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Tracking progress toward Universal Access in Eastern and Southern Africa

Over the last five years, countries in Eastern and Southern Africa have established ambitious targets required for scaling up Universal Access to prevention, treatment, care and support. In most countries, setting targets was integrated within the process of drafting National Strategic Plan on AIDS and was carried out through inclusive consensus building exercises. Below is a snapshot of the progress made by countries in terms of achieving universal access targets at the end of 2009. Treatment Universal Access indicator: Percentage of women, men and children with advanced HIV infection who are receiving antiretroviral combination therapy 1 The total number of people on treatment increased by 7.5 times over the last five years, with 5.2 million people accessing life-saving drugs in 2009, compared to 700,000 in 2004. However, 10 million people living with HIV who are eligible for treatment under the new WHO guidelines are still in need. The scaling up of treatment is profoundly affecting sub-Saharan Africa. At the end of 2009, 27% of adults and children eligible for antiretroviral therapy were receiving it in the region overall, compared to just 2% seven years earlier. At the end of 2009, there were an estimated 3.18 million people on antiretroviral treatment in eastern and southern Africa. In the region, approximately 41% of those in need of treatment are receiving it. Under the prior treatment guidelines that prevailed in 2009, six countries in Eastern and Southern Africa (Botswana, Mozambique, Namibia, Rwanda, Swaziland and Zambia) had already achieved national universal access targets for antiretroviral treatment a full 12 months before the December 2010 deadline. Under the revised 2010 guidelines, with their increased denominator for treatment eligibility, only one country in the region (Zambia) had achieved its 2010 target for antiretroviral treatment. However, a number of additional countries (Botswana, Mozambique, Namibia, Rwanda, and Swaziland) were by December 2009 very close to achieving their revised universal access targets. South Africa, while it has the biggest ARV programme in the world in terms of absolute numbers, has the lowest coverage of Southern African countries.

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1

Global Report on the AIDS Epidemic, 2008 and 2010

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Universal Access Targets

2009 Country 2007 WHO 2010 WHO 2006 guidelines guidelines 24% 83% 18% 37% 37% 48% 48% 2% 46% 22% 26% 76% 88% not reported 37% 59% 35% >95% 26% 39% 51% 65% 68% 4% 63% 38% 45% >95% >95% not reported 56% 85%

Angola Botswana Comoros Eritrea Ethiopia Kenya Lesotho Malawi Mauritius Namibia Rwanda Seychelles Swaziland Tanzania Uganda Zambia Zimbabwe

25% 79% not reported 13% 29% 38% 26% 35% 22% 88% 71% not reported 42%

50% 80% 100% 76% 75% 80% 80% 30% 80% 75% 39% 90% 100% not reported 70% 60% 350,000 people 80% 60% 100%

Madagascar 4%

Mozambique 24%

South Africa 28%

31% (135,696 30% (199,413 44% people) people) 33% 46% 17% 53% 2 64% 34% 53% 85% 49%

Care and support Universal Access indicator: Percentage of orphans and vulnerable children (boy/girl) aged under 18 living in households whose household have received a basic external support package The support package could include food, education, health care, family/home and/or community support 3 As the number of orphaned and vulnerable children continues to grow, adequate support to families and communities needs to be assured. In practice, care and support for orphaned children comes from families and communities. As a foundation for this support, it is important that households are connected to additional support from external

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Uganda UNGASS Country Report, 2008 2007 data: UNICEF: Third Stocktaking Report, 2008; 2009 data: Global Report on the AIDS Epidemic, 2010

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sources. The total number of children aged 10 to 17 years who have lost their parents due to HIV increased to 16.6 million in 2009. Almost 90% of HIV positive children live in sub-Saharan Africa. The number of orphans due to AIDS living in six countries - Kenya, Nigeria, South Africa, Uganda, Tanzania and Zimbabwe - is more than 9 million. More than 10% of all children have lost one or both of their parents due to AIDS in Zimbabwe (16%) , Lesotho (13%) and Botswana and Swaziland (12%). Whilst scaling up support for children affected by AIDS remains a priority, very few households with orphans and vulnerable children (OVCs) are receiving external support. The UNGASS and Unite for Children, Unite against AIDS target of 80% of households with orphans and vulnerable children receiving free, basic and external support was not met by many countries in 2009. Overall, in eastern and southern Africa, less than 50% of households in were receiving support for OVCs with South Africa having the highest coverage at 75% of households. Such support included education assistance, medical care, clothing, financial support and psychosocial services.

Country Angola Botswana Comoros Eritrea Ethiopia Kenya Lