behaviours. Questions on having sex before the age of 15 years, ever having had premarital sex in the 12 months prior to the surveys, condom use during

the last premarital sex, having sex with more than one partner (non-cohabiting and non-married partners; multiple sexual relationships) in the 12 months prior to the surveys and condom use at the last higher risk sex (with non-marital, noncohabiting) among those reporting having one or more sexual partners in the last 12 months are asked.

Universal Access to priority health sector interventions 2013 UPDATE

29 31

20102011

Sexual debut

Data from DHS/AIS surveys in the region indicate sexual debut before the age of 15 years was common (Figure 2.15). Whereas women in Ethiopia, Uganda, the United Republic of Tanzania, Cameroon, Ghana and Nigeria were more likely to report

being sexually active before the age of 15 years than men, the reverse was true in Congo, Lesotho, Rwanda, Gabon, Burundi and Sao Tome and Principe. In Zimbabwe and Mozambique, the proportions of women and men engaging in sex before age 15 years were very close.

Figure 2.15: Proportion (%) of young people aged 15-24 years reporting having sex before age 15 years in selected countries, WHO African Region, most recent year Women Men

Women

Men

35.0 30.0

proportion of people (%)

25.0

15.0 10.0 5.0

11 12

20.0

1616

20 9 8

9 25

25 Principe

2009

2009 Lesotho

2010-2011 Zimbabwe

zambique

2010-2011 2010 2009 2009 Uganda Tanzania Rwanda Mozambique Lesotho

2011

0.0

2011 2010-2011 Ethiopia Zimbabwe

2012 2011 Gabon Uganda

2009 2011 2008-2009 2010 2008 2010 2010-2011 2010 2011 2012 2009 Congo Cameroon Sao Burundi Nigeria Burkina Fas Tanzania Rwanda Tome Ethiopia Gabon Congo C and Central Africa Eastern Africa

Southern Africa

Eastern Africa Southern Africa

Western Afr Cen

Women 32 35.0 30.0

Men

Women

Men

Women 32

Men

propor11 tion of people (%) 16

25.0 20.0

20 22 25

12 16

11 11

9 11

7 8

4 3

10.0 5.0

11 9 2009 2008

15.0

2009

ambique

2010-2011 Tanzania

2009

Lesotho

2010

2010-2011 Zimbabwe

2011

0.0 2011

Rwanda

Ethiopia

Uganda

2012 2009

2010-2011 Tanzania

2009

2010

Gabon Mozambique

Congo Lesotho

Rwanda

2011 2010-2011 Cameroon Zimbabwe

2011

Ethiopia

2008-2009 2011 Sao Uganda Tome and Principe

2012

Gabon

2010 2010-2011 Burundi Tanzania

2009

Congo

2008 2010

2011

Nigeria Rwanda

Cameroon

Sao Burundi Nigeria Burkina Faso Tome Burkina Fasoand Ghana Ethiopia Gabon Congo Cameroon Principe Tom

2010 2011

2008-2009

2008 2012

2010

2011

2010

Southern Africa

Eastern Africa

Central Africa

Pr Western Afric

Eastern Africa

Central Africa Southern Africa

Eastern Africa

Western Africa

Central Africa

Sources: MEASUREDHS HIV/AIDS Indicators survey database and country DHS/AIS reports in selected countries

Premarital sex

reported having had premarital sex in the 12 months preceding the surveys. On Premarital sex was common among young the whole, young men were more likely people aged 15-24 years (Figure 2.16). to report engaging in premarital sex than About 31% and 34% of the young women women. and men aged 15-24 years respectively 28

200

HIV in the WHO African Region Progress towards achieving

Figure 2.16: Proportion (%) of young people (aged 15-24 years) who reported having had premarital sex in the 12 months preceding the surveys by sex in selected countries, WHO African Region, most recent year

Women 100 90 100 100 80 90 100 7090 80 90 6080 70 80 5070 60 70 4060 50 60 3050 40 50 2040 30 40 1030 20 30020 10 20 10 0 10 0 Proportion of people (%) Propor tipeople on of people (%) Propor tion of (%) Proportion of people (%)

Men Men Men Men 57 100 90 100 80 90 100 70 80 90 60 70 80 50 60 70 40 50 60 30 40 50 20 30 40 10 20 300 10 20 0 10 Proportion of people (%) Propor tipeople on of people (%) Propor tion of (%)

Women Women Women

Men Men Men

Women Women Women 54 54 62 62

54 37 24

62 34 37 18 2010

35 35 34

37 24 37 24 37

57 31 32 13

27 27

34 34

37 37

34 18 34 18 34

31 32 31 32 7 11 8

27 13

35 2009

13 27 11 8 7 132010-2011 4 Zimbabwe 2010-2011 2011 2010-2011 Zimbabwe Ethiopia 2010-2011 Rwanda

24 2008-2009 Kenya 2008-2009 Kenya 2008-2009 2010-2011 Tanzania 2010-2011 Tanzania 2010-2011

31 32 2011

18 2010

2010-2011 Zimbabwe

Mozambique 2008-20092010 2010-2011 Mozambique 2010 Tanzania Kenya

Lesotho 2010 2009 2011 Southern Africa Lesotho Malawi2009 Uganda

Malawi Uganda 2010 2011 Eastern Africa Malawi Uganda 2010 2011

11 7 2010-2011 11 7 Rwanda 2010-2011 Rwanda 2010-2011

8 4 2011 8 4 Ethiopia 2011 Ethiopia 2011

Mozambique

Women Southern Africa Men 100 90 100 80 100 90 70 90 10080 60 80 9070 50 8060 4070 7050 3060 6040 2050 5030 1040 4020 0 30 3010 20 20 0 10 10 0 0 Proportion of people (%) Propor tipeople on of people (%) Propor tion of (%) Proportion of people (%)

Southern Lesotho Eastern Africa Africa

Zimbabwe

Kenya

Tanzania

MalawiEastern Africa Uganda

Rwanda

Ethiopia

Women Eastern Africa Men 100 90 100 80 90 70 100 80 60 90 70 50 80 60 40 70 50 30 60 40 20 50 30 10 40 20 300 10 20 0 10 Proportion of people (%) Propor tipeople on of people (%) Propor tion of (%)

64 68 64 68

66 66 66 66

Women Women Women 49 32 49

Men Men Men 44 44

Women

Men

Women 51 50 51 50 34 34 30 30 31 29 31 29

Men

64 68 51 50

66 66

36 36

32 49 34 30

32 31 29 2008-2009 Sao Tome 2008-2009 and Sao Tome Principe 2008-2009 2008 and Central Africa Sao Tome Principe Nigeria and Central Africa Principe Western Africa

44 27

51 50

22 22

27 27 18 7 18

2012 Gabon 2012 Gabon 2012 2008 Gabon Sierra Leone

2009 Congo 2009 Congo 2009 2008-2009 Congo Ghana

22 2011

4 6 2010 18

34 2008 Sierra Leone 2008 Sierra 2008Leone

2010 Burundi

Cameroon 2011 Cameroon 2011 2010 Cameroon Burkina Faso

4Burundi 76 2010 Burundi 2010 2010 Burundi Senegal

31 29 2008 Nigeria 2008 Western Africa Nigeria 2008 Western NigeriaAfrica

2008-2009 Ghana 2008-2009 Ghana 2008-2009

27 2010

Burkina Faso 2010 Burkina 2010 Faso

7 Senegal 2010 Senegal 2010

7 18 2010

Sierra Leone

Ghana

Burkina Faso

Senegal

Sources: MEASURE DHS HIV/AIDS Indicators survey database and country DHS/AIS reports in selected countries

Central Africa

Western Africa

Of the young people aged 15-24 years who reported having had premarital sex in the last 12 months, 42% of the women and 63.6% of the men used a condom at the last premarital sex (Figure 2.17). Men were more likely to use a condom at last premarital sex than women. The data from

countries that have had repeat population based surveys indicated increasing trends in condom use at last premarital sex for both men and women aged 15-24 years, but the increases were more marked among young men than young women.

Universal Access to priority health sector interventions 2013 UPDATE

Figure 2.17: Proportion (%) of young people aged 15-24 years who reported having premarital sex in the last 12 months and used a condom at the last premarital sex in selected countries, WHO African Region, most recent year Women Proportion of people (%) 100 80 60 40 20 0 2011 Ethiopia 2010-2011 Rwanda 2008-2009 Kenya 2010-2011 Tanzania 2010 Malawi 2011 Uganda 37 68 42 66 40 64 49 54 49 51

Men

42 46

Eastern Africa

Women Proportion of people (%) 100 80 60 40 20 0 2010 Burkina Faso 2010 Senegal 2008 Nigeria Western Africa 62 40 76 64 50 36

Men

45 29 9 2008-2009 Ghana 20

2008 Sierra Leone

Women Proportion of people (%)

Men Propor tion of people (%) Propor tion on of people (%) Propor ti on of people (%) Propor ti of people (%)

Women Women Men Men

100 80 60 40 20 0 2010-2011 Zimbabwe 2009 Lesotho Southern Africa 2010 Mozambique 48 73 66 65 45 44

100 100 100 80 80 80 80 60 60 60 60 40 40 40 20 20 20 20 0 0 0 0

100

78 63 63 48

Women 66

Women

Men

72 72 59 59

65 64 64 56 64 56 56

27 27 27

46 46 45 46

44 43 43 43 33 33 33

2012 2011 2008-2009 2010-2011 2009 2012 2008-2009 2011 2008-2009 Gabon Cameroon Sao Zimbabwe Lesotho and Gabon Sao Gabon Cameroon Tome Sao Southern Africa Principe

Tomeand and Tome Central Africa Principe Principe

Burundi Burundi

Burundi Congo Mozambique

2010 2010 2009 2009 2010

2010

2009

Congo Congo

CentralAfrica Africa Central Sources: MEASURE DHS HIV/AIDS Indicators survey database and country DHS/AIS reports in selected countries

Multiple sexual relationships

was common among young people, both women and men. Men were more likely Figure 2.18 shows that having multiple to report engaging in multiple sexual sexual partners in the last 12 months relationships than women (Figure 2.18).

HIV in the WHO African Region Progress towards achieving

Figure 2.18: Proportion (%) of young people aged 15-24 years who reported having sex with multiple partners in the last 12 months in selected countries by sex in the WHO African Region, most recent year Women 50

Men

Proportion of people (%)

40 30 20 10 0 2010 Tanzania 2011 Uganda 2008-2009 Kenya 2010 Malawi 2010-2011 Rwanda 2011 Ethiopia 5 5 3 28 23

14 9 1 2 1 5

Eastern Africa

Women 50

Men

Proportion of people (%)

40 30 20 10 0 2008 Sierra Leone 2008 Ghana 2008 Nigeria Western Africa 2010 Burkina Faso 6 19 17 17 16 12 1

2010-2011 Senegal

Women 50 Proportion of people (%)

Men Propor tion of people Propor tion of people (%) (%) Propor ti on of people (%)

Women Women 50 50 40 40 50 40 30 30 30 20

Men Men Men 29 29

40 30 20 10 0 7

Women 32 32

31 23 21

20 20 10 10 10 0 0 0

17 10 17 10 7

21 21

11 4

3 3

1 1

2009 Lesotho

2008-2009 Madagascar

2009 Mozambique

2010-2011 Zimbabwe

2011 2009 2011

2012 2009 2009 2008-2009 2010-2011 2010 2008-2009 2009 2012 2008-2009 2010

Lesotho Cameroon

Cameroon

Southern Africa

Madagascar Congo Mozambique Gabon Sao Tome Zimbabwe Burundi and Principe and Principe Southern Central Africa Africa

Gabon

Congo

Sao Tome

Burundi

Central Africa

Sources: MEASURE DHS HIV/AIDS Indicators survey database and country DHS/AIS reports in selected countries

Condom use at the last higher risk sex

Young people aged 15-24 years who reported having sex with more than one sexual partner in the last 12 months were asked about the use of condom at the last sex with a non-married noncohabiting partner (higher risk sex). In general, condoms were not always used

during higher risk sex (Figure 2.19). Of the young people who reported having multiple sexual partners in the last 12 months in 20 countries, only 32.5% (range 1.1% - 61%) of the women and 50.2% (range 4.8% -78.1%) of the men used a condom at the last higher risk sex. Men were more likely to report using condoms than women at last higher risk sex.

Universal Access to priority health sector interventions 2013 UPDATE

Figure 2.19: Proportion (%) of young people aged 15-24 years who reported having sex with multiple sexual partners in the last 12 months and used a condom at the last higher risk sex, most recent year 100 100 80 80 60 60 40 40 20 20 0 0

Men en Propor tion Propor tion of people (%) of people (%)

Women Women 64 64 33 33 62 62 62 62

Men Men 49 51 49 51

1 5 1 5 2009 2008-2009 2009 2008-2009 ozambique Madagascar zambique Madagascar rica rica

23 5 23 5

39 39

41 41

31 24 31 24 2011 2011 Uganda Uganda

2008-2009 2008-2009 Kenya Kenya

2011 2011 Ethiopia Ethiopia

2010-2011 2010 2010-2011 2010 Rwanda Tanzania Rwanda Tanzania Eastern Africa Eastern Africa

Women 64 64

14 5 14 5 2010 2010 Malawi Malawi

Men

100

Proportion of people (%)

Proportion of people (%) Proportion of people (%)

Men en Propor tion Propor tion of people (%) of people (%) 44 32 44 32 2009 2009 Congo Congo 38 38 10 10 2011 2011 Cameroon Cameroon

100 100 80 80 60 60 40 40 20 20 0 0

Women Women 75 61 75 61 64 64

80 Men Men 48 60 40

100 80 60 40 100 60 40 20 0

Proportion of people (%)

42 42

49 20 36 49 100 0 36 80 60 40

2010-2011 48

Women 46 28 46 74 64 64 28

Men

23 1 5 2008-2009

2009

ica ca

2010 2010 Burkina Faso Burkina Faso

2010-2011 2010-2011 Senegal Senegal

Zimbabwe Madagascar 2008 20 2008 Lesotho 2008 5 1 5 2008 2008 2008 Southern Africa Nigeria 0 Ghana Sierra Leone 2010-2011 2009 2008-2009 Nigeria Ghana 2009 Sierra Leone Western Africa Zimbabwe Lesotho Mozambique Madagascar Western Africa Women Women Women Southern Africa

22 10 22 2009 10

0 80

23 Mozambique

Women 100

Men Proportion of people (%) Propor tion on Propor ti on Propor ti Propor tion of people (%) of people (%) of people of people (%) (%)

Proportion of people (%)

Proportion Propor tion Propor on Propor ti on of people people (%)ti of (%) of (%) ofpeople people (%)

80 60 40 20 0 48

64 64 23 5 1 5

100 100

Men Men Men

Women 62

Men

2010-2011 Zimbabwe

2009 Lesotho

2009 Mozambique

2008-2009 Madagascar

80 80 100 60 60 60 80 40 60 40 40 40 20 20 20 20 0 0 0

80 40 20

74 64 64 64 64 62 60 54 64 64 78 48 60 48 45 39 54 64 60 33 45

7874

Women

Men

100 100

100

5 5

23 32 23

44 41 32 44

0 2010-2011 2009 2012 2008-2009 2010-2011 2009 2010 2011 2012 2008-2009 2008-2009 2010

10 1 1

38 5 5

49 51

2009 2008-2009 2009 2011 2009 2008-2009 2010-2011 2010

Southern Africa

Zimbabwe Lesotho Mozambique Madagascar Gabon Kenya Sao Tome Burundi Congo Cameroon Tanzania Zimbabwe Lesotho Mozambique Madagascar Ethiopia Rwanda and Gabon Sao TomeSouthern Burundi Congo Cameroon Africa Principe Southern Africa Eastern Africa

2009

2011

100 8080 60 60 80 31 40 6040 24 60 20 40 20 40 0 0 20 20

2011 0

0 Uganda

and Principe

Central Africa

100 78 64 80 60 54 45 44 60 32 26 sexual Trends 40 in reported multiple 20 relationships 0 2012 2008-2009 2010 2009

Propor tion Propor tion of people (%) of people (%) Proportion of people (%)

Women Men Central Africa Women Men Women Women Men Men Sources: MEASURE DHS HIV/AIDS Indicators survey database 100 and country 78 DHS/AIS reports in selected countries 38 10 2011 100 64 80 100 60 78 54 64 80 45 44 60 60 75 54 26 45 64 32 44 60 80 40 61 32 26 20 40 60 42 0 20 402012 2008-2009 2010 2009 0 20 2012 2008-2009 2010 2009 Gabon Sao Tome Burundi Congo and 0 Gabon Sao Tome Burundi Congo Principe 2010 2010-2011 and Principe Central Africa Burkina Faso Senegal Central Africa

100

Propor tion Propor tion of people (%) of people (%) 28 2008 Ghana

100

Proportion of people (%)

Overall there were decreasing trends Gabon Sao Tome Burundi Congo Cameroon in the proportionandof young people who reported having Principe multiple sexual partners in Central Africa the last 12 months (Table 2.6). However, notable increases in the proportions of

10 young people, both men and women, 36 2011 reporting having more than one sexual 2011 Cameroon partner in the last 12 monthsCameroon were 2008 observed in Ethiopia, Rwanda, Tanzania Nigeria and Zimbabwe. In Uganda, the increase Western Africa was among women only.

10 49

60 46 40 40 20

20 0

HIV in the WHO African Region Progress towards achieving

Table 2.6:Trends in the proportion (%) of young people aged 15-24 years reporting having more than one sexual partner in the past 12 months and condom use at last higher risk sex in selected countries, WHO African Region, 2002-2012 Higher risk sex in the past 12 months Women Lesotho Madagascar Southern Africa Mozambique Zimbabwe Ethiopia Kenya Malawi Eastern Africa 2004 2009 2003-2004 2008-2009 2003 2009 2005-2006 2010-2011 2002 2005 2011 2003 2008-2009 2002 2004 2010 2000 2005 2010-2011 2004 2005 2008 2010 2004-2005 2006 2011 2004 2011 2003 2010 2003 2008 2003 2008 2005 2010-2011 8.8 7 5.3 29.6 8.1 5.2 1.8 19.8 2.6 0.5 1 3.1 3.1 1.5 1.7 1.2 1.1 1 2.3 7.5 5 4.1 5.3 5.1 3 5 10.4 10.2 2.7 1.6 3.6 2.8 3.6 2.1 1.9 0.7 Men 35.5 33.5 4.4 30.7 39.1 22.5 19.8 21 18.6 4.8 5.1 24.2 17.9 19.5 13.2 13.9 6 4.4 8.8 32.7 33.2 22 27.5 28.3 22.7 22.7 41.4 37.4 23.2 16.3 17.8 17.2 24.7 17.1 21 12.2 Condom use at last higher risk sex Women 50.1 64 1.1 5.5 29.1 40.1 42.4 48 17.1 28.4 32.5 25.4 39.2 3.9 3.3 4.5 22.5 26.4 40.7 41.7 38.6 46.3 49.4 52.9 38.3 24.2 46.5 59.9 53.9 61 32.7 28.2 24.4 35.5 35.6 42.1 Men 47.9 64 1.1 4.8 33.2 39.8 48 73.6 30.5 49.4 62.4 46.8 64.3 16.2 15.5 16.8 55.1 39.4 61.8 47.1 45.5 49 51 55.1 54.5 30.7 57.4 71.8 69.9 74.7 51.7 46.4 46.3 49.4 52.4 63.8

Subregion

Country

Year

Rwanda

Tanzania

Uganda Central Africa Cameroon Burkina Faso Ghana Western Africa Nigeria Senegal

Sources: MEASUREDHS HIV/AIDS Indicators survey database and selected country DHS/AIS reports

There was also an overall increase in condom use for both men and women aged 15-24 years at last higher risk sex in the Region (Table 2.20). However in

Malawi, Nigeria and the United Republic of Tanzania condom use remained almost the same while it decreased in Uganda and Ghana.

Universal Access to priority health sector interventions 2013 UPDATE

Figure 2.20:Trends (%) of young people aged 15-24 years reporting having multiple sexual partners in the last 12 months and using a condom at last higher risk sex in selected countries, WHO African Region, 2008-2012 100 Proportion of people (%) Proportion of people (%)

Women Men Women Men 100 Proportion of people (%)

64 64 50 48

Proportion of people (%)

80 60 40 20 0

74 64 64 33 29 40 40 33 40 40 42 48 42 48 48 48

100 100 80 60 40 20 0 80 60 40 20 0 31 31 17 28 28 49 49 33 33 62 62

Women Women

Men Men

50 48 60 40 20 0

64 64 47 47 25 25 55 39 39 23 23

55 39 26 39 41

62 41

2004

2009 2003 2009 2005-2006 2010-2011 2004 2009 2003 2009 2005-2006 2010-2011 Lesotho Mozambique Zimbabwe Lesotho Mozambique Zimbabwe Southern Africa Southern Africa

2002 2002

2005 2005 Ethiopia Ethiopia

2011 2011

2003 2003

2008-2009 2000 2008-2009 2000 Kenya Kenya Eastern Africa Eastern Africa

2005 2010-2011 2005 2010-2011 Rwanda Rwanda

100 Proportion of people (%) Proportion of people (%)

Women Men Women Men 100 60

Proportion of people (%)

80 60 40 20 0

80 60 40 20 0 47 47

72 57 60

Proportion of people (%)

100 100 80 60 40 20 0 80 60 40 20 0 54 54 70 70 61 61 75 75

Women Women

Men Men

46 46 24 24

36 36

49 49 36

52 36

52 42

64 42

2004

2011 Cameroon Cameroon Central Africa Central Africa

2011

2003 2010 2003 2010 Burkina Faso Burkina Faso

2003 2003

Nigeria Nigeria Western Africa Western Africa

2008 2008

2005 2005

2010-2011 2010-2011 Senegal Senegal

Sources: MEASURE DHS HIV/AIDS Indicators survey database and country DHS/AIS reports in selected countries

2.5 HIV prevalence among key populations

HIV prevalence among key populations is much higher than in the general population in the region Sex workers

Among female sex workers HIV prevalence ranged from <1% in Madagascar to 69.7% in Swaziland (Figure 2.21). HIV prevalence among sex workers increased from 1.7% in 2000 to 4.4% in 2010 in Tamanrasset, in Algeria (13). In Senegal, sex workers had an HIV prevalence of 18.5% in 2010, a slight decrease from 19.6% in 2006 (14). In Madagascar, 0.29% of the sex workers were HIV

infected in 2010. In Sao Tome and Principe, HIV prevalence rate among sex workers was 2.8% in 2009, a decrease from 4.2% in 2008 (15). In Niger, HIV prevalence rate among sex workers was 31.5% (varied from 16.7% in Tillaberi to 60.6% in Maradi in 2009 (16). In Ghana, sex workers had an HIV infection rate of 25.1% in 2009, a decline from 34% in 2006 (17). Studies in sex workers have mainly been conducted among female sex workers. Nevertheless, a cross sectional study conducted in male sex workers in Abidjan in Cote d’Ivoire found male sex workers with an HIV prevalence of 50% in 2007-2008. (18) 34

HIV in the WHO African Region Progress towards achieving

Figure 2.21: HIV prevalence (%) among sex workers in selected countries, WHO African Region, most recent year 80 70 Median HIV Prevalence (%) 60 50.8 50 40 30 20 10 0 2011 2010 2010 Uganda 2009 Niger 2010 Mauritius 2009 Ghana 2010 Nigeria 2010 Senegal 2011 Togo 2010 Algeria Swaziland Rwanda 33 69.7

31.5

28.9

25.1

21.7

18.5 13.1 4.4

Source: Country GARPR 2012 reports

Men who have sex with men (MSM)

MSM are highly stigmatized in most countries in the region, and in most of the countries sex between men is a criminal offence. Harsh punishments are imposed on those found engaging in the practice. In Kenya, the conviction of sex between men is 14 years in prison (19). As a result, the response to HIV/AIDS, including surveillance of HIV prevalence among MSM is poor in most countries in the region; though a recent review showed that there were no major differences in the conduct of surveys among MSM in countries that decriminalise MSM and those that do not (8).

HIV prevalence among MSM in 11 countries ranged from 10% in Algeria (2010) to 21.8% in Senegal (2007). Studies conducted in Namibia in 2009 indicated an HIV prevalence of 12.9% among MSM and in Blantyre, Malawi in 2007, found MSM with an HIV prevalence of 21.4% (20). In Swaziland a BSS found an HIV prevalence of 16.7% among MSM in 2011, and among MSM aged 30-44 years the rate was more than 50% in 2011 (21). In Seychelles, a Biological and Behavioural Survey conducted in 2011 found MSM with an HIV prevalence of 13.2% and of these 41.9% were also infected with hepatitis C (22).

Universal Access to priority health sector interventions 2013 UPDATE

Figure 2.22: HIV prevalence (%) among Men who has Sex with Men (MSM) in selected countries, WHO African Region, most recent year 25 21.4 Median HIV Prevalence (%)

20.3 17.2 16.7 14.9 13.7 13.2 12.9 10 8.1

0 MalawiBlantyre

2011 Togo

2010 Nigeria

2011 Swaziland

2012 Madagascar

2010 Uganda

2011 Seychelles

2009 Namibia

2010 Algeria

2010 Mauritius

Source: Country GARPR 2012 reports

People Who Inject Drugs (PWID)

Few countries in the WHO African Region have HIV prevalence data among people who inject drugs (PWID). Criminalisation of the practice in most countries in the region limits access to PWID. A review of the 2012 country GARPR reports and selected recent National Strategic Plans on HIV/AIDS indicate that countries in the region are acknowledging that injecting drug use is an emerging but growing phenomenon. In the 8 countries that reported HIV prevalence among PWID, HIV prevalence ranged from 4.2% in Nigeria to 51.6% in Mauritius. In Mauritius, HIV prevalence rose from 47.4% in 2009 to 51.6% in

in 2011 (23). In 2008, HIV prevalence among PWID in Mombasa, Kenya was 43%, and in Nairobi the capital city of Kenya, HIV prevalence among PWID was 36% (24). In 2010 in Dar es Salaam, Tanzania, 55% of women PWID were HIV infected as compared to a rate of 12% among men PWID. In Zanzibar, a BSS conducted in 2007 found an HIV prevalence of 16% among PWID, as compared to a rate of <1% among the general population. Women PWID in Zanzibar were found to have an HIV infection rate of 74% as compared to 14% among men (24). In Seychelles, 5.8% of the PWID were HIV infected and of these 53.5% had hepatitis C in 2011 (22).

HIV in the WHO African Region Progress towards achieving

Figure 2.23: HIV prevalence (%) in People Who Inject Drugs (PWID) in selected countries, WHO African Region, most recent year 60 50 51.6 43 36

HIV Prevalence (%)

40 30 20 10 0

16 9.2 7.6 5.8 4.2 2010 Nigeria

2011 Mauritius

2008 Kenya (Mombassa)

2008 Kenya (Nairobi)

2007 Tanzania (Zanzibar)

2010 Senegal

2012 Madagascar

2011 Seychelles

Source: GARPR 2012 reports

Other Key Populations

2.6 Sexually Transmitted Infections (STIs)

Countries in the WHO African Region have identified other groups such as migrants, prisoners, truck drivers, fisher men, cross border traders and miners as populations that need to be targeted with HIV interventions. In 2010, surveyed migrants in Algeria had an HIV prevalence of 0.82%. Algeria also found an HIV prevalence of 1.74% among STI patients in the same period (13). HIV prevalence among truck drivers in Senegal decreased from 1.4% in 2006 to 0.6% in 2010 (14). On the other hand HIV prevalence increased among fishermen from 0.2% in 2006 to 0.8% in 2010 in Senegal (14). In Uganda, HIV prevalence among a fishing community around Lake Victoria was 22%, and plantation workers had a rate of 7% in 2010 (25). Migrant workers in Swaziland had an HIV infection rate of 30.4% and among prisoners, the prevalence was 34.9% in 2011 (21).

Data on STIs are limited in the WHO African Region. In South Africa, syphilis prevalence among ANC attendees was 1.6% in 2011, almost the same as 1.5% in 2010 (26). Syphilis prevalence in Lesotho among ANC attendees was 2.5% in 2011 (27). In Malawi, syphilis prevalence among ANC attendees decreased from 7% in 1996 to 1.2% in 2010 (20). In 2010, ANC attendees in Burkina Faso had a syphilis prevalence of 1.9% (28). In Botswana prevalence rates of syphilis have consistently remained low; syphilis prevalence among ANC attendees was 1.3% in 2011 (29). The low median national prevalence of syphilis among ANC attendees in most countries may mask ‘the hotspots’ in the country. For example in Lesotho, syphilis prevalence among ANC attendees varied from 0.7% in Quthing to 7.9% in Leribe in 2011. In Botswana HIV prevalence rates varied from 0% in Gantsi and Boteti districts

Universal Access to priority health sector interventions 2013 UPDATE

to 5.8% in Kgalaga South in 2011. In South Africa, the prevalence rates varied from 0.4% in KwaZulu Natal to 4.1% in Mpumalaga in 2011 (26). The 2011 AIS in Uganda found that 3% of Ugandans had a positive syphilis serology (30). In 2007, the Kenya AIS showed a syphilis prevalence rate of 2% in adults aged 15-64 years. Higher syphilis prevalence rates were found among older adults aged 50-64 years; 4.4% in men and 2.5% in women. The same survey found relatively high prevalence rates of herpes simplex type II (HSV); 41.6% among women and 26.3% (31).

The low prevalence rates of syphilis in the countries in the region are more likely an indication of good management of STIs. However, prevalence rates of syphilis can be affected by differences in testing strategies, health seeking behaviours, and self-medication practices, all of which have to be taken into account while interpreting the data. There appears to be an inconsistent relationship between the prevalence of syphilis and the prevalence of HIV in the WHO African Region.

Figure 2.24: Prevalence (%) of syphilis among ANC attendees in selected countries, WHO African Region, most recent year

Syphilis Prevalence (%)

2.5 2 1.5 1 0.5 0

2.5 2.1 1.6 1.3 1.2

2011 Lesotho

2010 Burkina Faso

2011 South Africa

2009 Botswana

2010 Malawi

Source: Country GARPR reports and ANC HIV surveillance reports in selected countries

2.7 Challenges and the way forward

Current data on HIV prevalence and trends in the WHO African Region show that countries in the region are on track “to have halted by 2015 and begin to

reverse the spread of HIV/AIDS”. HIV prevalence rates are on the decline or stabilizing in several countries. However, on the whole, HIV prevalence rates remain unacceptably high, especially in southern and eastern Africa.

HIV in the WHO African Region Progress towards achieving

Many countries in the region have made progress in strengthening HIV surveillance systems. The conduct of national population based surveys with an HIV testing component has expanded and the surveys are providing valuable information on sexual behaviours and HIV infection levels that are complementing data from HIV sentinel surveillance among ANC attendees. However, the conduct of HIV sentinel surveillance among ANC attendees in the last few years has become inconsistent in several countries. Measuring trends in the HIV epidemic requires repeated comparable surveys. Countries, with the support of partners, must make every effort to conduct HIV sentinel surveillance among pregnant women attending antenatal clinics at least once every two years. Reporting on HIV prevalence among young people aged 15-24 years is part of the Global AIDS Response Progress Reporting system. Countries are expected to report on this indicator under the GARPR system so as to monitor progress towards the attainment of MDG-6 by 2015. This can only be possible if countries are conducting regularly and consistently ANC based surveillance. ANC based data are also able to provide ‘early’ changes in HIV prevalence, otherwise countries will have to wait longer to ‘notice’ changes in the epidemic as population based surveys are usually conducted every five years. HIV sentinel surveillance among ANC attendees remains the cornerstone in monitoring HIV trends in countries with generalised epidemics. Population based

surveys should not replace HIV sentinel surveillance among ANC attendees. HIV surveillance among key populations, especially among female sex workers is improving. Data on MSMs and PWID are not as readily available. Criminalisation, stigmatization and discrimination make it difficult for key populations to be accessed with surveillance systems and HIV interventions. As the dynamics of the HIV epidemic evolve in the region, it is paramount that countries double their efforts to obtaining an accurate “picture” of the HIV situation, including accurate epidemiological (biological and behavioural) data among key populations so as to design tailor made, effective and accessible interventions and services. Data on prevalence of STIs remain scarce in the region. Countries should revitalise their efforts in collecting, analysing and reporting on STI data, in particular on syphilis. In addition, countries should endeavour to collect data on STIs from special studies, research or projects and include these data in their national HIV surveillance and GARPR reports. As countries expand and accelerate the provision of antiretroviral therapy to people living with HIV, they may start experiencing a rise in HIV prevalence because people infected with HIV are living longer. This makes the measuring of HIV incidence critical in monitoring the transmission of new HIV infections and in assessing the effectiveness of HIV programmes. However, measuring HIV incidence in the region using the

Universal Access to priority health sector interventions 2013 UPDATE

variety of laboratory assays that have been developed for this purpose remains a challenge. There has been no simple and reliable method yet to routinely assess HIV incidence in the region (33). Countries will have to pay more attention to measuring HIV prevalence trends among young people aged 15-24 years as this is a feasible “proxy” for measuring HIV incidence in the region. In general, empirical data on mortality, including HIV/AIDS related mortality, are limited in the region. Most of the data on mortality and trends are derived from mathematical modelling. Countries need

to revitalize their vital statistics registration systems, which would help them to assess causes and trends of mortality including HIV/AIDS related deaths. Surveillance of HIV infection among infants and children is limited in the Region. As countries make efforts to improve early infant diagnosis (EID) of HIV, they should be encouraged to put mechanisms in place to systematically collect, compile and analyse the results from EID. This could assist in monitoring trends in HIV infection in infants. Countries should be encouraged to include children, where feasible, in population-based surveys.

HIV in the WHO African Region Progress towards achieving

References 1. UNAIDS. Global Report UNAIDS Report on the global AIDS epidemic 2013. 2013 UNAIDS, Geneva. 2. WHO/AFRO. HIV in the WHO African Region Progress towards achieving Universal Access to priority health sector interventions 2011 Update. 2011. WHO/AFRO, Brazzaville. 3. UNAIDS. Report on the Global AIDS epidemic 2012. 2012 UNAIDS, Geneva. 4. WHO and UNAIDS. Guidelines for second generation HIV surveillance. 2000. UNAIDS/ WHO working group on Global HIV/AIDS and STI surveillance.www.who.int/hiv/pub/surveillance/en/ cds_edc_2005_pdf, accessed 5 September 2013 11. Magadi Monica A., The disproportionate high risk of HIV infection among the urban poor in sub-Saharan Africa. AIDS Behave ( April 2013) 17:1645-1654 DOI 10.1007/s10461-012-0217-y 12. United Nations. Millennium Goal Indicators. http:mdgs.un.org/unsd/mdg/metadata.aspx?indicato rsId=D&seriesId=741 13. Algeria. Raport d’activìté sur la riposte nationale au sida –Algéria 2012- Suivi de progress sur Declaraction Politique sur leVIH/SIDA de 2011 14. Republique Du Senegal, Conseil National Lutte Contre le SIDA Secrétariat Exécutif National, ONUSIDA Programme Commun des Nations Unies Sur le VIH/SIDA. Raport de situation sur la Riposte Nationale a l’epidemie de VIH/SIDA Sénégal: 2010-2011. Suivi la Declaration Politique Report sur le VIH 2011. Mars 2012 15. Sao Tome and Principe. GARPR country report 2012 16. Republique du Niger, Presidence de la Republique, Conseil National de Lutte Contre le SIDA, Coordination Intersectroriella de Lutte Contre les IST/VIH/SIDA. ‘Suivi de la Déclaration Politique sur le VIH/SIDA 2011 Rapport d’activité sur la Riposte au SIDA au Niger 2012. 2nd April 2012 17. Ghana AIDS Commission. Ghana Country AIDS Progress Report Reporting period January 2010December 2011. March 2012 18. Vuylsteke B, Semde G, Sika L., et al. HIV prevelance of HIV and sexually transmitted infections among male sex workers in Abidjan, Cote d’Ivoire: need for services tailored to their needs. 2012 Sexually Trans Infect. (4):288-93. Doi:10.1136/sextrans-2011-050276 19. Sonya Arreola, Pato Hebert, Keletso Makofane., et al. Access to HIV prevention and treatment for men who have sex with men Findings from the 2012 Global Men’s Health and Rights study (GMHR). December 2012. The Global Forum on MSM and HIV (MSMGF), Oaklands, USA

5. Garcia-Calleja JM, E Zanlewski, P D Ghys., et al. A global analysis of trends in the quality of HIV serosurveillance. Sex transm 2004; 80 (Suppl.1) :125-134 6. WHO. Sentinel Surveillance for HIV infection: A method to monitor HIV infection trends in population groups. 1988. WHO/GPA/DIR 88.8. WHO Geneva. http://cedoc.cies.edu.ni/general/2nd_ generation%20(D)/Surveillance%20Guidelines/ HIV%20serosurveillance/sent%20surv.pdf, accessed 5 September 2013 7. WHO/UNAIDS. Guidelines for measuring national HIV prevalence in population based surveys. 2005. WHO, Geneva. 8. Jacobson J. HIV surveillance of key populations in Sub-Saharan Africa. 29 September 2013. Draft version 1.0 (in press) 9. Country GARPR reports 2012. http//www.unaids. org/en/dataanalysis/knowyourresponse/country progress reports/2012 countries (for all the countries mentioned in the section) 10. UNAIDS RTS ESA. Mauritius. http://www. unaidsrstesa.org/region/countries/mauritius, UNAIDS Sunning hill, South Africa accessed 20 Sept 2013

Universal Access to priority health sector interventions 2013 UPDATE

20. Malawi Government. 2012 Global AIDS Response Progress Report: Malawi Country Report 20102011. 3rd March 2012 21. The Kingdom of Swaziland. Swaziland Country Report on monitoring the Political Declaration on HIV and AIDS. March 2012. 22. Seychelles. Global AIDS Response Country Progress Report 2012. Reporting period Jan 2010December 2011. 31st March 2012 23. Republic of Mauritius, National Secretariat Prime Minister’s Office. Global AIDS Response Progress Report. March 2012 24. Philip Nieburg and Clisa Carthy. HIV prevention among Injections Drug Users in Kenya and Tanzania. New Opportunities for Progress. A report of the Centre for Strategic and International Studies. 2011 CSI , Washington DC, USA 25. The Republic of Uganda, National AIDS Commission. National Strategic Plan for HIV and AIDS 2011/12-2014/15. Draft November 2011 26. Republic of South Africa, Department of Health Directorate of Epidemiology and Surveillance. The 2011 National Antenatal Sentinel HIV and Syphilis Prevalence Survey in South Africa. 2011 27. Ministry of Health, Lesotho. Sentinel HIV/Syphilis Survey 2011. March 2012

28. Institut National de la Statistique et de la Démographie (INSA) and MEASURE DHS, ICF International. Enquéte Démographique et Santé et á Indicatateurs Multiples du Burkina Faso (EDSBF-MICS IV) 2010 Prevalence VIH. 2010 Ouagadougou, Burkina Faso, MEASURE DHS, ICF Calverton, Maryland, USA 29. Ministry of Health Botswana. 2011 Botswana Second Generation HIV/AIDS Antenatal Sentinel Surveillance Technical Report 30. Uganda AIDS Indicator Survey (AIS) 2011. August 2012. Ministry of Health Uganda, ICF Calverton Maryland USA, Centre for Disease Control and Prevention, Entebbe, Uganda, US Agency for International Development, Kampala, Uganda, WHO Uganda, Kampala. 31. National AIDS and STI Programme, Ministry of Health. Kenya Indicator Survey 2012: Preliminary Report. September 2013. Nairobi, Kenya. 32. Asamoah Odei, E., Calleja, JMG and Boerma JT. HIVprevalence and trendsin Sub Saharan Africa: no decline and large subregional differences. 2004. The Lancet Vol.364, Issue 9428 pgs 35-40 33. UNAIDS: UNAIDS. Regional Fact sheet 2012 Sub Saharan Africa. UNAIDS; 2012. Geneva, Switzerland

HIV in the WHO African Region Progress towards achieving

3. HIV testing and Counselling Key messages

• Availability and uptake of HIV testing the people living with HIV not knowing and counselling services in the WHO their HIV serostatus. African Region have improved greatly • People in urban areas, women and over the years with some countries the wealthier are more likely to have heading towards Universal Access. received an HIV test and counselled in the last 12 months. Uptake of HIV • Most countries in the region are testing and counselling is relatively implementing the HIV Provider Initiated low among adolescents. Testing and Counselling (PITC) policy in health facilities. This is being • All persons should be motivated to supplemented with community-based test and know their HIV serostatus as approaches for HIV testing and it is key to accessing HIV prevention, counselling. treatment, care and support services. • Knowledge of HIV serostatus largely remains low with more than half of

3.1 Introduction

HIV testing and counselling (HTC) is a key entry point to achieving Universal Access to HIV prevention, treatment, care and support services. Available evidence indicates that HCT has led to increased uptake of HIV interventions and services. For example, HIV testing rates have increased in antenatal clinics (1). Knowledge of HIV serostatus helps people who test HIV negative to make specific decisions on how to reduce their risk of exposure to HIV. Knowing one’s HIV serostatus enables initiation of timely treatment and care. It also allows one to take action to protect one’s sexual partner and to plan for the future. HIV testing and counselling is the first step to ensuring that the benefits of antiretroviral therapy are maximized.

In 2004, UNAIDS and WHO recommended the following types of HIV testing; voluntary counselling and testing (VCT); diagnostic testing for persons with signs and symptoms of HIV related diseases or AIDS including testing of all tuberculosis (TB) patients; routine offer of HIV testing by health care providers to clients with sexually transmitted infections (STIs), HIV testing in PMTCT programmes and mandatory HIV testing of donors (body fluids including blood and body parts (2). In line with this, the WHO Regional Office for Africa developed and disseminated Regional Guidelines for HTC to all the countries in the WHO African Region in 2006 (3).

Universal Access to priority health sector interventions 2013 UPDATE

WHO encourages countries to decentralize HIV testing and counselling services and provide them in a wide variety of settings appropriate to the local context. In line with this, countries have utilized multiple innovative approaches in addition to health facility based testing, to increase the availability and uptake of HIV testing and counselling services. Some of the approaches include home based (door to door testing, setting up mobile sites within communities etc.), mobile testing (using vans, trucks or other mobile sites in addition to the fixed sites), stand-alone testing sites, workplace testing, school and university testing, testing during events such as on World AIDS Day, national or sub-national AIDS campaigns, and testing during times when most

clients are not expected such as on weekends, evenings and at night. This chapter reviews the progress in improving access to HIV testing and counselling services made by countries in the WHO African Region during the period 2008 and 2012. 3.2 Uptake of HIV testing and counselling

The number of people aged 15 years and above who received an HIV test and were counselled increased from 23,424,868 in 2007 to 44,997,719 in 2010 in the WHO African Region, an increase of more than 90%. This increase was seen in all the sub-regions (Figure 3.1).

Figure 3.1: No. of people aged 15 years and above who were tested for HIV and received results per 1000 population, WHO Africa Region, 2008-2010 2008 250 200 150 100 50 Southern Africa Eastern Africa Central Africa Western Africa African Region 45.2 47.6 58.9 37.7 57.0 70.1 58.7 69.8 140 137.8 221 230.1 211 193.0

2009

2010

No. of people tested per 1,000 population

79.7

Sources: WHO/AFRO HIV in the WHO African Region Progress towards achieving universal access to priority health sector interventions 2011 update and WHO/AFRO HIV/AIDS database and WHO/UNAIDS/UNICEF Global HIV/AIDS Response Epidemic update and health sector progress towards Universal Access Progress Report 2011

HIV in the WHO African Region Progress towards achieving

Table 3.1 shows the number of tests performed among people aged 15 years and above and the number of HIV tests among this age group per 1000 population for 2008 and 2010 by country. Uptake of HIV testing and counselling was uneven between countries in 2010. The ratio of people aged 15 years who were tested for HIV and received results per 1000 population ranged from 2.6 in Algeria to 20.2 in DRC, 30.9 in Nigeria and then 469.2 in Rwanda in

2010. The regional and subregional trends mask the incredible achievements made by some countries. For example the ratio increased from 259.2 in 2008 to 469.2 in 2010 in Rwanda while in Nigeria and DRC progress was slow. In Nigeria, the ratio of number of tests performed among people aged 15 years and over per 1000 population increased from 31.4 in 2008 to 35.1 in 2009 and then dropped to 30.5% in 2010.

Table 3.1:Trends in numbers and proportion (%) of HIV tests performed among people aged 15 years and above, and number of tests per 1000 population by country and by subregion, WHO African Region, 2008-2010 Number of people aged 15 years and over who received HIV testing and counselling, reported number 2008 African Region Southern Africa Botswana Comoros Lesotho Madagascar Mauritius Mozambique Namibia South Africa Swaziland Zambia Zimbabwe Eastern Africa Eritrea Ethiopia Kenya Malawi Rwanda Seychelles Uganda United Republic of Tanzania 23,424,868 2,651,019 218,313 2,570 213,521 629,642 … … 163,871 … 108,334 511,266 803,502 14,251,246 137,339 4,817,100 1,833,689 1,693,923 1,241,616 8,858 2,015,057 2,503,664 2009 39,772,358 12,257,928 330,159 3,281 251,242 324,809 33,744 1,201,942 249,011 6,989,312 149,755 1,582,621 1,142,052 18,923,698 132,829 6,630,647 4,433,557 1,449,645 1,932,420 10,808 2,363,468 1,970,324 2010 44,997,719 11,739,593 353,430 4,428 235,295 192,813 44,769 1,139,166 136,305 6,553,952 148,072 1,318,975 1,612,388 24,187,876 127,202 9,407,180 5,738,282 1,726,762 2,407,073 10,867 2,654,683 2,115,827 186.3 90.9 130.3 137.8 55.6 129.3 97.5 258 259.2 192.3 146.3 128.6 People aged 15 years and over who received HIV testing and counselling, estimated number per 1000 adult population 2008 58.7 139.8 209.6 7.5 216.1 70.1 … … 149.3 2009 69.8 221 311 9.4 250.6 35 47.4 114.4 221 256.1 251.3 273.9 182.9 193 52.2 172.3 230 213.7 393.8 233.4 165.1 98.3 2010 79.7 211 323.6 12.6 211 19.9 61.6 106.3 114.8 240.1 243.7 224.1 254.8 230.1 48.2 235.6 290.8 258.4 469.2 224.6 181 103.1

Country

Universal Access to priority health sector interventions 2013 UPDATE

Table 3.1:Trends in numbers and proportion (%) of HIV tests performed among people aged 15 years and above, and number of tests per 1000 population by country and by subregion, WHO African Region, 2008-2010 Number of people aged 15 years and over who received HIV testing and counselling, reported number 2008 Central Africa Angola Burundi Cameroon Central African Republic Chad Congo Democratic Republic of the Congo Equatorial Guinea Gabon Sao Tome and Principe Western Africa Algeria Benin Burkina Faso Cape Verde Côte d'Ivoire Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo 1,705,086 … 236,988 866,083 56,177 53,056 79,422 393,000 … … 20,360 4,817,517 … 312,418 424,758 17,000 311,145 44,127 467,936 67,275 21,061 63,442 116,361 15,444 130,354 2,241,727 245,670 157,120 181,679 2009 1,480,215 … 281,959 450,022 136,202 66,191 82,332 392,491 24,256 33,550 13,212 7,110,517 … 280,982 602,961 25,075 727,290 47,549 1,253,312 74,090 24,871 80,295 255,835 9,498 358,071 2,570,386 352,197 281,218 166,887 2010 2,416,590 442,200 373,895 648,019 118,045 57,878 89,546 599,895 24,075 48,348 14,689 6,653,660 53,736 318,389 565,311 … 791,424 58,326 1,063,085 166,576 73,476 170,341 239,115 7,738 425,696 2,287,805 … 232,452 200,190 259.3 37.7 … 77 60 64.9 31.9 56.6 39.9 14.7 29.3 35.5 19.3 9.5 20.9 31.4 42 58.7 57.3 People aged 15 years and over who received HIV testing and counselling, estimated number per 1000 adult population 2008 45.2 … 57.3 93.9 27.1 10.8 45.2 13.8 2009 47.6 … 65.6 47.6 64.2 13.1 45.8 17.7 74.6 44.5 164.8 56.95 … 67 82.6 93.5 72.5 66 104.4 15.8 33.8 43 41.3 5.7 55.6 35.1 58.3 102.7 51.1 2010 58.9 51.6 85.8 67.7 55.6 11.4 45.5 20.2 70.2 62.2 179.3 70.1 2.6 76.9 73.4 … 84.6 70.1 87.3 35.8 102.2 90.3 34.3 4.4 64.8 30.9 … 82.4 66.5

Country

Source: WHO/AFRO HIV/AIDS database

3.3 Coverage of HIV testing and counselling services

as Demographic and Health Surveys (DHS) or AIDS Indicator Surveys (AIS), in which respondents respond to the Coverage of HIV testing and counselling question on ‘whether they have ever had in the general population is assessed an HIV test’. In the case of respondents through population based surveys such who say “Yes”’ they are asked ‘’how 46

HIV in the WHO African Region Progress towards achieving

many months ago was your most recent HIV test?” The respondents who report that their most recent test was in the past 12 months are the ones recorded as ‘tested in the 12 months preceding the survey’. Being tested in the past 12 months is the closest proxy for knowledge of one’s current HIV serostatus.

The data show that women were more likely to report taking an HIV test in the past 12 months than men in 24 out of the 30 countries in the WHO African Region that conducted DHS/AIS surveys between 2003 and 2012 (Table 3.2).

Table 3.2: Uptake of HIV testing and counselling in the last 12 months by sex in selected countries, WHO African Region, most recent year Subregion Country Lesotho Madagascar Malawi Mozambique Namibia Swaziland Zimbabwe Ethiopia Kenya Tanzania Uganda Zambia Burundi Cameroon Congo DRC Gabon Benin Burkina Faso Chad Cote d’Ivoire Ghana Guinea Liberia Mali Niger Nigeria Rwanda Senegal Sierra Leone Survey DHS DHS DHS AIS DHS DHS DHS DHS DHS DHS AIS DHS DHS DHS AIS DHS DHS DHS DHS DHS AIS DHS DHS DHS DHS DHS DHS DHS DHS DHS Year 2009 8-09 2010 2009 6-07 2006-2007 2010-2011 2011 2012 2010 2011 2007 2010 2011 2009 2007 2012 2006 2010 2004 2005 2008 2005 2007 2006 2006 2008 2010 2010-2011 2008 Women N 7,624 8,547 23,020 5,674 9,804 4,987 9,171 16,515 ... 10,139 11,160 7,146 9,389 7,457 6,550 9,995 ... 17,794 17,087 6,085 5,183 4,916 7,954 7,092 14,583 9,223 33,385 13,671 15,688 7,374 % 42 4.2 ... 17 28.6 21.9 33.6 20 ... 29.5 ... 18.5 18.7 22.3 8.5 4.1 12.4 6.5 11.2 0.5 3.7 6.8 1.1 1.6 3.1 0.9 6.6 38.6 13.6 4.1 N 3,008 7,645 6,818 4,168 3,915 4,156 7,110 12,834 ... 2,527 8,735 5,995 3,760 6,455 5,863 4,316 ... 4,615 6,500 1,682 4,503 4,058 2,709 6,009 3,704 3,101 13,808 5,687 4,417 2,944 Men % 24 3.6 31.3 8.9 17.6 8.9 20.5 20.7 ... 25 23.2 11.7 11.7 20.4 7.1 3.8 8.9 4.8 8.4 1.7 3.2 4.1 2.9 2.3 2.7 1.6 6.5 37.7 9 3.4

Southern Africa

Eastern Africa

Central Africa

Western Africa

…=data not available Sources: www. measuredhs.com (HIV/AIDS Indicators Survey Database), Staveteig,S., et al 2013 ‘Demographic Patterns of HIV testing uptake in Sub Saharan Africa DHS Comparative reports 30’ and DHS country reports in selected countries.

Universal Access to priority health sector interventions 2013 UPDATE

Rwanda (2010) had the highest proportions of both women and men reporting having an HIV test in the past 12 months (Figure 3.2). The family centred approach to HIV prevention, care and support with a focus of involving

men in PMTCT services which includes couples HIV testing and counselling largely explains the increased uptake of HIV testing and counselling in men in Rwanda.

Figure 3.2: Proportion (%) of women and men aged 15 years and above reporting having taken an HIV test and received results in the past 12 months by sex in selected countries, WHO African Region, most recent year Women 45 40 Proportion of people (%) 39 38

Men

35 30

25 20 15 10 5 0 2010

12 9

7 4

2010-2011

2011

2010

2009

2010-2011

2012 Gabon

2008 Ghana

2008

Rwanda Zimbabwe Cameroon Ethiopia

Burundi Mozambique Senegal

Nigeria Sierra Leone

Sources: www. Measuredhs.com (HIV/AIDS Indicators Survey Database), Staveteig,S., et al 2013 ‘Demographic Patterns of HIV testing uptake in Sub Saharan Africa DHS Comparative reports 30’ and DHS country reports in selected countries.

Women and men in urban areas were more likely to report having ever had an HIV test than their rural counterparts (Figure3.3). However, in Malawi (2010), Rwanda (2010) and Zimbabwe (2010/ 2011), the differences between women and men in rural and urban areas

reporting ever having an HIV test were small. In Malawi, national testing days and national testing weeks have largely contributed to the increased uptake of HIV testing and counselling services, including in rural areas (4).

HIV in the WHO African Region Progress towards achieving

Figure 3.3: Proportion (%) of women and men aged 15 years and above reporting ever having an HIV test by sex and by residence in selected countries, WHO African Region, most recent year Urban women 90

Rural women

Proportion of people (%)

80 70 60 50 40 30 20 10 0

2010 Rwanda

2011 Uganda

2010 Malawi

2010 Tanzania

2011 Cameroon

2011 Ethiopia

2010 Burundi

2010-2011

2010

2010-2011 Senegal

Zimbabwe Burkina Faso

Urban men 80 70

Rural men

Proportion of people (%)

60 50 40 30 20 10 0

2010 Rwanda

2011 Uganda

2010 Malawi

2010 Tanzania

2011 Cameroon

2011 Ethiopia

2010 Burundi

2010-2011

2010

2010-2011 Senegal

Zimbabwe Burkina Faso

Sources: www. measuredhs.com (HIV/AIDS Indicators Survey database), Staveteig,S., et al 2013 ‘Demographic Patterns of HIV testing uptake in Sub Saharan Africa DHS Comparative reports 30’and DHS country reports in selected countries.

Population based surveys conducted in the WHO African Region indicate that uptake of HIV testing and counselling is influenced by age in all countries with

adolescents (men and women) less likely to report taking an HIV test than those in the older age groups (Figure 3.4).

Universal Access to priority health sector interventions 2013 UPDATE

Figure 3.4: Uptake of HIV testing and counselling by age in selected countries, WHO African Region, most recent year

Women 100 90 80

Men 100 90 80

Women Women

Men Women

Men

100 90 80 Percentage ever tested Percentage ever tested

100 90 80

Percentage ever tested

70 60 50 40 30 20 10

60 50 40 30 20 10

Percentage ever tested

70 60 50 40 30

70 60 50 40 30 20 10

15-19 30-34

20-24 35-39

25-29 40-44

30-34 45-49

35-39 15-19

40-44 20-24

45-49 25-29

15-19 30-34

20-24 35-39

25-29 40-44

30-34 45-49

35-39 15-19

40-44 20-24

45-49 25-29

15-19 15-19 30-34 40-44

Zimbabwe DHS 2010-11 10Zimbabwe DHS 2010-11

RwandaDHS DHS2010-11 2010 Zimbabwe Rwanda DHS 2010

Cam Rw Cameroon DHS 2011

35-39

40-44

45-49

15-19

20-24

25-29

30-34

35-39

40-44 15-19

45-49 20-24

15-19 25-29

20-24 30-34

25-29 35-39

30-34 40-44

35-39 45-49

40-44 15-19

45-49 20-24

15-19 25-29

20-24 30-34

25-29 35-39

30-34 40-44

35-39 45-49

40-44 15-19

45-49 20-24

25-29

30-34

35-39

45-49 45-49

010-11

Women

Rwanda DHS 2010 Women Women Men

Cameroon DHS 2011 Zimbabwe DHS 2010-11 Men Men

Burkina Faso DHS 2010 Rwanda DHS 2010 Women Women

Cameroon DHS 2011 Men Men

100 90 80

100 90 80 Percentage ever tested

100 90 80

Percentage ever tested

60 50 40 30 20 10

70 60 50 40 30

Percentage ever tested

70 60 50 40 30 20 10

15-19 15-19

20-24 20-24

25-29 25-29

30-34 45-49

35-39 15-19

20-24 40-44

45-49

15-19

20-24

25-29

30-34

35-39 20-24 20-24

40-44 25-29

45-49 30-34

35-39 15-19

40-44 20-24

25-29 45-49

30-34 15-19 40-44

30-34 40-44

45-49 35-39

25-29 45-49

15-19 15-19

15-19

20-24

25-29

30-34

35-39

40-44

30-34

35-39

40-44

45-49

da 11 DHS 2010

Zimbabwe DHS 2010-11 Cameroon DHS 2011 Rwanda DHS 2010

Rwanda DHS 2010 Faso DHS 2010 Zimbabwe 2010-11 Cameroon DHS 2011 Burkina Burkina Faso DHS DHS 2010

Cameroon DHS 2011

Source: Staveteig,S., et al 2013 ‘Demographic Patterns of HIV testing uptake in Sub Saharan Africa DHS Comparative reports 30’ 40-44 15-19 45-49 20-24 15-19 25-29 20-24 30-34 25-29 35-39 30-34 40-44 35-39 45-49 40-44 15-19 45-49 20-24 15-19 25-29 20-24 30-34 25-29 35-39 30-34 40-44 35-39 45-49 40-44 15-19 45-49 20-24 25-29 30-34 35-39 20-24 25-29 30-34 35-39

40-44

45-49

15-19

0-11

Rwanda DHS 2010

Zimbabwe DHS 2010-11 Cameroon DHS 2011

Rwanda Burkina DHS 2010 Faso DHS 2010

Cameroon DHS 2011

Other factors that appear to influence the uptake of HIV testing and counselling in the WHO African Region include wealth, the level of education, ever having had sex and marital status (5). However, except for age, the differences were less marked in

countries with a high uptake of HIV testing and counselling. HIV testing in the majority of the countries, with the exception of Rwanda and Malawi, increases with level of education and wealth (Figure 3.5). 50

15-19

45-49

35-39 20-24

40-44

45-49

30-34

25-29

30-34

35-39

40-44

15-19

20-24 20-24 35-39

15-19

20-24

25-29

HIV in the WHO African Region Progress towards achieving

Figure 3.5: Proportion (%) of women and men reporting having ever had an HIV test by wealth category in selected countries, WHO African Region, most recent year Highest 79

Lowest

90 80 Proportion of people (%)

73 63 68

70 60 50

30 18 13

20 10 0 2010 Rwanda 2011 Uganda 2010 Malawi

2011 Ethiopia

2010-2011

2010

2011 Cameroon

Zimbabwe Burkina Faso Burundi

Senegal

Sources: www. measuredhs.com (HIV/AIDS Indicators Survey Database), Staveteig,S., et al 2013 ‘Demographic Patterns of HIV testing uptake in Sub Saharan Africa DHS Comparative reports 30’ and DHS country reports in selected countries

3.4 Trends in the coverage of HIV testing and counselling services

HIV test in the last 12 months over the years. Kenya, Lesotho, Rwanda, Tanzania and Zimbabwe showed marked Data from population based surveys increases among both men and women show increasing proportions of women while Nigeria, Madagascar and Congo and men reporting having taken an had a small increase (Figure 3.6). Figure 3.6:Trends in the proportion (%) of women and men aged 15 years and above who reported having an HIV test in the past 12 months by sex in selected countries, WHO African Region, 2001-2012 Women 45 40 35

Proportion of people (%)

30 25 20 15 10 5 0 2004-2005 Lesotho 2009 2003-2004 2008-2009 2003 2009 2005-2006 2010-2011 2005 Ethiopia 2011 2003 Madagascar Southern Mozambique Zimbabwe

2011

Ken

Sources: www.measuredhs.com (HIV/AIDS Indicators Survey Database), DHS country reports in selected countries. Universal Access to priority health sector interventions 2013 UPDATE

Cont’d: Figure 3.6:Trends in the proportion (%) of women and men aged 15 years and above who reported having an HIV test in the past 12 months by sex in selected countries, WHO African Region, 2001-2012 Women 45 40 35

Men

Women

Proportion of people (%) 2005-2006

30 25 20 15 10 5

0 2010-2011

2005 2004-2005

2011 2009 2003 2003-2004 2008

2005 2008-2009 Rwanda

2010 2003

2004-2005 2010-2011 2004 2009 2005-2006

2011 2010-2011

2005 2005

2009 2011 2003

2008 2003 Nigeria Western Kenya

2008

2005

Zimbabwe

Ethiopia Lesotho

Kenya Madagascar Eastern

Tanzania Mozambique

Cameroon Zimbabwe Central

Congo Ethiopia

R Eastern

Southern

Sources: www.measuredhs.com (HIV/AIDS Indicators Survey Database), DHS country reports in selected countries.

implemented to further expand and rapidly scale up HTC services in countries. For example the 2010 National HIV Testing Campaign conducted in South Africa (Box 3.1) resulted in over 13 million people being tested and counselled. Couples testing in Rwanda (Box 3.2) has resulted in an increased uptake of HIV testing and counselling among men. In Kenya, the adoption of multiple approaches to HIV testing and counselling (Box 3.3) is improving access to HTC services in remote countries and to key populations. District-wide Home Based HIV counselling 3.5 Expanding HIV testing and and testing in one district in Uganda counselling through innovative (Box 3.4) demonstrated that HTC is mechanisms and approaches feasible and can contribute to increasing In addition to PITC, other HIV testing the percentage of people knowing their and counselling approaches are being HIV serostatus. Other factors that appear to influence the uptake of HIV testing and counselling in the WHO African Region include wealth, the level of education, ever having had sex and marital status (5). However, except for age, the differences were less marked in countries with a high uptake of HIV testing and counselling. HIV testing in the majority of the countries with the exception of Rwanda and Malawi increases with level of education and wealth (Figure 3.5).

HIV in the WHO African Region Progress towards achieving

Box 3.1: National HIV Testing and Testing Campaign in South Africa

In April 2010, the President of South Africa launched the largest ever in the world national HCT campaign lasting for 12 months. The campaign was to offer opportunities to South Africans to be tested for HIV, screened for TB and other chronic diseases such as diabetes and hypertension. This was one of the biggest partnerships between government, civil society and the private sector (mining, automobile and textile). The campaign

resulted in a large number of people coming for counselling and HIV testing. The number of persons tested throughout the campaign was three times more than the number that the public sector was able to screen annually. By June 2011, over 13 million South Africans had been tested for HIV against the set target of 15,000,000 by 2015 (Source: Republic of South Africa, GARPR 2012) (6)

Box 3. 2: Couples Testing in Rwanda

IIn 2009, Rwanda promoted a familycentred approach to HIV prevention, care and support services with a focus on involving men in preventing mother to child transmission. The following strategies were used: high level advocacy with the involvement of high level leaders, building the capacity of health care workers on

HIV counselling and testing for couples, public awareness campaigns on couple testing, involving male partners and organizing weekend HIV counselling and testing sessions. As a result, uptake of HIV testing among male partners reached an average of 85% in 2009, up from 7% in 1999 (Source: Rwanda GARPR 2012) (7)

Box 3.3: Multiple Approaches to HIV Testing and Counselling in Kenya

IThe Kenya Government target is to counsel and test 2 million Kenyans for HIV annually. In line with this, Kenya has shifted from primarily client initiated models; mainly based on voluntary counselling and testing (VCT) to include other approaches to HIV testing and counselling. By the end of 2009, 73% of health facilities were providing Provider Initiated Testing and Counselling (PITC). As a result, the number of HIV tests performed in health facilities rose by 65% in 2010 alone. PITC led to the highest proportion (39%) of people diagnosed with HIV in 2009, as compared to 32% in VCT services, 17% in PMTCT clinics and 10% in TB care settings in the same year. ‘Moonlight’ HIV testing and

counselling (HTC) at truck stops provided counselling and HIV testing to 8,900 men and female sex workers over an 8-month period in 2009. Another project in Kiritiri reached more than 400 people with HTC on two weekends only. Two national campaigns, one lasting for one month and the other three weeks, reached 2.6 million people with HTC in 2010. A home based pilot project in the Suba district of Nyanza province showed an acceptance rate of HIV testing of over 90% and demonstrated that home-based testing was feasible. This led to the scale up of home-based door to door testing, even in remote rural areas with little access to health care Sources: NASCOP 2010, NACC and NASCOP, 2012 (8,9)

Universal Access to priority health sector interventions 2013 UPDATE

Box 3. 4: District-wide Home Based HIV Counselling and Testing in one Rural District in Uganda

In April 2010, the President of South A home based HIV counselling and testing programme was implemented in Bushenyi, a rural district in Uganda from September 2004 to March 2007. About 90% of the people aged more than 14 years did not know their HIV serostatus and had never been tested for HIV. Teams, each including a counsellor and a laboratory assistant, systematically visited homes offering HIV counselling and testing for all people aged 14 years and above and exposed children (children whose mothers had died of AIDS). People found HIV positive were provided with cotrimoxazole

prophylaxis, given insecticide treated nets (Bushenyi district is a malaria endemic district) and equipment for treating drinking water at home. Those found living with HIV were referred for assessment for antiretroviral therapy. The acceptance level for HIV testing and counselling was high (94%) and 90% of people who had never been tested for HIV got to know their HIV serostatus. The results from this programme demonstrated that home based HTC was feasible. Source: Tumwesigye E., Wana G.,Kasasa, S.,et al, 2010 (10)

3.6 Serodiscordant couples and HIV testing and counselling

in Kenya to 56% in Rwanda and that the probability of HIV transmission within a cohabiting serodiscordant couple was HIV transmission increases substantially 0.2 over a 12 month period (11). in couples with one partner infected and the other partner not infected 3.7 Challenges and the way forward because condom use is least likely and there are repeated sexual exposures. In the last 3-5 years, there has been Serodiscordant couples are found both an increase in the proportion of people in rural and urban areas but because receiving HIV testing and counselling in of the higher HIV prevalence in urban the last 12 months. This is largely due areas serodiscordant occurrence is to the adoption of a policy on PITC and higher in urban areas. Serodiscordant the use of multiple and wide ranging couples cannot be distinguished from the approaches, including community based general population and thus can only approaches. be identified through HIV testing and counselling services. Most serodiscordant Despite the progress made, the majority couples do not know their HIV serostatus of the people in the WHO African Region and have a low level of knowledge about do not know their HIV serostatus. Indeed discordancy (11). Modes of Transmission more than half of the people living with (MOT) analyses conducted in countries HIV do not know their HIV serostatus. such as Lesotho, Mozambique, Rwanda, HIV testing and counselling rates are low Uganda and Rwanda in 2007-2008 among adolescents and serodiscordant estimated that the proportions of new couples. HIV infections arising from transmission within a stable union ranged from 10%

HIV in the WHO African Region Progress towards achieving

Other challenges include inadequate human resource capacity for HIV testing and counselling, stock outs of testing kits and other supplies and infrastructural issues that do not allow for discreet HIV testing and counselling especially in health facilities. There is still inadequate funding for programmes, high levels of stigma and discrimination, legal frameworks, that make it difficult for some populations such as teenagers and key populations to access HIV services. In addition, there are weak systems for monitoring and evaluation of HIV testing and counselling services. All people including those in rural areas, adolescents and key populations should be motivated to test and know their HIV serostatus through the use of multiple models and approaches. Further decentralization of HIV testing and counselling services and linkage of HTC to other health programmes such as Maternal and Child Health Care, adolescent and reproductive health, sexually transmitted infections (STI) treatment clinics, TB clinics, inpatient wards and outpatient clinics and Primary Health Care outreach activities need to be promoted.

HIV self-testing could serve as an additional approach to improve uptake of HIV testing. However, it does not provide a chance for the person testing him/herself to receive basic information on HIV/AIDS or pretest counselling. More information will be needed on the psychological effects on a person who tests positive from HIV self-testing. Follow up and referral services including those for confirming a positive HIV test be accessible to the users of HIV selftesting kits. Structural barriers including legal and regulations that make it difficult for adolescents and key populations to access HIV testing and counselling services and for health care providers to access these populations, need to be addressed. There is the need to ensure that as countries expand and scale up HIV testing and counselling services, the quality of HIV testing be closely monitored so as to maintain standards and ensure high quality care.

Universal Access to priority health sector interventions 2013 UPDATE

References 1. Baggaley, R., Hensen.B., Ayoge,O., et al: From caution to urgency: evolution of HIV testing and counseling in Africa. Bulletin of World Health Organisation 2012:90:652-658B 2. WHO and UNAIDS. UNAIDS/WHO policy statement on HIV testing. http://www.who.int/ rpc/research_ethics/hivtestingpolicy_en_pdf.pdf, accessed 24 September 2013 3. WHO/AFRO. HIV testing and counseling services in the WHO African Region: A survey of the eastern and southern Africa Subregion, 2010. Brazzaville, Congo 4. Malawi Government: 2012 Global AIDS Response Progress Report. Malawi Country report for 20102012. March 31, 2012 5. Staveteig, Sarah, Shanxiao O. Wang, Sarah K. Head, et al. Demographic Patterns of HIV testing uptake in sub Saharan Africa.DHS comparative reports No.30.2013. Calverton, Maryland, USA: ICF international. 6. Republic of South Africa. Global AIDS Response Progress Report 2012 7. Rwanda Government. Country Progress Report. Narrative Report Submission date 2012-03-30. www.unaids.org 8. National AIDS and STI Control Programme, Ministry of Public Health and Sanitation. National Guidelines for HIV testing and counseling in Kenya’ second edition, October 2010. 9. National AIDS Control Council (NACC) and National AIDS and STI Control programme. Kenya AIDS epidemic update 2011. 2012, Nairobi, Kenya. 10. Tumwesigye E., Wana, G., Kasasa, S., et al. High uptake of home based, district wide, HIV counseling and testing in Uganda. 2010 AIDS patient care STDs, 2010;24(11): 753-41.doi.10.1089/ apc.2010.0096 11. Bishop M. and Foret K. Serodiscordant couples in sub-Saharan Africa. What do survey data tell us? February 2010 Washington DC: Futures Group. Health Policy Initiative Task Order 1 12. WHO/UNAIDS/UNICEF. Global HIV/AIDS Response Epidemic update and health sector progress towards Universal Access Progress Report 2011. 2011. WHO, Geneva 13. WHO/AFRO HIV in the WHO African Region Progress towards achieving Universal Access to priority health sector interventions 2011 Update. 2011. WHO/AFRO; 2011. Brazzaville, Congo

HIV in the WHO African Region Progress towards achieving

of the health sector in HIV prevention Key messages

4. Maximizing the contribution

• Countries in the WHO African Region • Considerable progress has been made have HIV prevention programmes that in ensuring blood safety in the region. target young people. However, there However, only 45% of the total blood are variations in the implementation of requirements is currently being met. these programmes. • “Virtually no country in the WHO African • As a result of strong leadership, Region is providing interventions for commitment and good planning, conkey populations on an adequate scale siderable progress has been made in and intensity”. the 14 priority countries in scaling up of Voluntary Medical Male Circumcision services.

4.1 Introduction

The updated ‘HIV/AIDS: Strategy for the African Region’ (1) which was adopted by the WHO Regional Committee for Africa during its sixty-second session held in November 2012 provides directions for implementing the ‘WHO Global Health Sector Strategy on HIV/AIDS 2011-2015’ (2) in the WHO African Region. The aims of the Regional Strategy are to accelerate national HIV response and advance progress in achieving country targets for Universal Access to HIV prevention,

treatment, care and to contribute to achieving MDG 6 and other health related MDG goals, associated targets and to addressing the broader determinants of health. One of the key interventions promoted by the regional strategy is the scaling up of HIV prevention. The strategy underscores the importance of combining behavioural, biomedical and structural HIV prevention interventions tailored to national epidemics as the most effective approach to reducing new infections (Box 4.1).

Universal Access to priority health sector interventions 2013 UPDATE

Box 4.1: Scale up HIV prevention interventions in the WHO African Region

• Health promotion • Behaviour change counselling • Quality assured HIV testing and counselling • Male and female condom programming • Safe voluntary medical male circumcision (in high HIV prevalence settings with low male circumcision rates)

• Early initiation of antiretroviral therapy • Infection control and standard precautions including injection and surgical safety blood safety • Safe waste disposal and post exposure prophylaxis for occupational exposure to HIV. Source: WHO/AFRO. HIV/AIDS strategy for the WHO African Region, 2013 (1)

The chapter focuses on HIV prevention among young people, key populations at higher risk of HIV infection, voluntary medical male circumcision and blood safety. 4.2 Policies and programmes

A review of the 2012 country Global AIDS Response Progress Reports (GARPR) shows that all countries in the WHO African Region have adopted a multisectoral approach for the national response to HIV/AIDS. The multisectoral approach is a policy programming strategy which engages all sectors, including the health sector, in a holistic response to the HIV/AIDS epidemic. All key stakeholders, including all relevant sector ministries, the private sector, NGOs, Faith Based Groups, community groups, professional and non-professional associations, academic and research institutions, bilateral and multilateral agencies are involved in the multisectoral response. To facilitate this approach, all countries have developed National Strategic Plans for HIV/AIDS. Health sector interventions in most of the National Strategic Plans include strategies related to combination HIV prevention which involves implementing multiple

(biomedical, behavioural and structural prevention) interventions. All countries in the WHO African Region have adopted HIV prevention policies related to PMTCT, condom promotion, HIV testing and counselling, voluntary medical male circumcision, blood safety, management of STIs, adherence to universal precautions, promotion of medical infection control, and promotion of access to post exposure prophylaxis. A review of the 2012 country GARPR reports showed that the extent of implementation of these policies varied considerably between countries. 4.3 HIV prevention among young people

Young people aged 15-24 years are vulnerable to HIV; they are at an age when they are more likely to experiment with sexual activity and engage in high risk sexual behaviours and experiment with drugs (3). This continues to draw the attention of countries and the international community to the need to focus on young people. In general, there have been modest positive changes in sexual behaviour, including delay in sexual debut and increasing condom use in premarital and 58

HIV in the WHO African Region Progress towards achieving

multiple sexual relationships. However, the level of comprehensive knowledge of HIV remains relatively low and condoms are not always used in higher risk sex and premarital sex. An analysis of data on sexual behaviours from recent DHS/AIS surveys conducted in the region between 2008 and 2012 found an increasing trend of young people aged 15-24 years in Ethiopia, Rwanda, the United Republic of Tanzania and Zimbabwe reporting having multiple sexual relations in the last 12 months, and a declining trend in condom use at last higher risk sex in Uganda and Ghana. WHO recommendations for health-sector HIV prevention programmes for young people aged 15-24 years include contributing to acquiring correct and comprehensive knowledge of HIV, promotion of safer sexual behaviours including promoting condom use for sexually active young people, preventing sexually transmitted infections, male circumcision, HIV testing and counselling, providing youth friendly sexual and reproductive health services and linking HIV programmes to other relevant health related programmes (5) A review of the 2012 country GARPR reports showed that all countries in the WHO African Region have HIV prevention programmes that target young people. In general, HIV prevention programmes targeting young people in the region focus on both school and out of school youth. Some of the strategies and activities that have been implemented include integration of HIV/AIDS education

in school curriculum from primary school level, anti HIV/AIDS awareness talks and campaigns, use of drama, role plays, audiovisual materials, debates, essay writing, poems, songs, and plays, electronic and print media messages, life skills training, peer education and condom promotion and distribution to young people who are sexually active. In addition, some countries engage out of school youth in income generating activities. Despite these efforts, no countries are making any efforts to target young people who are engaging in sex work, injecting drugs and who have sex with men. 4.4 HIV prevention among key populations

Key populations at higher risk of HIV infection are populations that have an increased probability of getting infected with HIV. Countries in the region are beginning to recognize that key populations have special needs. For example, the South Africa National Strategic Plan 20122016 specifically states that health care providers need to be responsive to the needs of sex workers (6). 4.4.1 Sex workers

Sex workers are among the key populations most affected by the HIV epidemic. The lifetime probability of a sex worker becoming infected with HIV is higher than among people in the general population due to multiple risk factors including having multiple sexual partners, unsafe working conditions, barriers to

Universal Access to priority health sector interventions 2013 UPDATE

negotiating consistent condom use, lack of access to appropriate lubricants, high prevalence of STIs and at times sharing of drug injecting equipment (7). A sex worker is 13.5 times more likely to acquire HIV than all other women aged 15-49 years (8). Sex work covers a broad range of transactions and thus sex workers are not a homogeneous group. Women, men, young and old are involved. Sex work entails exchange of money or goods for sexual services, either regularly or occasionally involving female, male and transgender adults and young children (9) The WHO guidelines for sex workers “Prevention and treatment of HIV and other STIs for sex workers in low and middle income countries: recommendations for a public health approach” (7) recommend the following: making health services available, accessible and acceptable to sex workers based on the principles of avoiding stigma, discrimination and the right of sex workers to health; promotion of correct and consistent use of condoms among sex workers and their clients; periodic screening for STIs; and offering HIV testing and counselling, among others. With the exception of Senegal where sex work is legally recognized, persistent criminalization of sex work across Africa reduces the sex workers’ control over

their working conditions, impedes their access to health services and also obstructs health service provision and legal protection (9). A systematic review of studies conducted among sex workers between January 2000 and June 2011 that reported having interventions for reducing HIV transmission among sex workers concluded that there was “virtually no country in the WHO African Region providing interventions for sex workers on adequate scale and intensity”(10). A review of the 2012 country GARPR reports found that 40% of the countries in the WHO African Region, mainly from western Africa (Algeria, Angola, Benin, Cape Verde, Burkina Faso, Chad, Cote d’Ivoire, Ghana, Guinea, Mauritania, Niger, Nigeria, Senegal and Togo) and in Central Africa (Cameroon, Democratic Republic of Congo and Angola) and in southern Africa (Madagascar and Mauritius) the percentage of sex workers reached by HIV interventions in the past 12 months. Analyses of trends showed that the numbers of sex workers reached with HIV interventions in selected countries in the region varied over time and that in general there was no consistent trend (Table 4.1). In Benin, the proportion of sex workers reached with HIV prevention programmes increased from 56% in 2009 to 91% in 2012.

HIV in the WHO African Region Progress towards achieving

Table 4.1: Number and proportions (%) of sex workers reached by HIV prevention programmes in selected countries, WHO African Region, 2009 and 2012 2009 Number of respondents who replied yes to both questions % of sex workers reached with HIV prevention programmes Number of respondents who replied yes to both questions 2012 % of sex workers reached with HIV prevention programmes

Country

Total number of respondents surveyed

Angola Benin Burkina Faso Burundi Chad Comoros Côte d’Ivoire DRC Gabon Ghana Guinea Madagascar Mauritania Nigeria Swaziland Togo United Republic of Tanzania Niger Mauritius South Africa

430 592

1,848 1,050

23 56 639 704 91

201

1,171

17 127 726 2,378 368 1,054 87 31 89 58

208 16,742 90

601 34,990 101

35 48 89

326 614

143

100

237

349

68 411 322 681 765 400 1,136 54 81 60

Sources: GARPR country reports 2010 and 2012

On the whole, HIV interventions offered to sex workers have mainly been associated with research studies or projects. Available evidence in the region demonstrates the effectiveness of: peer mediated condom promotion, risk reduction counselling and skills building for safer sex, screening for STIs and syndromic management of STIs among sex workers (10). 61

4.4.2 Men who have sex with men (MSM)

Recent data on HIV prevalence among MSM and modes of transmission (MOT) analyses conducted in the region demonstrate that MSM are an important component of national HIV epidemics (4). Sex between men is heavily stigmatized and is a criminal offence in most of the countries in the region. Only three

Universal Access to priority health sector interventions 2013 UPDATE

countries (South Africa, Madagascar and Rwanda) have no criminal laws against sex between men. Due to these structural and legal barriers, the HIV epidemic among MSM continues to go largely unaddressed in many countries. HIV interventions and services targeting MSM are lacking in the National Strategic Plans (NSP) of most countries. Only eight countries (Mauritius, Madagascar, Cameroon, Cote d’Ivoire, Seychelles, Senegal, Togo and Nigeria) reported having interventions that reached MSM in 2011 (11). An online global survey involving 165 countries was conducted between April and August 2012 among MSM with 7% of the respondents from sub Saharan Africa (12). The survey also involved Focus

Group Discussions (FGDs) with MSM that were conducted only in the region at the request from of the networks of MSM in the region. Three countries; South Africa (Johannesburg), Nigeria (Abuja) and Kenya (Nairobi) participated. The survey found that, on the whole, less than one third of MSM had access to condoms and HIV testing and counselling. Only 21% and 42% of the surveyed MSM had access to lubricants and antiretroviral therapy respectively (13). Data on condom use and access to lubricants and antiretroviral therapy were not disaggregated by region. Selected findings from the FGDs highlight some of the barriers that hinder MSM from accessing HIV interventions and services as shown in Box 4.2.

Box 4.2: Selected findings from the FGDs with MSM (conducted in South Africa, Nigeria and Kenya)

In South Africa we do not have laws that criminalize gay/MSM but this does not mean that the legal system has a mechanism for protecting gay/MSM from hate crimes and violence”

“The staff, doctors and other providers need lots of training around how to treat patients humanely. They should focus on health concerns, not to shame you for being MSM or trying to make you be straight”.

“Same sex sexual activity among men has “I went to the hospital and the nurse pulled been legal in South Africa since 1998, and out a bible to lecture me about being gay. is illegal in Kenya (penalty up to 14 years She did not pay attention to my health” imprisonment) and in Nigeria (penalty varies)

The survey identified three categories of factors impacting access to HIV services by MSM. These were structural, community/interpersonal and individual barriers. The structural barriers included policy, cultural and institutional issues,

including criminalization of homosexuality, sexual prejudice, homophobia in health facilities and poverty. These structural barriers were said to be creating an environment where blackmail, extortion, discrimination, violence against MSM

HIV in the WHO African Region Progress towards achieving

The HIV/AIDS response among PWID is relatively poor and almost non-existent in most countries in the WHO African Region. Only 9 out of the 47 countries in the WHO African Region reported on the proportion of HIV interventions and services reaching PWID in the period 2010 to 2012 (12). Only three countries (Mauritius, Kenya and Nigeria) have policies related to PWID in their National Strategic Plans. A systematic review of coverage conducted from October 2008 to February 2009 indicated that sub Saharan Africa had the lowest rate of needle-syringe distribution of 0.1 needlesyringe per PWID per year (13). Whereas the HIV prevention services remain extremely limited in most countries, in the few countries with services these 4.4.3 People who Inject Drugs (PWID) are not tailored to the specific needs of The HIV epidemic among people who PWID (3). inject drugs (PWID) is an emerging and growing phenomenon in the WHO In 2009 and 2010, only one country African Region. HIV transmission through (Mauritius) in the region reported sharing contaminated injection equipment having syringe and needle exchange is a much more efficient mode of programmes and two other countries transmission, unlike sexual transmission including Mauritius reported having opioid that may remain invisible for several substitution programmes. Four other years. HIV prevalence among PWID may African countries reported implementing rise from zero to 50-60% within two other drug dependence programmes (14). years, as has happened in some cities Although injecting drug use remains illegal outside Africa (3). Depending on the in Kenya, in 2011 the National AIDS sexual behaviours of PWID, the epidemic Control Programme announced a plan to among PWID has a potential to spread provide free HIV prevention and treatment very fast to the general population for PWID. The plan also included needle because of sexual mixing patterns. This exchange, psychosocial support and opioid is likely to be the case in Mauritius substitution programmes. Twelve Primary where injecting drug use is the main Health Care facilities in Mombasa began mode of HIV transmission, and in recent offering opioid substitution, and piloting years the HIV prevalence among ANC of needle exchange programmes were initiated in two public hospitals (15). attendees has steadily increased. were allowed to exist. MSM were forced to hide their sexual behaviour from health care providers and other groups of people such as their families and employers to protect themselves and maintain a livelihood. Their inability to reveal their sexual behaviours to health providers more often than not led to misdiagnosis, delayed diagnosis and delayed treatment. The survey also indicated that community/ interpersonal and personal barriers undermined their relationships and trust of others hence increasing their vulnerability to HIV and making them fear to access health interventions including HIV prevention, care and support services.

Universal Access to priority health sector interventions 2013 UPDATE

4.5 Voluntary medical male circumcision (VMMC)

countries would entail performing 20.3 million circumcisions by 2015 and would avert 22% of new infections through Male circumcision is an effective HIV 2025 (18). prevention intervention that reduces heterosexual transmission among non-infected As a result of strong leadership, commimen (16). There is increasing evidence tment and good planning, considerable that female partners of circumcised HIV progress has been made in the 14 priority negative men have a lower prevalence of countries. All the 14 priority countries had human papilloma virus than the female developed target driven multi-year plans partners of uncircumcised men, a pattern on VMMC by the end of 2012. The that may lead to reduction of cervical countries are aiming at performing about cancer among partners of circumcised 20.3 million MC procedures by the end male partners, and also incidence of penile 2015 (Table 4.2). As of December 2012, cancer among circumcised men (14) a cumulative total of 3,162,036 VMMCs procedures had been performed in the Since 2007, 14 priority countries in eastern 14 countries. This represented 15.1% of and southern Africa meeting the WHO/ the estimated male circumcisions that UNAIDS criteria of high HIV prevalence would be needed among men aged 15and low prevalence of male circumcision 49 years in the priority countries to have been supported by WHO and achieve 80% prevalence. The number its partners to initiate and scale up of VMMCs performed in the priority services for medical male circumcision. countries in 2012 (1,710,531) represented These countries are: Ethiopia (Gambella a 1.9-fold increase over the number Region), Botswana, Kenya, Lesotho, performed in 2011 (884,283) (Figure Malawi, Mozambique, Namibia, Rwanda, 4.1). Between 2010 and 2012, there was South Africa, Swaziland, Uganda, a 300% increase in the number of MCs United Republic of Tanzania, Zambia performed in the 14 priority countries and Zimbabwe (17). Impact and costing (17). Approximately 90% of the total estimates suggest that scaling up VMMC MCs performed in 2012, were among to reach 80% coverage among men males aged over 10 years, and of these aged 15-49 years in the 14 priority 85% were aged 15 years and above (17).

HIV in the WHO African Region Progress towards achieving

Figure 4.1: Annual number of voluntary medical male circumcisions in the 14 priority countries, WHO African Region, 2008-2012 Botswana Rwanda Ethiopia South Africa Kenya Swaziland Lesotho Tanzania (Mainland) Malawi Uganda Mozambique Zambia Namibia Zimbabwe

1,800,000 1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 2008 2009 2010 Year 2011 2012

Source : WHO/AFRO Progress in Scaling up Voluntary Medical Male Progress in Scaling up Voluntary Medical Male Circumcision for HIV Prevention in East and Southern Africa: January – December 2012 – Draft Report

Table 4.2: Numbers of voluntary medical male circumcisions (VMMCs) performed and % achievement towards estimated number of MCs to reach 80% by year in the 14 priority countries, WHO African Region, 2008-2012 Potential infections averted by scaling up MC to reach 80% prevalence in five years 62,773 1,479 73,420 106,427 240,685 215,861 18,373 56,840 1,083,869 56,810 202,900 339,524 339,632 565,751 3,364,344

Number of male circumcisions

Number of MCs performed among all ages, by year and total

Country

Estimated number of MCs needed to reach 80% prevalence

2008

2009

2010

2011

2012

Total

% Achievement towards estimate number of MCs to reach 80% prevalence 18.50% 57.40% 63.10% 2.80% 1.70% 16.30% 3.90% 9.50% 19.90% 26.20% 23.50% 11.00% 17.50% 4.80% 15.20%

Botswana Ethiopia Kenya* Lesotho** Malawi Mozambique Namibia Rwanda South Africa Swaziland Tanzania Uganda Zambia Zimbabwe Total

345,244 40,000 860000 376,795 2,101,566 1,059,104 330,218 1,746,052 4,333,134 183,450 1,373,271 4,245,184 1,949,292 1,912,595 20,855,905

0 0 11,663 No data 589 0 0 0 5,190 1,110 0 0 2,758 0 21,310

5,424 769 80,719 No data 1,234 100 224 0 9,168 4,336 1,033 0 17,180 2,801 122,988

5,773 2,689 139,905 No data 1,296 7,633 1,763 1,694 131,117 18,869 18,026 21,072 61,911 11,176 422,924

14,661 7,542 159,196 No data 11,881 29,592 6,123 25,000 296,726 13,791 120,261 77,756 85,151 36,603 884,283

38,005 11,961 151,517 10,521 21,250 135,000 4,863 138,711 422,009 9,977 183,480 368,490 173,992 40,755 1,710,531

63,863 22,961 543,000 10,521 36,250 172,325 12,973 165,405 864,210 48,083 322,800 467,318 340,992 91,335 3,162,036

Source: Ministries of Health in the 14 priority countries * Kenya’s estimate is based on the national goal of 94% coverage for males aged 15 to 49 years **2008-2011 data for Lesotho not available Universal Access to priority health sector interventions 2013 UPDATE

Population based data corroborate the findings of increased prevalence of male circumcision in the priority countries that have conducted two population based surveys between 2007 and 2012. The increase in Uganda was small (19) (Figure 4.2). In Kenya, the proportion of men reporting being circumcised increased from 85% in 2007 to 91% in 2012 (20) while in the United Republic of Tanzania the increase was from 67% in 2007/2008 to 72% in 2011-2012. In

the urban areas of mainland Tanzania, the rate of circumcision was 94% and that in the rural areas was 64% in the same period (21). In Rwanda, 13% of the men aged 15-59 years reported in the 2010 DHS that there were circumcised with the highest rates being in urban areas, in those educated to secondary level and above and among the wealthy. Prevalence rates of male circumcision were 32% and 10% in the urban and rural areas respectively in 2010 (22).

Table 4.2: Numbers of voluntary medical male circumcisions (VMMCs) performed and % achievement towards estimated number of MCs to reach 80% by year in the 14 priority countries, WHO African Region, 2008-2012 Proportion of male circumcision (%) 100 90 80 70 60 50 40 30 20 10 0 2007 Kenya 2012 2007 2011-2012 2010 Ethiopia Gambella 2004-2005 2011 2010 Malawi 2010-2011 2010-2011 Rwanda Zimbabwe Tanzania Uganda 25 26.7 22 13 9.2 85 91 72 76

Source: Country DHS/AIDS reports in selected countries

Countries are utilising several innovative ways to scale up male circumcision. These include the use of champions (as role models and mentors), involvement of other ministries and programmes, school campaigns, home to home awareness campaigns, national or sub-national mass

mobilization/campaigns such as in Lesotho (Box 4.3), engaging elders and influential people such as parliamentarians in the launch of VMMC documents, programmes and sites (17), task shifting in Zimbabwe (Box 4.4) and providing ‘user friendly’ clinics as in Lesotho (Box 4.3).

HIV in the WHO African Region Progress towards achieving

Box 4. 3: Intensive mass male circumcision in Lesotho

A voluntary male circumcision policy and operational plan were developed and completed in 2011/2012. In February 2012, male circumcision commenced at 4 hospitals in the country. Between 25 June 2013 to 13 July 2013, Lesotho embarked on an intensive mass circumcision programme with phase 1 starting at Scott Hospital on pilot basis, with 40 men being circumcised every day. Before this, male circumcision procedures were only carried out in the hospitals twice a week. This intensive phase coincided with the winter school break to allow male youth to be free to come for the services. As the clients came in, they received group education and counselling followed by one to one counselling after which they were offered HIV testing and counselling, and then informed consent obtained for male circumcision. More than 1,715 men were tested and 1,114 were circumcised Source:http://www.afro.who.int/en/lesotho/ press-materials/item/4874-ministry-ofhealthcommences-voluntary-male-medical-circumcisionservices-scalingup-totackle-HIV-epidemic-inlesotho (23)

Adult VMMC in Lesotho

Lesotho established a VMMC clinic that caters for men over 29 years of age so as to improve uptake among ‘older men’. Lesotho decided to create a specialized clinic when experience showed that these ‘older men’ were uncomfortable receiving VMMC services with boys and young men. Men over 29 years of age receive the same package of VMMC services as other programme recipients but are now able to do so in a more consumer friendly environment. Following the creation of the clinic, an improvement was reported in the number of ‘older men’ presenting for VMMC. The country plans to consider replicating this approach in other parts of the country where older men are not presenting for VMMC in sufficient numbers Source: WHO/AFRO. Progress in scaling up voluntary medical male circumcisions for HIV prevention in East and Southern Africa: JanuaryDecember 2012- Draft Report (17)

Box 4.4: Broadening the scope of practice for nurses and midwives in Zimbabwe

In order to support accelerated scale up of VMMC services, Zimbabwe developed the “Broadening the scope of practice for nurses and midwives” policy. Through a consultative process with the Health Professions Authority, the Zimbabwe Councils of Nurses and of Medical and Dental Practitioners explored the feasibility of allowing nurses to conduct medical male circumcisions. It was determined that ‘The Health Professions Council Act Chapter 27: 19 Part VII clauses 1a) and e) had sufficient provisions for the

nurses and midwives to shoulder added responsibilities, including VMMC. Under the agreed new approach, the Nurses Council is now able to authorize appropriately trained and mentored nurses and midwives to take on added responsibilities that include surgical VMMC procedures and provision of VMMC services using MC devices. Source: WHO/AFRO. ‘Progress in scaling up

Voluntary medical male circumcision for HIV prevention in East and Southern Africa: JanuaryDecember 2012-Draft Report (17)

Universal Access to priority health sector interventions 2013 UPDATE

4.6 Blood safety

2009 (5). Only 45% of the demand for blood transfusions in Africa is currently The key areas for action by countries to being met (25). ensure blood safety as articulated in the WHO Strategic Plan 2008-2015 on blood The accepted minimum rate of blood safety are as follows: establishment of donations to meet a country’s most basic well organised nationally coordinated requirements for whole blood donations blood transfusion services to ensure per 1000 population is estimated to be timely availability of safe blood and blood 10 units per 1000 population. In 2011, products for all requiring transfusion; about 82 countries worldwide reported collection of blood from voluntary unpaid collecting fewer than 10 donations per blood donors from low risk populations; 1000 population. Thirty-nine of these quality assured testing for transfusion countries were in WHO African Region transmissible infections, blood grouping (26). More than 80% of blood donations and compatibility; safe and appropriate in 21 countries were from voluntary use of blood; a reduction of unnecessary and non-numerated donors in 2011, transfusions; and establishment of quality a slight increase from 20 countries in systems covering the entire transfusion 2009 (5,26). HIV testing has significantly process from donor recruitment to followimproved with all countries reporting up of the recipients of transfusion. 100% of their blood supply tested for HIV, from 40 countries in 2009 (5,25). In line with this WHO has supported Twenty seven (27) countries have a countries to develop national blood national external quality assessment for transfusion services through its Blood transfusion transmitted infections and Safety Programme by providing policy guidelines on the appropriate clinical use guidance and technical assistance (24). of blood have been developed in 29 By the end of 2012, forty three countries countries as of November 2013 (25) in the WHO African Region had adopted national safety blood policies (25). 4.7 Challenges and the way forward

In 2009, forty countries in the WHO African Region reported testing 100% of blood for HIV before transfusion and the remaining 6 countries test at least 98% (5). In 2011, forty three countries in the WHO African Region reported collecting 4 million units of blood but this accounted for 4.3% of total donations although African countries account for 12% of the global population (26). This was an increase from 1.95 million in 2000 and approximately 3.5 million in

In general, scaling up of HIV prevention interventions and services in the past decade in the WHO African Region is beginning to bear fruits. The decline in new HIV infections in the region is largely attributed to reduction in sexual risk behaviours mainly among young people. Steadily but slowly young people are adopting safer sexual behaviours and their level of comprehensive knowledge of HIV is increasing.

HIV in the WHO African Region Progress towards achieving

However, the level of comprehensive knowledge of HIV remains relatively low. Early sexual debut, multiple sexual partners and premarital sex are common and condoms are not always used during higher risk sex and premarital sex. This calls for intensified efforts in engaging young people in the HIV/AIDS response; Young people should be equipped with skills to make responsible and informed decisions about their sexuality and reproductive health, HIV and gender inequalities. There is need to conduct further research to better understand and address issues related to difficulties in implementation, gender differences in the response to HIV interventions, the determinants of exposure to HIV, and other factors which influence sexual behaviour among young people. New strategies are emerging that may have a potential to reduce the vulnerability of young people to HIV such as social cash transfer that creates an incentive for adopting safer sexual behaviours. A randomized controlled study among young people aged 18-32 years in 29 rural and periurban villages in 5 districts in Lesotho involving short term financial incentives reduced the probability of acquiring HIV infection by 25% over a period of two years (27). Another study in Zomba, Malawi involving conditional cash transfers to adolescents and their households for schooling reduced new HIV infections by 64% and the incidence of Herpes simplex type 2 (0.7% in the arm that received cash transfers and 3.0% in the control arm) (28). These emerging innovative approaches need to

be paired with other HIV interventions among young people. Countries will have to assess the feasibility of these structural interventions. While the pace of scaling up access to VMMC services is increasing in almost all the 14 priority countries, a number of challenges remain. These include inadequate human and financial resources, inadequate supplies, delayed procurement and weak supply chain management (stock outs of MC kits, equipment and other supplies), low demand for VMMC services more so among 25-49 year old men and minimal domestic investment for VMMC activities. VMMC activities largely remain funded by development partners. Monitoring and reporting systems for VMMC services remain parallel to the national health management information system (HMIS) in the majority of the countries and is heavily reliant on partners for reporting. Socio-cultural factors especially in countries where circumcision has not been traditionally a practice are a challenge to the uptake of VMMC services among adult males. There is need for countries to sustain and improve on the achievements made in improving access to VMMC services. Intensified efforts to increase the level of awareness of the public health and individual health benefits of VMMC, to enhance demand creation through innovative advocacy and communication approaches, to increase funding for the VMMC activities through diversifying funding from both domestic and partner

Universal Access to priority health sector interventions 2013 UPDATE

sources, and review regulations to allow health providers other than medical doctors (task shifting) to perform MC in the light of the availability of relatively safe, non-surgical devices such as Prepex are required. To promote sustainability, countries should consider integrating early infant male circumcision into Mother, Neonatal and Child Health (MNCH) programmes. HIV prevention services targeting key populations remain inadequate. Structural and legal barriers make it difficult for key populations to access HIV prevention, treatment, care and support services. These barriers need to be identified and addressed in the national HIV response. A review of the laws and regulations that criminalise key populations needs to be done to reach a balance between public order and public health. Key populations should be actively engaged in the national HIV/AIDS response starting from the design of interventions that meet their specific needs to implementation, monitoring and evaluation of the interventions. A multi-level approach involving a combination of interventions and methods is needed in the HIV/AIDS response among PWID. Provision of sterile needles and syringes (typically through needle and syringe programmes to avoid HIV transmission through sharing of

contaminated equipment), treatment of opioid dependence with opioid substitution therapy (leading to reduction in drug injection), promotion of safer sexual behaviours including promotion and use of condoms (reduction in HIV risk sexual behaviour), treatment of PWID who are infected with antiretroviral therapy, targeted information, education and communication on HIV/AIDS education, screening and treatment for TB, diagnosis and treatment of Hepatitis C would result in desirable health outcomes and decrease the spread of HIV among this population (3,13). While progress has been made with regards to blood safety, only 45% of the blood requirements are being met in the WHO African Region. A shortage of voluntary blood donors, low donation rates, irregular supply of kits, stock outs of test kits for transfusion transmissible infections (TTIs) are common challenges in the region. Countries will need to increase investment in blood transfusion services, design and implement attractive and innovative strategies to attract potential donors so as to increase blood donation rates and increase retention of voluntary donors. Improvement of logistics and supply management systems to minimize the occurrence of stock outs of kits and other supplies will also be required.

HIV in the WHO African Region Progress towards achieving

References 1. WHO/AFRO. HIV/AIDS: Strategy for the WHO African Region. 2013. WHO/AFRO, Brazzaville. 2. WHO. WHO Global Health Sector Strategy on HIV/ AIDS 2011-2015. 2011. WHO, Geneva. 3. WHO/UNAIDS/UNODC. Advocacy guide: HIV/ AIDS prevention among injecting drug users.2004 WHO Geneva. 4. UNAIDS. Global Report on the global AIDS epidemic 2013. 2013 UNAIDS, Geneva. 5. WHO/AFRO. HIV in the WHO African Region Progress towards achieving universal access to priority health sector interventions 2011 update. 2011. WHO/AFRO, Brazzaville. 6. Republic of South Africa. National Strategic Plan on HIV, STIs and TB 2012-2016. 2011. http:// www.doh.gov.za/docs/stratdocs/2012/NSPfull.pdf, accessed 18 September 2013 7. WHO/UNFPA/UNAIDS/NSWP. Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low-and middleincome countries Recommendations for a Public Health approach December. 2012; WHO Geneva. 8. Morrison L., Weiss H., Buve A., et al. Commercial sex and the spread of HIV in four cities in Sub Saharan Africa. 2001 AIDS Suppl 4:56-9 9. UNFPA. HIV/AIDS, Gender and sex work. http:// www.unfpa.org/hiv/docs/factsheets_genderwork. pdf , accessed 14 September 2013 10. Chersich Matthew, Stanley Luchters, Innocent Ntaganira, et al. Priority interventions to reduce HIV transmission in sex work settings in Sub Saharan Africa and delivery of these services. 2013. Journal Int AIDS Soc 16(1) 17980, doi:10:7448/IAS. 16.1 11. Country GARPR Progress reports. http://www. unaids.org/en/dataanalysis/knowyourresponse/co untryprogressreports/2012countries, accessed 12 September, 2013 12. Sonya Arreola, Pato Hebert. Keletso Makofane., et al. Access to HIV prevention and treatment for men who have sex with men Findings from the 2012 Global Mens’ Health and Rights study (GMHR). December 2012. The Global Forum on MSM and HIV (MSMGF), Oaklands, USA 13. Bradley M. Mathers, Degenhardt L., Hammadi Ali., et al. HIV prevention, treatment and care services for people who inject drugs: a systematic review of global, regional and national coverage. www. thelancet.com/journals/lancet/article/PII01406736 (10)60232-2/abstract#cor1 14. WHO/UNAIDS and UNICEF. Global HIV/AIDS Response epidemic update and health sector progress towards Universal Access progress report 2011. WHO, Geneva. 2011. 15. UNAIDS. Kenya to adopt comprehensive HIV package for people who inject drugs. 23 February 2011. http:/www.unaids.org/en/targetsand commitments/preventinghivamongdrugusers/ morefeauturesstories/2/, accessed 24 September 2013 16. Auvert, B., Taljaard, D., Largarde, E., et al. Randomised controlled intervention trial of male circumcision for reduction of HIV risk: The ANRS 1265 Trial. PLoS Med 2(11): e298.doi.10.1371/ journal.pmed.0020298 17. WHO/AFRO. Progress in scaling up voluntary medical male circumcision for HIV prevention in East and Southern Africa January –December 2012. July 2013 (Draft). WHO/AFRO, Brazzaville 18. WHO/UNAIDS. Joint strategic action framework to accelerate the scale up of voluntary medical male circumcision for HIV prevention in eastern and southern Africa 2012-2016.November 2011. UNAIDS, Geneva. JC2251E 19. Uganda AIDS Indicator Survey (AIS) 2011. August 2012. Ministry of Health Uganda, ICF Calverton Maryland USA, Centre for Disease Control and Prevention, Entebbe, Uganda, US Agency for International Development, Kampala, Uganda, WHO Uganda, Kampala.

Universal Access to priority health sector interventions 2013 UPDATE

20. National AIDS and STI Control Programme, Ministry of Health, Kenya. Kenya AIDS Indicator Survey 2012: Preliminary Report. September 2013. Nairobi, Kenya 21. Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF International. Tanzania HIV/AIDS and Malaria Indicator survey 20112012. 2013. Dar es Salaam, Tanzania:TACAIDS, ZAC,NBS, OCGS, and ICF International. 22. National Institute of Statistics of Rwanda (NISR) (Rwanda), Ministry of Health (MOH) (Rwanda), and ICF International. Rwanda Demographic and Health Survey 2010. Calverton, Maryland, USA:NISR, MOH, and ICF International

improving patient health and saving lives. http:// www.who.int/bloodsafety/StrategicPlan20082015AccessSafeBloodTransfusion.pdf, accessed 4 Oct 2013 25. WHO/AFRO database on blood safety, November 2013 26. WHO. WHO Global blood safety summary report 2011. www.who.int/bloodsafety/global_database/ GDBS_summary_report_2011.pdf, accessed 19 September,2013 27. Bjorkman-Nyqvist M.,Corno, L., de Walque D., and Svensson, J. Evaluating the impact of short term financial incentives on HIV and STI incidence among youth in Lesotho. A randomized trial’ Abstract for a poster discussion session TUPDCO106, IAS 7th International Conference on HIV pathogenesis, treatment and prevention. Kualu Lumpur, Malaysia July 2013 28. Lori Heise, Brian Lutz, Meghna Ranganathan and Charlotte Watts. Cash transfer for HIV prevention: considering their potential. 2013. Journal of the International AIDS Society 16:18615

23. http://www.afro.who.int/en/lesotho/press-materials/

item/4874-ministry-ofhealth-commences-voluntarymale-medical-circumcision-services-scalinguptotackle-HIV-epidemic-in-lesotho

24. WHO. WHO Universal Access to safe blood transfusion scaling up the implementation of the WHO strategy for blood safety and availability for

HIV in the WHO African Region Progress towards achieving

5. HIV prevention and treatment among women and children Key messages

• Considerable progress has been made the region having received antiretroviral towards the elimination of mother to medicines for PMTCT in 2012. child transmission of HIV in the WHO African Region since 2009 with the • The coverage of antiretroviral therapy among HIV infected children is steadily region experiencing an overall decline improving, but remains low with only of 37% in the number of new HIV 33% receiving ARVs in 2012. Similarly, infections among children between early diagnosis of HIV among exposed 2009 and 2012. infants remains low. • Coverage rates for HIV testing and counselling among pregnant women • Big countries in the region such as the Democratic Republic of Congo, Ethiopia have increased from 38% in 2009 to and Nigeria which contribute the highest 50% in 2012, an increase of 12% numbers of pregnant women living with between 2009 and 2012. HIV have been facing challenges in • The uptake of ARV for PMTCT has providing PMTCT services and will improved substantially with 63% of need to step up their efforts. pregnant women living with HIV in

5.1 Introduction

Following the 2011 UN Declaration on HIV/AIDS “Intensifying our efforts to eliminate new HIV infections by 2015”, a Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive was launched in July 2011 (1). The Global Plan includes 22 countries that account for 90% of all pregnant women living with HIV, with 21 of these countries being in the WHO African Region (Angola, Burundi, Botswana, Cameroon, Chad, Cote d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Kenya,

Lesotho, Malawi, Mozambique, Namibia, Nigeria, Swaziland, South Africa, Uganda, United Republic of Tanzania, Zambia and Zimbabwe). In 2012, the WHO Regional Office for Africa, in collaboration with partners, developed a “Strategic Framework for the Elimination of New HIV Infections Among Children in Africa by 2015” (2). The framework outlines the aim, objectives, targets and priority actions for eliminating new HIV and syphilis infections in children in the African Region by 2015 and

Universal Access to priority health sector interventions 2013 UPDATE

keeping their mothers alive. It provides countries in the region with a systematic approach for the elimination of mother to child transmission of HIV (eMTCT) based on country typology (epidemiology and response), and improvement of maternal and child health and survival in the

context of HIV/AIDS. Its main objectives and targets (Box 5.1) are in line with the Regional HIV/AIDS Strategy— “HIV/ AIDS: Strategy for the WHO African Region” (3) and harmonized with those of the Global Plan.

Box 5. 1: Strategic Framework for the elimination of new infections among children in Africa by 2015 Objectives and targets-:

• Reduce the number of new HIV infections among children by 90% from the 2009 baseline. • Reduce the number of AIDS–related maternal deaths by 50%. Proposed priority interventions for the eMTCT initiative are based on seven building blocks for accelerated actions

• Improve coverage, access and utilization of services. • Strengthen quality of Mother Neonatal Child Health services to deliver effective PMTCT interventions. • Enhance provision of linked services. • Strengthen human resource capacity, supply chain management and information systems. • Improve measurement of performance and impact. • Develop and engage community systems.

• Ensure leadership and country ownership.

A substantial decline in the number of new HIV infections among children after the commencement of prevention of mother to child transmission (PMTCT) programmes in the WHO African Region provides a ‘ray of hope’ and optimism that it is feasible to eliminate new infections among children and to improve the health of their mothers by 2015. In 2012, about 260,000 children were newly infected with HIV in low and middle income countries (4). At the global level, there was a decline of 35% in new infections among children between 2009 and 2012. (4) In the 21 Global Plan priority countries, mother to child transmission rates declined from an estimated 26% in 2009 to 17% in 2012 (1).

Countries such as Botswana and South Africa are achieving low HIV transmission rates similar to those seen in high income countries as a result of the high coverage of PMTCT services among pregnant women living with HIV (1) This chapter tracks the progress made by countries in the WHO African Region in the prevention of HIV transmission from pregnant or breastfeeding women living with HIV to their infants and in the provision of appropriate treatment to mothers living with HIV and their children who have been exposed to HIV.

HIV in the WHO African Region Progress towards achieving

5.2 HIV testing and counselling among pregnant women

Timely HIV testing and counselling is critical to identifying pregnant women living with HIV who can benefit from interventions to reduce the risk of HIV transmission to their children; and for pregnant women living with HIV to receive timely treatment and care for their own health. The proportion of pregnant women who receive an HIV test in the past 12 months in Sub Saharan Africa has been steadily increasing over the years. Antenatal care offers a critical opportunity for pregnant women and their partners to receive HIV testing and counselling (HTC).

Over two thirds (67%) of pregnant women in sub-Saharan Africa attend antenatal care at least once during pregnancy (5). Trends in the coverage of HIV and testing rates among ANC attendees continue to increase in all sub regions (Figure 5.1). This increase is largely due to the expansion and scale up of provider-initiated testing and counselling in antenatal clinics, maternal, neonatal and child health (MNCH) care settings. From a coverage rate of 8% in 2005, the region achieved almost a fivefold increase to 38% in 2009; and since then a slow but steady increase to 50% in 2012 (6).

Figure 5.1: Estimated proportion (%) of pregnant women tested for HIV, WHO African Region, 2009-2012 2009 100 90 83 77 67 57 55 59 47 33 22 38 26 28 32 44 46 29 88

2010

2011

2012

% of pregnant women tested

80 70 60 50 40 30 20 10 0

25 26

Southern Africa

Eastern Africa

Central Africa

Western Africa

African Region

Source: The Numerator for the data was taken from the Indicator 3.4 Pregnant Women who know their HIV status of GARPR October 2013 update. Some of the figures were imputed data from the previous year, if the respective country did not report to the GARPR in a given year. The Denominator was from the UN Population Division - the 2012 update.

HIV testing among antenatal clinic attendees varies greatly between countries and sub regions in the WHO African Region (Figure 5.1). Big increases in HIV testing rates were seen between 2009 and 2012

in southern Africa from a coverage of 67% to 88%, followed by eastern Africa from 47% to 59%, western Africa from 22% to 32%, and central Africa from 25% to 33%.

Universal Access to priority health sector interventions 2013 UPDATE

5.3 Providing antiretroviral medicine to pregnant women living with HIV for preventing mother to child transmission of HIV

Following the release of the 2010 WHO guidelines which recommended provision of lifelong antiretroviral therapy (ART) to all HIV-infected pregnant women eligible for such treatment and two short-term antiretroviral prophylaxis options (Option

A and Option B) for women not eligible for treatment for their own health, WHO/ AFRO organized four dissemination meetings with countries in the region and supported them to revise/adapt their national PMTCT guidelines and to develop their country roll-out plans. Table 5.1 shows the different PMTCT options adopted by the priority countries as at June 2013.

Table 5.1: Implementation of the 2010 WHO Guidelines among selected countries in the Africa Region, as at June 2013 PMTCT option after 2010 WHO ARV guidelines Implementation status of ART for all pregnant and breastfeeding women living with HIV (Option B or B+)

Country

PMTCT regimen as of June 2013

Angola Benin Botswana Burundi Cameroon Chad CAR Cote d'Ivoire D R Congo Ethiopia Ghana Guinea Guinea-Bissau Kenya Lesotho Liberia Malawi Mozambique Namibia Niger Nigeria Sierra Leone Senegal South Africa Swaziland Tanzania Uganda Zambia

B B+ B B A B A B A A A B B A A A B+ A A A/B A/B A B+ A A A A A

B+ B+ B B B+ B B+ B/B+ B+ B+ B B B A/B B+ B+ B+ B+ B+ A/B A/B A B+ B A B+ B+ B+

Select regions … National National Planned (being discussed) National Adopted (but only in demonstration sites) National Planned (being discussed) Select regions National National National Select regions National Planned National Select regions Planned National Select regions National National National Piloting B+ in select regions Planned National Planned

Source: Country quarterly progress reports

HIV in the WHO African Region Progress towards achieving

Notably, initially Malawi and later several other countries started putting all HIV positive pregnant and breastfeeding women on lifelong ARVs (option B+). This

has had a positive impact on PMTCT services, including integration with Mother Neonatal and Child Health (MNCH) and ART programmes (Box 5.2).

Box 5.2: Implementation of B+: The Malawi experience

Following the release of the WHO 2010 PMTCT Guidelines Malawi decided to initiate all HIV-positive pregnant or breastfeeding women on antiretroviral therapy (ART), irrespective of their CD4 cell count. This approach was called ‘B+’ and aimed to 1) increase access to ART for HIV-positive pregnant or breastfeeding women in a setting with limited access to CD4 testing, (2) maximize the mothers’ health and reduce post-partum mortality, (3) reduce HIV transmission to sexual partners especially in stable discordant relationships, (4) avoid starting and stopping prolonged ARV use, (5) reduce stigma brought about by curtailing

breastfeeding, (6) reduce malnutrition among infants and (7) avoid the need for extended infant HIV prophylaxis. The implementation of Option B+ in Malawi has resulted in increased availability, access to and utilization of PMTCT services. This initiaitive has been associated with rapid expansion of integrated PMTCT/ART services to all Maternal Neonatal and Child Health (MNCH) sites. With offer of HIV testing and counseling (HTC) to all women accessing ANC and delivery care, over 80% of those testing positive are initiated on ART in the country.

Changes in numbers of sites accredited for B+, exposed infant follow and the percentages of HIV positive pregnant women initiated on B+ during the first year of B+ implementation in Malawi (July 2011-June 2012)

Source: Malawi Documentation Report, 2013

The high antenatal attendance rate of 95% in Malawi, (2010), availability of HTC in all ANC outlets, commitment to integrate ART and PMTCT services, maximization of use of existing human resources through integration of services and task shifting, supportive policy and guidelines for institutionalizing the programme and

its effectiveness make high ART coverage among HIV-positive women possible and Option B+ provides the opportunity of treating them. Available partnerships, involvement of PLHIV, increased male involvement and community engagement and support are also critical to this end.

Universal Access to priority health sector interventions 2013 UPDATE

As of December 2012, pregnant women living received antiretroviral treatment in the WHO As shown in Figure 5.2,

about 860,000 with HIV had prophylaxis or African Region. the coverage of

pregnant women living with HIV receiving antiretroviral medicines for the prevention of mother to child transmission (PMTCT) increased from 34% in 2009 to 63% in 2012 (7,8).

Figure 5.2:Trends (%) in provision of effective ARVs for pregnant women for prevention of mother-to-child transmission, WHO African Region, 2009-2012

% of pregnant women receiving ARVs for PMTCT 100 90 80 70 60 50 40 30 20 10 0

Target (90%) by 2015 90

% of pregnant women receiving ARVs

63 50 34

2009

2010

2012 Year

2015

Sources: WHO/UNICEF/UNAIDS Global HIV/AIDS Response epidemic update and health sector progress towards Universal Access Progress Reports (2009 and 2010) UNAIDS database on HIV/AIDS 2013.

Progress in the coverage of ARVs for PMTCT has been different between countries and sub-regions (Figure 5.3). Progress has been more among countries in southern Africa. Twelve countries (Botswana, Ghana, Liberia, Mozambique, Namibia, Rwanda, Sierra Leone, South Africa, Swaziland, Togo, Zambia, Zimbabwe) have PMTCT ARV coverage rates of 80% or more with five of them (Botswana, Namibia, Zambia, Ghana and Sierra Leone) having reached the

2015 target in providing 90% or more of the pregnant women living with HIV antiretroviral medicines for preventing mother to child transmission (PMTCT) in 2012. Another 10 countries had moderate coverage of 50-79%. However, of concern are the 9 countries that have coverage rates of less than 50%, with five of them (Angola, Chad, Democratic Republic of Congo, Ethiopia and Nigeria) being eMTCT priority countries.

HIV in the WHO African Region Progress towards achieving

Figure 5.3: PMTCT ARV coverage (%) for selected countries in WHO Africa Region, 2012

High Coverage: (80 % and above) Botswana* Ghana* Liberia Mozambique* Namibia* Rwanda Sierra Leone South Africa* Swaziland* Togo Zambia* Zimbabwe*

Moderate coverage: (50-79%) Burundi*

Low Coverage: (Less than 50%) Angola*

Cameroon* Central African Republic Côte d’Ivoire* Gabon Guinea Bissau Kenya* Lesotho* Malawi* Uganda* Tanzania*

Benin Burkina Faso Chad* Congo D R C* Eritrea Ethiopia* Guinea Nigeria*

* Global Plan EMTCT Priority countries Source: UNAIDS Global Report on AIDS epidemic 2013.

5.4 Reduction in AIDS related maternal deaths

HIV remains an important cause of maternal deaths in the WHO African Region (9). Both the Global Plan and the regional strategic framework aim to reduce the number of AIDS related maternal deaths by 50% from 2009 to 2015. Empirical data on maternal deaths in general and those attributed to AIDS in particular are not readily available in several countries. Table 5.2 shows estimates of maternal deaths in the

region attributed to HIV/AIDS for the periods 1990-2008 and 1990-2010. In general, between 2008 and 2010, there were declines in AIDS related maternal deaths in several countries where data were available These include Botswana, Swaziland, Zambia and Zimbabwe. During the same period there were increases in South Africa, Namibia, Gabon, Equatorial Guinea, Cote d’Ivoire, Uganda and United Republic of Tanzania.

Universal Access to priority health sector interventions 2013 UPDATE

Table 5.2:Trends (%) in AIDS related maternal deaths in selected countries, WHO African Region, 2008 - 2010 Country Angola Botswana Burundi Cameroon Central African Republic Chad Congo Cote d’Ivoire Democratic Republic of Congo Djibouti Equatorial Guinea Eritrea Ethiopia Gabon Ghana Kenya Lesotho Malawi Mozambique Namibia Nigeria Rwanda South Africa Swaziland Uganda United Republic of Tanzania Zambia Zimbabwe % AIDS related maternal deaths (2008) … 77.9 … 14.2 11,6 … 11.8 15.2 …. 14.9 12.6 6.6 … 26.1 … 13.9 … 31.8 … 50.1 … 5 42.5 75.1 24 11.1 37 52.7 % AIDS related maternal deaths (2010) 5 56 7 10 10.9 4 8.2 17 4 -21.8 --4 25.8 8 20 42 29 27 59 8 3.5 60 67 25 18 31 39

Sources: WHO, UNICEF, UNFPA and World Bank. Trends in maternal mortality: 1990 to 2008. WHO 2010. WHO, UNICEF, UNFPA and World Bank. Trends in maternal mortality: 1990 to 2010. WHO 2012

5.5 Early Infant diagnosis of HIV

Virological testing of HIV exposed infants within two months of birth is critical to identifying those that might have been infected with the virus in utero and during delivery, and to ensuring that they are timely linked to treatment, care and support services. This has been shown to markedly improve their health outcomes by reducing morbidity and mortality rates given that 50% of untreated children infected with HIV during pregnancy and childbirth die before their second birthday untreated (10).

Analyses of trends on virological testing among infants within 2 months of birth in countries that reported data for the period 2009 to 2012 indicate that progress is being made slowly (Table 5.3). Only seven countries (Cape Verde, South Africa, Swaziland, Rwanda, Namibia, Zambia and Gabon) had 50% or more of the HIV exposed infants tested by 2 months of age. On the other hand six countries (Guinea, Chad, Democratic Republic of Congo, Sierra Leone, Malawi and Angola) were testing 10% or less of the HIV exposed infants by 2 months of age. 80

HIV in the WHO African Region Progress towards achieving

Table 5.3: Proportion (%) of infants born to women living with HIV who had a virological test within two months in selected countries, WHO African Region, 2009-2012 Subregion Southern Africa Country Botswana Comoros Lesotho Madagascar Malawi Mauritius Mozambique Namibia South Africa Swaziland Zambia Zimbabwe Ethiopia Kenya Rwanda Uganda United Republic of Tanzania Angola Burundi Central Africa Republic Chad Congo Demo. Republic of Congo Gabon Benin Burkina Faso Cameroon Cape Verde Cote d’Ivoire Ghana Guinea Liberia Mali Nigeria Senegal Sierra Leone Togo 2009 … … 33 … … … … -… … 53 … 4 … … 6 13 … … … … … … … … 26 … … … … …. … 3 … … … 2010 53 … 78 … … … 34 62 69 54 21 14 … 64 … 11 22 3 7 …. 2 …. 2 … …. … 21 … 36 1 …. … … 4 … … … 2011 37 2 69 0.1 … … 43 96 61 77 57 20 11 39 68 30 28 6 10 7 1 6 4 37 14 14 29 >95 4 19 6 31 9 5 10 … 6 2012 42 <1 -<1 5 21 42 89 94 90 68 38 22 44 86 --32 8 14 … 4 12 7 54 15 25 41 >95 34 22 <1 19 5 15 4 20

Eastern Africa

Central Africa

Western Africa

Sources: 2011&2012: UNAIDS global HIV/AIDS database 2009 & 2010: WHO/UNICEF/UNAIDS Global HIV/AIDS Response epidemic update and health sector progress towards Universal Access Progress Reports

5.6 Antiretroviral treatment for HIV positive-children

Provision of ARVs to children aged less than 15 years has been lagging behind than that for adults in the WHO African Region. Between 2009 and 2012, there

was an increase from 19% in 2009 to 32% in the provision of ARVs to children living with HIV, a modest increase of 15% (Figure 5.4). This increase is minimal given that the 100% target by 2015 is close.

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Figure 5.4:Trends (%) in the coverage of ARVs for children in WHO African Region; 2009- 2012 % coverage of ARVs for children < 15 years 100 Coverage (%) of ARVs for children 80 60 40 20 0 2009 2010 2011 2012 Year 2015 19 21 29 32

Target (100%) by 2015 100

Sources: 2011 & 2012: UNAIDS global database 2013(21 priority countries) 2009 &2010: WHO/UNAIDS/UNICEF Global HIV/AIDS Response epidemic update and health sector progress towards Universal Access Progress Reports t (2009 and 2010)

Progress in ARV coverage among HIV positive children varies widely between countries (Figure 5.5). As of December 2012, only Botswana reported providing

more than 95% of the HIV infected children with ARVs. Ethiopia (24%), Nigeria (12%) and Democratic Republic of Congo (9%) were lagging behind in 2012.

Figure 5.5: Coverage of ARV among children in selected countries, WHO African Region, 2009 – 2012 2009 120 100 80 60 40 20 0 2010 2011 2012 Target of 100% by 2015

Sources: 2012: WHO/ UNICEF/UNAIDS Global Update on HIV treatment 2013: Results,impact and opportunities 2011: UNAIDS Global Report on AIDS epidemic 2012, 2009 and 2010: WHO/UNAIDS/UNICEF Global HIV/AIDS Response epidemic update and health sector progress towards Universal Access Progress Reports 2010, 2011 82

ART coverage (%) among children eligible for ART

HIV in the WHO African Region Progress towards achieving

The performance of PMTCT programmes in general has not been optimum, particularly with children. As of 2012, only 7 out of the 20 priority countries in Africa with data had reduced new infections

among children by 50% compared with 2009 (Figure 5.6). Another 7 countries had moderate declines (30-49%) while 6 countries experienced very low declines of less than 30%.

Figure 5.6: Reduction in new HIV infections among children in the 20 eMTCT priority countries,WHO African Region, 2009-2012 Rapid Decline (50% or more) Botswana Ethiopia Ghana Malawi Namibia South Africa Zambia Moderate decline (30–49%) Burundi Cameroon Kenya Mozambique Swaziland Tanzania Zimbabwe Slow decline (Less than 30%) Angola Chad Côte d’Ivoire D R Congo Lesotho Nigeria

Source: UNAIDS. 2013 Progress Report on the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive

As a consequence, mother -to-child trans- rates have been generally declining since mission rates remain very high in the 2009 in the region comparing favourably region. Figure 5.7 shows that the MTCT with the global trends. Figure 5.7: Decrease (%) in MTCT in the WHO Africa Region Compared with global rates, 2009 - 2012 30 25

Decrease (%) in MTCT

20 15 10 WHO Africa Region 5 0 2009 2010 Year 2011 2012 Global

Source : UNAIDS database 2013 Universal Access to priority health sector interventions 2013 UPDATE

Analysis of MTCT rates in different countries reveals that the decline is heterogeneous with only Botswana (3%) and Mauritius (3%) estimated to have reached the target value of 5% or less for breastfeeding communities (Figure

5.8); while South Africa (7%), Namibia (9%) and Ghana (9%) have also made impressive progress. Ghana has had the largest decline in MTCT rates (Box 5.3) largely due to integration of PMTCT services in MNCH services.

Figure 5.8: MTCT Rates in selected countries in the WHO African Region, 2012

Zimbabwe Zambia Tanzania Swaziland South Africa Nigeria Namibia Mozambique Malawi Lesotho Kenya Ghana Ethiopia D R Congo Code d'Ivoire Chad Cameroun Burundi Botswana Angola 0 5 10 15 20 25 30 35 MTCT Rates (%) Source: UNAIDS. 2013 Progress Report on the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive

HIV in the WHO African Region Progress towards achieving

Box 5.3: Ghana country case study on reduction of MTCT rates:

Ghana is one of the 21 priority countries with a high burden of mother-to-child transmission of HIV. Led by high level political and stakeholder support, the country developed a PMTCT national scale-up plan for 2011-2015 in 2010 with a vision to ensure a generation free of AIDS and to eliminate MTCT by 2015. Ghana achieved the highest reduction in new infections among children and was ranked high amongst countries with successful PMTCT programmes. The risk that a woman living with HIV will transmit the virus to her child has declined from 31% in 2009 to 9% (7–11%) in 2012. These results were driven by integration of PMTCT within MNCH services:

• PMTCT delivery in the context of focused antenatal already and collaboration with Family Health Department of Ghana Health Service • Move from PMTCT Option A to B for more efficacious and effective ARVs. • PMTCT course being part of the preservice curriculum for midwifery and community health training schools • Integration of Family Planning in PMTCT services including procurement and distribution of key commodities and using SMS texting (common IT platform) for commodity stock monitoring for both SRH and HIV commodities • A highly motivated multi-task and dedicated cadre of health care workers

• Strong programmatic leadership, clear national guidelines, protocols and manuals for implementation and training

5.7 Unmet need for family planning

There are significant gaps between women’s desire to delay or avoid having children and their actual use of contraception. Although data are not available for all countries, the unmet need for family planning in the WHO African Region was estimated at 25% in 2010. This means that in this region one in every four women 15-49 who is married or in union has an unmet need

for family planning (11). Analysis of DHS data on unmet needs in 11 countries in the region with at least 2 data points reveals that reduction in the unmet need for family planning has been very slow and at varying rates. The Global Plan target of reduction to zero of the unmet need for family planning by 2015 is far from being achieved by countries in the WHO African Region. (Figure 5.9)

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Figure 5.9: Trends (%) in unmet need for family planning,WHO African Region Survey 1 40 (%) in unmet need for family planning 31

Survey 2 36 38 35 36

35 30 20 21

25 20 16 18

15 10 5 0

Zimbabwe 2005-10

Nigeria 2003-08

Namibia 2000-06

Lesotho 2004-09

Tanzania Kenya 2003- Malawi 2004-10 08 2005-2010

Ethiopia 2005-11

Zambia 2002-07

Uganda 2006-11

Ghana 200308

Source : Demographic and Health Surveys country reports

5.8 Challenges and the way forward

All countries in the region recognize PMTCT as one of the national priorities and are committed to elimination of new HIV infection among children and keeping their mothers alive by 2015. Progress has been made in expanding and scaling up HIV prevention and treatment for women and children resulting in increasing numbers of pregnant women and children being tested for HIV and of HIV positive pregnant women getting ARV for PMTCT and ART for their own health since 2009. However, coverage of PMTCT services varies greatly in the region. While some countries (Botswana, Ghana, Namibia, Sierra Leone and Zambia) have reached the 2015 target of putting at least 90% of HIV positive pregnant women on ARVs, some others (Angola, Chad, DRC and Nigeria) have been lagging far behind.

The challenges that countries have to face include addressing the bottlenecks related to the availability of skilled human resources at all levels, ensuring continuity of services along the PMTCT cascade through long term retention and adherence, and making health systems more responsive. The high rate of coverage of first antenatal visit in the WHO African Region is a great opportunity, a positive enabling factor and an entry point for most women to access HIV prevention and treatment interventions for themselves, their children and their partners. The implementation of the 2013 WHO consolidated treatment guidelines that recommend early initiation of antiretroviral prophylaxis and treatment with the move to Option B/B+ requires strengthening of the maternal, newborn and child health platform.

HIV in the WHO African Region Progress towards achieving

To maintain the momentum and meet the internationally agreed upon goal, intensified efforts are needed to ensure that all pregnant women are tested and counselled and treatment provided for those that are pregnant and living with HIV. Countries are encouraged to adopt and replicate innovative approaches that have produced success in their own countries or elsewhere, while taking into account the country context. These include:

Intensified efforts are needed to improve the diagnosis of HIV among infants as well as in older children born of women living with HIV, and to link them to HIV treatment, care and support services. In addition, follow up of HIV exposed children, as well as their mothers, needs to be rigorous to minimize attrition and loss to follow up. Further strengthening of linkages and integration of HIV programmes with other health programmes such as maternal, neonatal and child health, sexual and reproductive • Integration of PMTC services health, TB and STI control programmes within Mother Newborn and Child need to be accelerated. Health programmes • Couples counselling and testing The 2013 WHO guidelines that recommend simpler, effective ART regimens and and a family-centred approach early initiation of antiretroviral therapy will • Community based services that will increase the numbers of pregnant women ensure that all pregnant women and children living with HIV who need and children hard to reach have antiretroviral medicines. This will require access to PMTCT and antenatal more investments into programming of care services. PMTCT interventions especially financial • Task shifting policies and other and human resources, more training and measures to address the human capacity building for health providers, task shifting policies and others measures to resource challenges. address the human resource challenges, • Strategic information system for strengthened laboratory capacity and designing, guiding and evaluation of further integration of PMTCT services in the implementation of tailor made other related health sector programmes interventions to meet the needs of and further decentralization of services. pregnant women living with HIV and children. • Adoption of more efficient models of service delivery including availability and proper use of medicines, diagnostics and commodities, health financing, and governance.

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References 1. UNAIDS. Global Plan Towards the Elimination of New HIV Infections, Among Children by 2015 and Keeping their Mothers Alive. 2011 UNAIDS, Geneva. 2. WHO/AFRO. Strategic framework for the elimination of new HIV infections among children in Africa by 2015. 2013. WHO/AFRO, Brazzaville. 3. WHO/AFRO. HIV/AIDS: Strategy for the WHO African Region. WHO/AFRO, Brazaville. 4. UNAIDS. Global Report on the global AIDS epidemic 2013. 2013. UNAIDS, Geneva. 5. Omeilla Lincetto, Seipati Mothbesoane, Anonh J, Patricia Gomez & Stephen Munjana. Antenatal care.http://www.who.int/pmnch/media/ publications/aonsectionIII_2.pdf. Accessed on 20 November 2013. 6. WHO Global HIV/AIDS database 7. WHO/AFRO. HIV in the WHO African Region Progress towards achieving universal access to priority health sector interventions 2011 Update. 2011. WHO/AFRO, Brazzaville. 8. UNAIDS HIV/AIDS database 9. WHO, UNICEF, UNFPA and World Bank. Trends in maternal mortality: 1990 to 2010. 2012. WHO, Geneva.

10. WHO. Global update on HIV treatment 2013: results, impact and opportunities. June 2013.WHO, Geneva.

11. http://www.measuredhs.com/data. Country DHS reports 2000-2010

HIV in the WHO African Region Progress towards achieving

6. Scaling up treatment and care for people living with HIV Key messages

• Considerable progress has been made • Improved access to antiretroviral in improving access to antiretroviral therapy is beginning to increase life therapy for eligible people living with expectancy in some countries and HIV. As at the end of December 2012, has significantly reduced the number a total of 7,526,400 (68%) people of new HIV infections, AIDS related were receiving antiretroviral therapy, deaths and TB related deaths among an increase of more than 90% from people living with HIV in the region. 3,192,000 in December 2009. • Despite the good progress made on • The main factors driving the increase the whole, in several countries the pace in access to ART the steep rise has been slow. For example Nigeria, in the number of facilities providing which has the second highest number ART services, decentralization of ART of people living with HIV in the WHO services beyond referral and urban African Region, had ART coverage of areas to rural areas, and primary 36% in 2012. The Democratic Republic health care facilities, adoption of taskof Congo, also with high numbers of shifting policies, capacity building, and people living with HIV, had coverage increased domestic and international of 38% in 2012. funding. • Greater investment in health systems • Good progress is being made in the strengthening will be required to address implementation of TB/HIV collaborative the implications of implementing the activities. Coverage of antiretroviral 2013 WHO guidelines on antiretroviral therapy in people with TB/HIV has treatment in order to achieve universal increased from 37% in 2009 to 57% access and maximize the impact of in 2012; and 74% of people with TB ART in the region. knew their HIV serostatus, up from 69% in 2011.

6.1 Introduction

The scaling-up of life-saving and infectionprevention HIV treatment in the WHO African Region constitutes one of the great public health achievements during the past decade. By the end of

December 2012, a total of 7,524,000 (68%) people in need of ARVs were receiving antiretroviral therapy, an increase of more than 90% from 3,192,000 in December 2009 (1). The

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accomplishments are a reflection of the strong political commitment, community mobilization, technical innovation, and increasing domestic and international funding. WHO and partners have continued to provide normative guidance and technical support for the scale up of HIV treatment and care programmes. The recent 2013 WHO guidelines “Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infections. Recommendations for a public approach” which recommend earlier initiation of antiretroviral therapy at CD4 count ≤500 cells/µl, immediate provision of ART for serodiscordant couples, pregnant women living with HIV, people with TB and HIV, people with HIV and hepatitis B, and all children living with HIV who are less than 5 years will lead to many more people living with HIV becoming eligible for antiretroviral therapy. It is expected to contribute to an improvement in the

quality of life of people living with HIV and reduce AIDS related mortality as well as contribute to further reductions in new HIV infections (2). This chapter reviews the progress made by countries in the provision of ART for people living with HIV, management of TB and HIV coinfection, and surveillance and monitoring HIV drug resistance (HIVDR) in the WHO African Region in the recent past. 6.2 Coverage of antiretroviral therapy among people living with HIV

As at the end of December 2012, a total of 7,524,000 people were receiving antiretroviral therapy in the WHO African Region (Figure 6.1) based on the 2010 WHO guidelines. This represented a 90% increase from 3,912,000 in 2009. About 6,991,492 (68%) were adults aged 15 years and above (1).

Figure 6.1:Trends in numbers of people (adults and children) living with HIV receiving antiretroviral medicines in the WHO African Region, 2005-2012 Number of people with HIV receiving antiretroviral therapy Millions 8 7 6 5 4 2.950 3 1.987 2 1 0 2005 2006 2007 2008 2009 2010 2011 2012 0.619 1.321 3.912 Eastern and Southern Africa West Africa Central Africa African Region

7.524

6.180

5.059

HIV in the WHO African Region Progress towards achieving

There were wide variations in antiretroviral coverage rates between countries (Table 6.1). Coverage of antiretroviral therapy among eligible people living with HIV in the 42 countries in the WHO African Region that reported varied from 1% in Madagascar to over 95% in Botswana and Cape Verde in 2012. The expansion of access to ART has been particularly impressive in eastern and southern Africa, subregions that account for about 50% of all people living with HIV and where almost 6.4 million people were receiving ART in 2012. Ten countries of which 6 were in southern Africa (Botswana, Namibia, South Africa, Swaziland, Zambia and

Zimbabwe) and three in eastern Africa (Eritrea, Kenya and Rwanda) and one (Cape Verde) in western Africa had ART coverage of more than 80% according to the 2010 WHO treatment guidelines in 2012. Access to ART also increased in western and central Africa. However in several countries the pace has been slow. For example Nigeria, which has the second highest number of people living with HIV in the WHO African Region, had an ART coverage of 36% in 2012. The Democratic Republic of Congo, also with high numbers of people living with HIV, had a relatively low ART coverage of 38% in 2012.

Table 6.1: Estimated number of adults receiving and in need of antiretroviral therapy and percentage coverage of ART,WHO African Region, 2012 Reported No. of eligible adults receiving antiretroviral therapy in 2012 23 201,822 87,352 357 368,690 1,517 282,687 105,347 2,010,340 80,103 446,841 518,801 7,608 270,460 548,588 n/a 107,021 403,089 399,886

Subregion Southern Africa

Country Comoros Botswana Lesotho Madagascar Malawi Mauritius Mozambique Namibia South Africa Swaziland Zambia Zimbabwe Eritrea Ethiopia Kenya Seychelles Rwanda Uganda Tanzania

Estimated No. of eligible adults needing Antiretroviral therapy in 2012 <500 200,000 150,000 25,000 480,000 4,200 590,000 120,000 2,500,000 93,000 520,000 610,000 9,400 400,000 680,000 n/a 110,000 580,000 540,000

Estimated ART coverage (%) based on 2010 WHO Guidelines 7 >95 59 1 76 36 48 91 81 87 86 85 81 68 81 n/a 94 70 68

Eastern

Africa

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Subregion Central Africa

Country Angola Burundi Cameroon Central Africa Republic Chad Congo DRC Equatorial Guinea Gabon Sao Tome and Principe Algeria Benin Burkina Faso Cape Verde Cote d’Ivoire Gambia Ghana Guinea Guinea Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo

Reported No. of eligible adults receiving antiretroviral therapy in 2012 39,704 27,098 117,791 …. 35,014 16,086 59,468 6,512 14,512 285 …. 23,400 39,049 798 104,750 3,300 66,366 25,552 5,766 5,048 26,839 1,830 11,137 459,465 13,485 7,802 28,213

Estimated No. of eligible adults needing Antiretroviral therapy in 2012 85,000 40,000 240,000 … 82,000 36,000 170,000 .... 22,000 <1,000 ….. 34,000 85,000 <1000 190,000 5,600 110,000 45,000 14,000 11,000 46,000 4,500 20,000 1,300,000 20,000 22,000 57,000

Estimated ART coverage (%) based on 2010 WHO Guidelines 48 67 49 … 43 44 38 … 67 51 …. 70 48 >95 44 64 62 57 43 47 58 41 56 36 67 35 50

Western Africa

Source: UNAIDS Global AIDS epidemic Report, 2013

There is a wide gap in ART treatment coverage between women and men with women more likely to be receiving antiretroviral medicines. In 2011, men comprised only 36% of the people receiving ART but constituted 44% of the people eligible for ART (1). Expansion and scale up of PMTCT services which increase access of women to HIV testing and ART treatment and prophylaxis may partially explain the greater access of women to antiretroviral therapy than men. Men generally also tend to have poorer healthseeking behaviour and in settings where men are more likely than women to have paid work, the opportunity costs of visiting treatment facilities may discourage some men from starting or continuing on ART.

6.3 Availability of anti-retroviral therapy facilities

The dramatic increase in the number of facilities providing antiretroviral therapy services is associated with the improved antiretroviral treatment coverage among people living with HIV in WHO African Region. The number of health facilities providing antiretroviral therapy increased from 8,462 in 2009 to 14,123 in 2012 in 41 countries that provided data, an increase of about 67% in three years (Annex 2). The majority of the ART treatment facilities were in public facilities (83%), 6% were in private sector facilities, the location for the rest was not specified. There has been decentralisation of ART treatment facilities 92

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beyond hospitals in the region and to some extent integration of HIV services into other health related programmes. In 2012 2.489 of the ART treatment facilities were in health centres, 1,659 in antenatal clinics, 2,080 in TB clinic settings and 2,076 in STI clinics. 6.4 Retention of people living with HIV on antiretroviral therapy

Step5: Ensuring long term adherence and ultimately achieving and maintaining viral load suppression (3). A systematic review of pre ART retention in care in 28 studies conducted in Africa found that there was attrition at every stage in the HIV treatment cascade. There was 59% retention from the time of HIV testing to receipt of CD4 count results or clinical, diagnosis 46% retention from staging to eligibility and 68% retention from ART eligibility to ART initiation. The review concluded that less than one-third of the people testing HIV positive and not yet eligible for ART when diagnosed were retained continuously in care (4). A systematic review of patient retention on antiretroviral therapy programmes in sub Saharan Africa, showed that at 6 months after initiation of ART the retention rate was 86.1%, and then it dropped to 80.2% at 12 months, 76.8% at 24 months and 72.3% at 36 months. Loss to follow up was cited as the major cause of attrition followed by death (5). Another study on retention among patients in the Tanzanian National Care and Treatment Programme showed that loss to follow up and not mortality was the major cause of attrition (6).

The stage at which someone begins antiretroviral therapy has a great impact on her/his chances of responding to treatment. Adherence to the prescribed regimen is important not only for the health outcome of the individual but also reduces the occurrence of drug resistance. Studies conducted in the WHO African Region have shown high attrition rates and loss to follow up of people living with HIV at the various steps in the HIV treatment cascade (Box 6.1). The treatment cascade involves the following steps: Step 1: Diagnosing HIV infection; Step 2: Linking people who take an HIV test to treatment and prevention services; Step 3: Enrolling and retaining people in pre-Antiretroviral therapy (preART) care,; Step 4: Initiating ART; and

Box 6.1: HIV Treatment Cascade

Source: WH0/UNICEF and UNAIDS: Global update on HIV treatment 2013:Results, Impact and opportunities (3)

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There are marked variations in retention rates among people living with HIV receiving antiretroviral medicines 12 months after initiation of antiretroviral therapy in countries in the WHO African Region (Table 6.2). The

proportion of adults and children receiving antiretroviral medicines after 12 months of antiretroviral therapy initiation varied from 28.7% in Equatorial Guinea to 95% in Botswana and then 100% in Comoros.

Table 6.2: : Proportion (%) of adults and children receiving antiretroviral medicine after 12 months of initiation of antiretroviral therapy in selected countries, WHO African Region, most recent year Subregion Southern Africa

Country Comoros Botswana Lesotho Madagascar Malawi Mauritius Mozambique Namibia South Africa Swaziland Zambia Zimbabwe Eritrea Ethiopia Kenya Seychelles Rwanda Uganda United Republic of Tanzania Angola Burundi Cameroon Central Africa Republic Chad Congo Democratic Republic of Equatorial Guinea Gabon Sao Tome and Principe Algeria Benin Burkina Faso Cape Verde Cote d’Ivoire Gambia Ghana Guinea Guinea Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo

Year 2012 2012 2010 2011 2011 2011 2010-2011 2011 ... 2011 2011 2011 ... 2009 ... 2012 ... 2011 2012 2009 ... 2012 2011 2011 ... 2011 2012 2009 ... 2010 2011 2012 2010-2012 2009 2011 2011 2008 2010 2010 2006 ... 2011 2011 2010 2011 2011

% adults and children on ARV after 12 months of ART initiation 100 95 74 94.7 80 87.4 74 81.5% adults, 83.9% children … 87.2% (adults=87.1%, children (87.7%) 59.9 85.7 ... 72.5 ... 100 ... 84.1 70.7 61.3 ... 61.5 58.7 34.6 … 74.9 (MSF/Kabinda) 28.7 86.3 ... 75.4 <15 years 86.9, >15 years 94.0 76.8 96.6 67 81.9 71 77.1 62 62 63.3 ... 71.7 73.4 74 83 87.1

Eastern Africa

Central Africa

Western Africa

Source: GARPR country reports 2012 94

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6.5 TB/HIV collaborative activities

by 65% the risk of people living with HIV developing tuberculosis and ART lowers The dual HIV and tuberculosis (TB) the risk of death among people living epidemics remain a challenge to people with HIV and who have TB by 50% (1). living with HIV and to the health sector. People living with HIV and latent TB Progress in the implementation of (infected but not active) are more collaborative TB/HIV activities likely to develop active TB than people who are not HIV infected. In 2012, Countries in the WHO African Region are 1,1 million (13%) of 8.6 million who making good progress towards achieving developed TB were HIV positive. The the targets on collaborative TB/HIV WHO African Region accounted for activities in the ‘Global Plan to Stop TB 75% of the HIV positive incident TB 2011-2015’ (9). The targets related to patients. The proportion of people who collaborative TB and HIV services in the developed TB and were also positive for Global Plan are; 100% of TB patients HIV dramatically decreased from 43% in tested for HIV; 100% of TB patients infected with HIV to be provided with 2011 to 13% in 2012 (7, 8). cotrimoxazole preventive therapy (CPT); WHO’s recommendations on interventions 100% of HIV positive TB patients to needed to prevent, diagnose and treat be treated with ART; 100% of people TB in people living with HIV are known living with HIV attending HIV care to be collectively as “Collaborative TB/HIV screened for TB; and 100% of people activities”.These activities include; testing living with HIV and without active TB of TB patients for HIV; provision of to be provided with isoniazid preventive antiretroviral therapy and cotrimoxazole therapy. preventive therapy (CPT) to TB patients living with HIV; offering isoniazid In 2012, 74% of notified TB patients in preventive therapy (IPT) to people living the WHO African Region were tested with HIV who do not have active TB; for HIV and received their results, an controlling the spread of TB infections increase from 69% in 2011. In 2012, through intensified case finding; and twenty-nine countries had more than 75% control of spread of TB in health and of TB patients tested for HIV, an increase congregate settings. The latter three from 22 countries in 2010. Six countries in the Region (Kenya, Malawi, Rwanda, are referred to as the ‘three Is” (7). Swaziland, Togo and Zambia) achieved The 2013 WHO guidelines on antiretroviral levels of >90% of testing TB patients for treatment and the WHO policy on HIV in 2012. Zambia tested 100% of the collaborative HIV/TB activities recommend notified TB patients for HIV with Rwanda immediate initiation of antiretroviral therapy having a testing rate of 99% (Table 6.3). for all people living with HIV and TB Countries with the lowest HIV testing regardless of the CD4 cell count (2,7). rates among notified TB patients were Antiretroviral therapy significantly reduces Angola (21%), Democratic Republic of

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Congo (31%) and Mali (28%). Ethiopia made a remarkable increase in HIV testing levels among TB patients, from 41% in 2011 to 65% in 2012. The number of people diagnosed with TB and living with HIV receiving antiretroviral therapy rose from 37% in 2009 to 57% in 2012 (2,7,8). Eighty percent of people living with HIV and TB in the region were started on cotrimoxazole preventive therapy (CPT) in 2012 and in 12 countries (Angola, Botswana, Burkina Faso, Burundi, Kenya, Lesotho, Mozambique, Namibia, Rwanda, Uganda, United Republic of Tanzania and Uganda), HIV positive TB patients who enrolled on CPT in 2012 exceeded 90%. The number of people living with HIV enrolled in HIV programmes that were

screened for TB increased by 39% between 2010 and 2011. The trend in numbers of people living with HIV without active TB who were started on isoniazid preventive therapy is rising but it is still relatively low. In 2012, about 520,000 people living with HIV received isoniazid preventive therapy (IPT), with South Africa, accounting for 75% (370,000). South Africa is implementing and investing in innovative approaches to address the issue of HIV and TB. This has led to improved screening of TB among people living with HIV and has increased the numbers of people living with HIV who were started on isoniazid preventive therapy (Box 6.3). Sixteen of the high TB/HIV burden countries in the region reported on the numbers of HIV positive people screened for TB in 2012, an increase from 32% in 2010.

Box 6.2: South Africa: Leadership and innovation in HIV

WHO endorsed Xpert MTB/RIF a new rapid molecular test that can diagnose TB and rifampicin in 100 minutes in 2010. Since then, South Africa has developed and initiated a national plan for phased implementation of Xpert MTB/RIF assay as a replacement for microscopy as the initial diagnostic method. Using existing microscopy centres, South Africa introduced more than 290 GeneXpert machines in more than 140 centres. As of March 2012, about 1.2 million TB screening tests had been performed in 9 provinces. As compared with smear microscopy, GeneXpert doubled the number of laboratory confirmed TB cases

and detected 7% rifampicin resistance. Enhanced TB screening has enabled South Africa to scale up isoniazid preventive therapy among people living with HIV with 373,000 people living with HIV and without active TB being started on IPT. In August 2012, there was a drop of 41% in the GeneXpert MTB/RIF cartridge price from US$16.86 to US$ 9.98. This was expected to increase the scale up of TB screening in the countries. GeneXpert MTB/RIF is being rolled out in many countries in the Region. Source: WHO Global TB Report 2012&UNAIDS Global AIDS update 2013

The coverage of cotrimoxazole preventive therapy among people living with TB and HIV in the region has increased to over 80% in 2012 (Table 6.3). Thirteen out of the 17 TB/HIV high burden countries in the region that reported had cotrimoxazole

preventive therapy (CPT) coverage of more than 90% in 2012, Angola was the only country in 2012 that reported 100% coverage and Congo had the lowest coverage of 20%. 96

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Table 6.3:Testing TB patients for HIV, Provision of cotrimoxazole preventive therapy (CPT) to TB patients living with HIV, coverage of ART among TB patients living with HIV and prevention of TB among people living with HIV in High TB/HIV burden countries in the WHO African Region No. of TB patients with known HIV status 12 6.0 4.6 5.7 21 3.8 4.8 2.0 21 35 96 12 93 10 19 1.5 110 5.8 80 3.2 4.8 390 15 1.4 42 30 32 42 1040

Country

Estimated No. of HIV positive incident TB cases 5.5 5.1 1.6 2.5 19 5.3 4.1 3.6 8.0 16 23 2.8 45 9.9 16 1.2 83 7.3 46 2.9 3.9 330 13 1.2 35 32 35 55 830

% of notified TB patients tested for HIV 23 89 84 82 82 46 44 17 85 31 65 78 94 88 93 23 94 88 84 99 87 84 95 91 86 82 100 42 74

% of tested TB patients found HIV infected 9.6 63 15 19 37 39 20 33 27 16 10 24 39 75 59 28 58 47 23 26 12 65 77 24 50 39 54 70 43

% of HIV infected TB patients started on CPT 100 91 96 94 83 28 20 75 61 37 72 98 97 88 42 98 99 80 99 26 74 98 87 94 96 93 88 79

% of HIV infected TB patients started on ART 100 66 75 55 55 20 65 23 44 40 82 37 74 53 81 100 55 72 56 … 69 54 66 76 49 60 60 18 55

No. of people living with HIV screened for TB 12 … 7.4 0.2 12 … 1.0 … … … 272 … … 21 393 … … 12 140 122 8.9 950 69 … 357 … … … 2392

No. of people living with HIV started on isoniazide preventive therapy 1.1 … … … .. … … … … 30 … … 16 21 … 17 12 2.3 … 1.1 370 1.9 … … … … … 473

Angola Botswana Burkina Faso Burundi Cameroun CAR* Chad Congo Cote d’Ivoire DRC Ethiopia Ghana Kenya Lesotho Malawi Mali Mozambique Namibia Nigeria Rwanda Sierra Leone South Africa Swaziland Togo Uganda UR Tanzania** Zambia Zimbabwe African Region

… no data reported, The numbers are for new TB patients only CAR= Central Africa Republic, UR Tanzania= United Republic of Tanzania Source: WHO Global TB report 2013

6.6 Surveillance and monitoring of HIV Drug Resistance (HIVDR)

With increasing coverage of antiretroviral therapy, it is anticipated that some degree of HIV drug resistance may occur, even The emergence of HIV drug resistance can when appropriate antiretroviral therapy is be minimized using appropriate strategies. provided to people living with HIV and Universal Access to priority health sector interventions 2013 UPDATE

adherence adherence fixed dose emergence

levels are to treatment combinations of HIV drug

high. However, and the use of can minimize the resistance (10,11)

Drug resistance can be grouped into two categories; transmitted resistance which occurs when previously uninfected people are infected with an HIV drug resistant virus, and acquired resistance when resistance mutations emerge because of drug selective pressure in

individuals receiving antiretroviral therapy (10,11). The WHO Classification of Level of transmitted HIV drug resistance in recently HIV infected populations is shown in Box 6.3. Data on HIV drug resistance provides the basis for selecting future first line treatment regimens, identifying the most effective second line regimens for people failing on first line regimen, and selecting optimal approaches for PMTCT and for pre-and-post exposure prophylaxis (10, 11).

Box 6.3: WHO Classification of level of transmitted HIV drug resistance in recently HIV infected populations in specific geographical areas

Low = Below 5% Moderate = Between 5% and 15% High = Over 15% Source: World Health Organization Global Strategy for the Surveillance and Monitoring of HIV Drug Resistance, 2012

In 2012, WHO launched an updated should be implemented in all countries version of the Global HIVDR Surveillance scaling up and maintaining people on and Monitoring Strategy (11) comprising of ARVs (Figure 6.2). a comprehensive package of surveys that Figure 6.2: WHO 2012 HIV drug resistance surveillance and monitoring strategy Surveillance of transmitted drug Surveillance of HIVDR in populations reseistance (TDR) in recently infected initiating ART populations Monitoring of HIVDR early warning indications Surveillance of HIVDR in in children <18 months of age Surveillance of aquired HIVDR in populations on ART for >12 months and >24 months

Source: Source: World Health Organization Global Strategy for the Surveillance and Monitoring of HIV Drug Resistance 2012

The routine monitoring of programmatic strategy includes a set of 5 early warning factors in the WHO Global HIV drug indicators that are to be monitored at resistance surveillance and monitoring all antiretroviral treatment settings/clinics

HIV in the WHO African Region Progress towards achieving

(Figure 6.3). The data on early monitoring indicators assist clinics and countries to take timely corrective measures if need arises (11).

All clinics providing antiretroviral therapy are should monitor early warning indicators annually as a component of routine programme monitoring and evaluation. (11).

Figure 6.3: WHO updated HIV drug resistance early warning indicators and targets, 2012 Early Warning Indicators 1. On-time pill pick -up

Target Red: < 80% Amber: 80-90 % Green: >90% Red: < 75% retained after 12 months of ART Amber: 75-85% retained after 12 months of ART Green: >85% retained after 12 months of ART Red: < 100% of a 12 month period with no stock-outs Green:100% of a 12month period with no stock-outs Red: > 0% dispensing of mono- or dual therapy Green:0% dispensing of mono- or dual therapy Red: < 70% viral load suppression after 12 months of ART Amber:70-85% viral load suppression after 12 months of ART Green: >85% viral load suppression after 12 months of ART

2. Retention in care

3. Pharmacy stocks-outs 4. Dispensing practices 5. Viral load suppression at 12 months*

* Childrened: < 2 years: red:< 60%; amber: 60-70%; green:> 70% viral load suppression after 12 months of ART

Source: WHO Global strategy for the surveillance and monitoring of HIVDR, 2012

Monitoring of early warning indicators

Monitoring HIV drug resistance

A literature review on monitoring of early warning indicators (EWI) in a cohort of 907 clinics providing antiretroviral therapy from 2004 to 2009 in the WHO African Region showed that 74% of the clinics met the recommended target of 100% on ”prescribing practices”. In the same period, 63% of the 537 ART clinics in the region that were monitored on “antiretroviral drug supply continuity” met the recommended target of 100%. Ninety-six percent of the 24 clinics that were monitored on “viral load suppression at 12 months” met the recommended target of ≥70%. On the whole, performance related to “loss to follow up”, “on time antiretroviral pick up” and “on time appointment keeping” was much below the recommended targets.

Forty three WHO surveys on transmitted HIV drug resistance were conducted in 18 countries in the WHO African Region between 2004 and 2010. The surveys were conducted in ANC sites among pregnant women mostly including only women in their first pregnancy to minimize the likelihood of including women with previous exposure to regimens for PMTCT, and women younger than 25 years of age to minimize the likelihood of including individuals with chronic infection and with previous exposure to ARVs. Men and women younger than 25 years were also enrolled in the surveys from VCT centres. One survey was conducted among sex workers in one country (11).

Universal Access to priority health sector interventions 2013 UPDATE

The findings from the surveys showed a small increase in transmitted HIV drug resistance in the region particularly to nonnucleoside reverse transcriptase inhibitors among recently infected populations in the areas surveyed (11). Resistance to all the ARV drugs increased from 0.2% in 2005 to 2.8% in 2010, while for nonnucleoside reverse transcriptase inhibitors (NNRTI), the increase was from 0.0% in 2005 to 2.0% in 2010. For nucleoside reverse transcriptase inhibitors (NRTI) the increase was from 0.0% in 2005 to 0.6% in 2010. On the other hand, there was a decline in resistance for protease inhibitors (PI) from 2.8% to 0.0% in the same period (11). In addition to monitoring transmitted HIV drug resistance, WHO recommends monitoring of acquired HIV drug resistance. Prospective surveys on acquired HIV drug resistance are conducted at clinics offering antiretroviral therapy. The surveys enrol both ARV drug naïve (no previous exposure) and antiretroviral drug exposed people living with HIV. A systematic review of nine studies including seven in Africa conducted between 2004 and 2010 revealed pooled estimates of HIV drug resistance prevalence among 574 people experiencing first line NNRTI failure at

median duration 12 months of 62% to all drugs, 57% to NRTI and 47% to NNRTI in Africa (11). In spite of the findings on transmitted HIV drug resistance, the surveys showed that if people were switched to second line regimens soon after virological failure, standard second line treatment combinations were likely to be effective for the majority of patients failing first line antiretroviral therapy (11) 6.7 Impact of antiretroviral therapy

The increased antiretroviral coverage in the WHO African Region has resulted in a marked decline in AIDS related deaths in both adults and children (Figure 6.4). It is estimated that antiretroviral therapy prevented 6.6 million deaths worldwide including 5.4 million in low and middle income countries (1). The link, for example, between Botswana’s early ART programme, the high uptake of ART and the significant reduction (72.8%) in AIDS deaths in the last decade cannot be underestimated. A study in a community in KwaZulu Natal Province in South Africa showed that improved access to ART led to increased life expectancy by 15-20% among people living with HIV who were started on antiretroviral therapy (12).

Figure 6.4: Decline in numbers of estimated AIDS related deaths in selected countries,WHO African Region, 2001- 2012 AIDS related deaths in 2001 140,000 120,000 100,000

AIDS related deaths 2012

AIDS related deaths

80,000 60,000 40,000 20,000 Botswana Southern Africa Kenya Eritrea Ethiopia Eastern Africa Malawi Congo Central Africa Burkina Faso Mali Ghana Western Africa Côte d'Ivoire Benin

Source: UNAIDS. Global Report on AIDS epidemic 2013 100

HIV in the WHO African Region Progress towards achieving

The expansion and scale up of ART in the WHO African Region has resulted in significant declines in the incidence of HIV. New HIV infections in the region have declined among adults and children by 38.5% between 2001 and 2012 (1). A recent study in South Africa found that the incidence of HIV infection fell by 17% for every 10% increase in the number of people receiving antiretroviral therapy (1). Antiretroviral therapy is associated with decreasing incidence of TB in communities where the coverage rates are high. A recent systematic review showed that ART causes substantial declines in incidence of TB (4). ART is also associated with significant declines in the incidence of common opportunistic infections by 68% to 95%, and with the substantial decline of oral candidiasis, herpes zoster (shingles) and pulmonary tuberculosis, all observed within the first year of ART initiation. Other opportunistic infections that were found to have decreased included Kaposi’s sarcoma, cerebral toxoplasmosis, and extra pulmonary tuberculosis. Lesser reductions were observed for cryptococcal meningitis and pneumocystis jirovecci pneumonia (13). The scaling up of antiretroviral therapy has also led to a reduction in TB related deaths among people living with HIV. Thirteen countries (Botswana, Burkina Faso, Burundi, Central African Republic, Cote d’Ivoire, Ethiopia, Ghana, Malawi, Namibia, Nigeria, Rwanda, Uganda and Zimbabwe) with high TB/HIV burden countries had a decline in TB related deaths among people living with HIV of more than 50%. An additional six countries (Cameroun, Chad, Kenya, Mali, United

Republic of Tanzania and Zambia) had a decline of 25% to 50% in TB related deaths in the region between 2004-2012. Countries where there was a decline of <25% in TB related deaths among people living with HIV include Angola, Congo, DRC, Lesotho, Mozambique, Sierra Leone, South Africa, Swaziland and Togo in the same period (1). 6.8 Challenges and the way forward

The WHO African Region has made remarkable progress in improving access to antiretroviral therapy to eligible people living with HIV. If the momentum is sustained, the region is on track to realising its contribution to the global target of reaching 15 million with lifesaving antiretroviral therapy by 2015. In spite of the progress made, about 30% of eligible adults living with HIV in the region are still in need of antiretroviral therapy. With the new 2013 WHO guidelines on antiretroviral treatment more eligible people living with HIV will need antiretroviral therapy. The wide gap in antiretroviral therapy coverage between men and women, and also between adults and children needs to be narrowed. It is not clear to what extent key populations such as sex workers and men who have sex with men are accessing ART treatment services. Barriers that hinder men, adolescents and key populations from accessing antiretroviral therapy need to be identified and addressed in the national HIV response.

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Maintaining the quality of HIV treatment and care services as countries continue to decentralize and accelerate the scale up of treatment and care interventions is a priority to ensure the greater benefits of antiretroviral therapy and to minimize the emergence of HIV drug resistance. Procurement and supply management systems are improving but they are still weak resulting in frequent stock-outs of antiretroviral medicines, diagnostics and other consumables.

Progress is being made in the implementation of TB/collaborative activities in the region. However, most countries are far from attaining the 100% targets with regards to testing of TB patients for HIV, and screening of people living with HIV for TB. Coverage rates of isoniazid preventive therapy among eligible people living with HIV are particularly low. The integration of HIV interventions and services including antiretroviral therapy into other related health programmes such as TB, maternal, child and infant health care, adolescent Countries need to speed up the scaling and reproductive health, STI control needs up of HIV treatment services while also to be strengthened. emphasizing the preventive benefit of ART. Countries need to be more innovative in The use of new technologies such as designing and implementing services that XpertMTB/RIF and CD4 point of care are focused and tailor made to meet the needs to be rolled out while taking into needs of eligible people living with HIV. account the country context. The move Furthermore countries need to expand and towards viral load testing as the preferred replicate the best practices/experiences in approach to monitoring the success of their countries that have produced success ART and diagnosing treatment failure, and if necessary adopt best practices from in addition to carrying out clinical and other countries while taking into account immunological (CD4) monitoring of people the country specific context. receiving ART, requires the building the necessary capacity in countries. There Approaches that will actively engage is need to lobby for reduced prices for communities, especially men, and improve some of these new technologies and for their access to HIV preventive, treatment further reduction of prices of antiretroviral and care services such as encouraging medicines and other related commodities couples HIV testing need to be adopted. as countries intensify efforts to scale-up There is need to increase the level of HIV treatment and TB/HIV collaborative awareness about the benefits of “knowing activities. one’s HIV status” especially among men and adolescents as this is key to accessing Greater investment in health systems early HIV treatment. strengthening to address the implications of implementing the 2013 WHO guidelines Retention of people is a challenge at each on antiretroviral treatment will be step in the HIV treatment cascade. Attrition required. Countries will need to scalerates are relatively high, and loss to follow up implementation of HIV treatment, care up is an issue. Identifying, monitoring and and support services while ensuring high addressing individual and programmatic quality of the services being provided in challenges at each stage of the treatment order to move towards the set regional cascade may help improve retention rates. targets. 102

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References 1. UNAIDS. UNAIDS Global Report on the global AIDS epidemic 2013. 2013. UNAIDS,Geneva. 2. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a Public Health Approach June 2013. 2013. WHO, Geneva 3. WHO/UNICEF/UNAIDS. Global Update on HIV treatment 2013: Results, Impact and Opportunities. June 2013. WHO, Geneva. http://www.who.int/iris/ bitstream/10665/85326/1/9789241505734_eng.pdf 4. Rosen, S., and Fox MP. Systematic review of preART retention in care in Africa.2011. PLosMed Juylesl;8(7):e1001056 doi:10.1371/journal. pmed.1001056.Epub 2011 Jul 19. Accessed 4 Oct 2013 5. Fox, MP and Rosen, S. Patient retention in antiretroviral therapy programmes upto three years on treatment in Sub-Saharan Africa, 2007-2009: Systematic review. 2010. Trop Med Int Health, 15 Suppl 1:1-15. doi:10.1111/j.1365.2010.02508.X., accessed 4 Oct 2013 6. Somi,G., Keogh,SC., Todd, J., et al. Low mortality risk but high loss to follow among patients in the Tanzania national HIV care and treatment programme. 2012. Trop Med Int Health April 17(4):497-506 doi:10.1111/ j.1365-3156.2011.02952.x.Epud 2012 Feb1, accessed 4 Oct 2013 7. WHO. Global Tuberculosis Report 2012. 2012 WHO Geneva. ISBN 978 924 156450 2 8. WHO.Global Tuberculosis Report 2013.2013. WHO,Geneva. 9. WHO. Global Plan to Stop TB 2011-2015. http:// www.sroptb.org/assests/documents/global/plan/ TB_GlobalPlanTostopTB2011-2015.pdf, accessed 7 Oct 2013 10. WHO. WHO Global Strategy for the surveillance and monitoring of HIV drug resistance 2012. 2012. WHO, Geneva. 11. WHO.WHO HIV Drug Resistance Report 2012. 2012 WHO Geneva. 12. Johnson LF., Mossong J., Dorrington RE., et al. Life expectancies of South African adults starting antriretroviral treatment. Collaborative analysis of cohort studies. 2013 PLos Med 10 (4):e1001418. Doi:1371/journal.pmed.10014118.epud 2013 April 19 13. Andrea Low, Georges Gavriidis, Natasha Larke., et al. Impact of antiretrovirals on the incidence of opportunistic infections in resource limited settings: a systematic review and meta analysis. Poster at the 7th IAS conference in Kuala Lumpur, Malaysia. www.who.int/entity/hiv/events/2013/IAS_poster_ ARVopport.pdf accessed 8 Oct 2013 14. WHO/AFRO. WHO Regional Committee for Africa Resolution AFR/RC59/R7 Call for intensified action for HIV prevention and TB/HIV co-infection control in the African Region. http://www.afro.who.int/en/ fifty-ninth session.html , accessed 4 Oct 2013 15. Ayles H., et al. Effect of household and community interventions on the burden of TB in southern Africa.: the ZAMSTAR community randomized trial. Lancet, 1 August 2013 doi.10.1016/S0140-6736 (13)61131-9 16. South Africa. National Strategic Plan on HIV, STIs and TB 2012-2016., accessed 4 Oct 2013 http://www.info.gov.za/view/ downloadfileAction?id=155622 17. WHO. Global Health Sector Strategy on HIV/AIDS 2011-2015.2011. WHO, Geneva.

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HIV in the WHO African Region Progress towards achieving

7. Looking forward Substantial progress has been made in scaling up HIV prevention, treatment, care and support interventions and services in the WHO African Region in the last decade. This has resulted in declines in new HIV infections and AIDS related deaths. Significant reductions in HIV prevalence have occurred especially among young people aged 15-24 years; a proxy for reduction in HIV incidence (1). The linkage between changes in sexual behaviour, especially among young people, and the declining incidence and prevalence in HIV infection, the dramatic reduction of new HIV infections among children as a result of PMTCT programmes, and the reduction in AIDS related deaths all make a compelling case for further intensifying the fight against the HIV/AIDS epidemic in the region. the use of non-invasive surgical devices for male circumcision, more engagement and mobilization of communities, increased financial and human investments in VMMC programming in particular and in health systems strengthening in general will be required to increase the pace of delivery of VMMC services.

With the use of multiple and innovative models and approaches, uptake of HIV testing and counselling services has improved in the region. This has contributed significantly to enabling people living with HIV to access antiretroviral therapy. Further decentralization of HIV testing and counselling services and the use of innovative models and focused and targeted approaches will enable more people to know their status and access HIV prevention, treatment and care services. Community mobilization to Voluntary medical male circumcision increase the level of awareness of the which reduces the risk of HIV infection benefits of “knowing one’s HIV serostatus” in men, in their female partners and also needs to be intensified. reduces HIV incidence in populations is being rolled out in 14 priority countries in More than 7.5 million adults and children the region (2). An impressive 1,710,531 were receiving antiretroviral therapy in the voluntary medical male circumcisions were WHO African Region as of December performed in 2012 alone in the priority 2012, an increase of more than 90% countries, more than double the number between 2009 and 2012 (1). The performed in 2011. Kenya and Ethiopia expansion of antiretroviral therapy has have so far reached coverage of about been more impressive in southern and 60% of the 80% target required for a eastern African countries. Nine countries public health impact on HIV incidence - Botswana, Eritrea, Kenya, Namibia, (3). However, coverage in several Rwanda, Swaziland, South Africa, Zambia countries remains low. Task shifting, and Zimbabwe - had attained universal

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access to antiretroviral treatment ( 80% coverage) based on the 2010 WHO ARV guidelines. These remarkable gains should inspire other countries that are lagging behind to scale up their antiretroviral therapy programmes in order to achieve the 2015 targets. Good progress has been made in the expansion of PMTCT services in the region. There was a marked decline of 35% in new HIV infections among children between 2009 and 2012, demonstrating that elimination of HIV new infections among children by 2015 is feasible (1). Sixty three per cent of pregnant women living with HIV received antiretrovirals for the prevention of mother to child transmission in 2012, an increase from 9% in 2005 (4,5). Countries that had attained Universal Access according to the 2010 WHO guidelines need to keep the momentum going and those lagging behind need to redouble their efforts and rapidly increase access to PMTCT services.

reporting on syphilis screening results among ANC attendees, remains weak in many countries. Building stronger HIV surveillance and other health information systems, including vital registration, is essential to monitoring and guiding the national HIV response. In going forward, the adoption of Resolution AFR/RC63/R7 “The 2013 WHO Consolidated Guidelines on the Use of Antiretroviral Drugs for treating and preventing HIV Infections; Recommendations for a Public Health Approach- Implications for the African Region” by African Ministers of Health in September 2013 provides the policy framework for countries in the WHO African Region (8). The Resolution calls on countries to: (a) to adapt their national antiretroviral therapy guidelines and related service delivery tools to the new WHO consolidated guidelines on the use of ARVs according to the specific context of each country;

HIV surveillance systems have generally (b) to increase investment in the HIV improved over time with many countries response by mobilizing adequate conducting national population based domestic resources including intensifysurveys to complement HIV sentinel ing efforts to achieve the Abuja surveillance among pregnant women Declaration target of allocating 15% attending antenatal care (ANC). More of national budgets to the health countries have expanded their ANC sentinel sector, and actively advocating for and HIV surveillance to improve rural and seeking additional international funding urban representation (6). However, the from sources such as multilateral and conduct of HIV sentinel surveillance among bilateral agencies; ANC attendees in the last few years has become inconsistent in several countries. (c) to address the human resource HIV surveillance in key populations is implications of implementing the new improving (7) and it is expected that ART guidelines including organizing countries will improve on this. On the refresher training courses, mentoring other hand, STI surveillance, including and supervising health care providers,

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adopting task-sharing policies, and strengthening HIV/AIDS care and treatment in existing pre-service courses in line with country policies; (d) to improve procurement and supply of drugs and other commodities including updating their national essential medicines lists to include the newly recommended ARV regimens, diagnostics and commodities; (e) to scale up early infant diagnosis (EID) services and interventions in order to increase access and coverage of ART for children; (f) to integrate and link HIV services with sexual and reproductive health, child health, nutrition and TB services and other related services at different levels of the health system and to decentralize HIV services in order to increase opportunities for initiating ART; (g) to promote awareness and uptake of HIV testing in the general population, key population groups and among all care seekers and ensure that all HIVpositive individuals are identified and enrolled in early treatment and care; (h) to improve access to diagnostics and viral load testing through the use of point-of-care technologies; In taking actions on the above, countries have the responsibility of ensuring that health systems have the capacity to deliver services. Governments should ensure stewardship and leadership, and forge partnerships with civil society and PLWHIV for developing plans. They

also have to mobilize and allocate the necessary human, material and financial resources for implementation, including both internal and external resources for accelerating HIV/AIDS interventions. Governments should ensure effective coordination of interventions. The health sector should provide technical guidance for the implementation of this updated HIV strategy, within the framework of intersectoral collaboration in the multisectoral response. Countries should develop appropriate policies and tools, update their strategic plans for Universal Access, implement planned activities, monitor programmes, and coordinate all partners. In its technical cooperation with countries, the World Health Organization will continue to provide technical leadership and normative guidance for developing plans of action, implementing programmes, monitoring and evaluation. WHO and other partners, including UNAIDS and other UN agencies, PEPFAR, the Global Fund, Bill and Melinda Gates Foundation, and bilateral and multilateral donors should provide harmonized support to countries in resource mobilization, planning, and strengthen national government capacity to implement and coordinate the national efforts. With intensified efforts, speed and innovation, countries in the WHO African Region can attain the 2015 HIV targets and move towards an “AIDS- Free Generation”.

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References 1. UNAIDS. Global Report on the global AIDS epidemic 2013. 2013 UNAIDS, Geneva. 2. WHO/UNAIDS and UNICEF. Global HIV/AIDS Response epidemic update and health sector progress towards Universal Access progress report 2011. WHO, Geneva. 2011. 3. WHO/AFRO. Progress in scaling up voluntary medical male circumcision for HIV prevention in East and Southern Africa January –December 2012. July 2013 (Draft). WHO/AFRO, Brazzaville 4. WHO/AFRO. HIV in the WHO African Region Progress towards achieving Universal Access to priority health sector interventions 2011 Update. 2011. WHO/AFRO, Brazzaville. 5. UNAIDS HIV/AIDS database 2013 6. Garcia-Calleja JM, E Zanlewski, P D Ghys., et al. A global analysis of trends in the quality of HIV serosurveillance. Sex transm 2004; 80 (Suppl.1) :125-134 7. Jacobson J. HIV surveillance of key populations in Sub-Saharan Africa. 29 September 2013. Draft version 1.0 (in press) 8. WHO/AFRO Regional Committee for Africa. Resolution AFR/RC63/R7. The WHO Consolidated Guidelines on the Use of Antiretroviral Drugs treating and Preventing HIV infection; Recommendations for a Public Health Approach; implications for the African Region (Doc AFR/ RC63/12).WHO/AFRO Congo, Brazzaville. 6 September 2013

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Annexes Annex 1: ART facilities in the WHO African Region Subregion Reporting year Botswana Comoros Lesotho Madagascar Mauritius Mozambique Namibia South Africa Swaziland Zambia Zimbabwe Eritrea Ethiopia Kenya Malawi Rwanda Seychelles South Sudan Uganda United Republic of Tanzania Angola Burundi Cameroon Central African Republic Chad Congo Democratic Republic of the Congo Equatorial Guinea Gabon Sao Tome and Principe Algeria Benin Burkina Faso Cape Verde Côte d'Ivoire Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo

Total 280 4 197 47 6 316 181 3,683 125 564 982 20 866 1,829 651 430 2 22 1,380 284 132 155 67 6 23 10 9 82 99 35 529 162 46 35 44 4 28 516 131 141

Public 280 4 169 45 6 316 181 3,574 101 524 976 18 821 1,678 581 2 22 766 278 78 109 60 4 18 10 9 81 81 35 6 146 34 32 32 4 24 457 117 70

Private 0 28 2 0 109 24 40 6 2 32 149 70 0 33 6 54 43 7 2 5 0 0 1 8 0 4 16 10 3 12 0 4 59 5 67

Hospital 34 3 47 4 52 8 113 164 20 181 42 1 163 49 59 9 1 9 5 4 32 8 31 4 22 28 41

Health centre 0 1 264 5 451 0 685 367 1 384 50 8 2 14 8 0 25 6 10 24 7 0 77 100

ANC 0 0 0 564 982 0 0 99 0 1 0 5 0 6 0

STI 0

TB service 1 0 564 982 0

Southern Africa

0 564 982 0

Eastern Africa

430 0 99 0 0 0 0 0 0 1

430 0

Central Africa

0 0 0

Western Africa

2 1

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109

Annex 2: Selected indicators in TB-HIV collaborative activities, WHO African Region, 2001-2012

No. of TB patients tested for HIV 2008 312,218 370,245 394,332 465,647 443,558 228,987 284,977 319,175 382,560 346,680 93,729 134,881 172,265 220,639 2009 2010 2011 2012 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 243,012

No. of TB patients found positive

Countries

HIV-positive TB patients started or continued on cotrimoxazole preventive therapy (CPT)

HIV-positive TB patients started or continued on antiretroviral therapy (ART)

2008

2009

2010

2011

2012

WHO AFRICAN REGION

664,034

816,338

888,765

1,013,342

1,040,262

Algeria 306 653 4,149 948 243 5,073 7,211 57 1,230 663 36 3,932 41 164 7,891 613 294 1,630 197 1,288 268 42,294 8,084 72 7 13,558 585 27 7 25,056 5,676 403 18,087 2,529 10 455 3 987 114,523 8,889 342 17,131 21,541 23,584 22,745 976 128,457 7,788 632 19,836 21,662 26,571 31,849 1 776 13 15 877 4 902 211,128 6,480 667 20,725 20,632 26,737 27,562 2,199 1,855 17,736 19,553 405 334 5,227 4,990 4,688 431 19,342 1,601 18 882 3 1,343 190,093 5,666 625 20,376 20,269 24,309 23,957 64,348 7,624 55 12,765 16,400 9,645 12,402 24,574 26,538 27,979 8 8 10 90 12 52 5 17,733 5,289 143 3,991 2,219 6 424 7 22,183 4,434 95 8,761 2,329 10 386 3 73 80,954 8,386 254 14,731 19,076 15,041 20,993 8 23,738 4,869 149 10,415 2,137 12 657 1 62 94,835 7,243 455 17,855 19,855 19,845 27,902 8 24,095 4,909 22 13,301 1,794 15 749 3 229 161,561 6,138 515 19,270 19,604 23,144 25,965 10 27,319 4,656 135 15,565 1,586 18 793 2 344 140,868 5,559 541 19,163 19,501 22,614 6,301 22,107 1,929 49 3,569 5,918 8,604 4,630 416 404 425 41 12,476 10,341 11,296 13,143 39 40 19 12,723 585 11,771 314 9,209 290 9,928 179 5,230 17 52 5 5,816 2,019 6,889 1,534 3 206 5 5,622 1,995 7,026 1,587 3 123 3 127 48,314 2,315 122 3,766 6,684 10,009 8,668 283 454 772 32 30 8,459 8,519 7,878 5,592 7,636 40,069 38,175 35,837 37,757 38,989 396 431 517 208 39,952 8,131 24 1,483 1,670 1,859 191 520 1,288 250 41,174 6,830 64 9 13,687 452 52 125 19,330 5,718 320 15,301 2,560 6 601 920 89,950 8,081 162 16,432 19,940 20,839 16,619 10 2,218 2,676 2,907 2,812 1,414 1,601 2,065 326 224 302 209 2,085 1,206 37,147 8,131 120 667 667 578 852 303 348 348 294 2,029 1,544 35,025 7,637 693 12,426 1,857 25 14,250 2,235 35 5 6,154 61 19,331 2,273 14 5,718 217 55 6 6,250 2,294 5,902 1,587 7 289 1 190 69,959 2,726 312 4,782 7,572 12,646 14,223 6,165 278 12 5 7,661 2,700 16 8,410 1,395 15 421 4 253 97,355 3,283 449 6,720 7,741 14,213 16,577 18 561 3 931 101,937 3,762 476 9,962 10,993 14,471 4,419 9 15,391 3,362 69 10,866 11,098 9,809 5,442 9,819 5,262 7,516 6,723 3,348 3,619 3,494 303 52 384 47 4,515 348 35 531 84 3,823 348 103 487 614 812 812 24,497 5,756 42 2,123 8,022 559 146 1,033 903 26,487 4,171 115 18 9,144 425 121 225 234 17 191 6,126 5,273 4,942 5,748 1,671 2,783 1,262 2,645 3,485 99 757 687 653 36 2 22 166 132 4 4 4 4 36 724 959 960 148 350 372 862 733 1,483 808 87 413 47 45 20 427 299 2 1,296 66 534 297 22 489 69 68 408 4 179 1,118 50 7,383 8,314 7,731 7,747 4,268 6,343 6,740 6,754 6,432 2,571 3,715 5,207 4,112 4,820 5,482 3,036 3,674 3,282 3,843 4,092 1,140 1,633 1,305 1,260 1,036 1,076 61 617 1,196 984 1,009 33 423 903 839 829 671 925 877 824 805 647 489 483 503 509 1,118 4,235 4,415 4,018 4,129 3,759 1,310 1,379 3,172 2,544 3,374 1,310 1,610 1,720 633 592 727 637 636 623 573 709 261 276 340 1,620 789 1,149 42 700 789 1,149 29 700 789 537 2,206 580 502 1,725 4,758 2,450 503 588 2,396 4,261 44 290 626 4 152 2,296 1,149

Angola

2,023

2,434

5,107

12,022

Benin

3,802

3,845

3,774

4,259

4,006

Botswana

6,120

6,795

6,147

6,545

5,940

Burkina Faso

4,308

4,602

4,761

4,944

4,567

Burundi

526

3,625

5,511

4,817

5,734

Cote d'Ivoire 378

17,201

17,253

16,991

18,297

20,663

Cameroon

17,885

18,218

19,117

20,280

20,810

Cape Verde

282

352

Central African Republic 4

3,749

2,638

1,890

3,839

Chad

3,801

4,124

4,766

Comoros

110

117

119

Congo

180

2,357

4,106

2,247

1,979

DRC

21,856

31,312

28,997

30,636

35,097

Equatorial Guinea Eritrea

741

331

786

911

1,913

Ethiopia

33,021

56,040

66,955

65,140

96,245

Gabon

966

1,130

2,252

5,415

110 126 21

Gambia

1,578

2,045

1,962

1,726

1,859

Ghana

7,373

9,870

10,147

12,587

11,825

Guinea

1,020

5,444

5,776

6,548

7,575

Guinea-Bissau

543

664

1,046

1,037

1,322

Kenya

91,463

96,676

96,930

97,136

92,890

Lesotho

9,008

10,563

11,005

11,413

10,476

Liberia

4,002

5,964

3,533

4,355

5,661

Madagascar

6,471

2,176

16,439

15,532

14,146

Malawi

21,557

21,041

19,855

17,334

19,009

Mali

3,041

3,760

2,303

1,963

1,544

Mauritania

281

608

Mauritius

101

110

117

108

Mozambique

32,182

38,087

40,554

43,096

47,960

Namibia

9,188

9,849

9,534

10,042

9,927

Niger

2,243

2,424

4,925

4,710

5,166

Nigeria

56,053

70,693

71,844

75,772

82,641

Rwanda

7,510

7,448

6,914

6,560

6,131

Sao Tome and Principe

112

146

Senegal

5,963

6,906

8,018

8,757

10,048

Seychelles

Sierra Leone

7,949

8,625

9,718

10,159

11,655

South Africa

150,542

197,448

213,006

322,732

294,196

Swaziland

9,635

10,730

9,536

8,419

7,363

Togo

512

1,734

2,242

2,513

2,657

Uganda

27,695

31,695

36,742

39,394

40,581

Tanzania

48,846

56,388

56,849

53,842

52,499

Zambia

30,654

34,992

40,704

48,594

45,269

Zimbabwe

22,062

28,952

41,062

37,029

34,212

WORLD HEALTH ORGANIZATION Regional Office for Africa Brazzaville • 2013

Key facts

Organisation World Health Organization (WHO)

Document type Publications

Adoption date December 31, 2013

Source World Health Organization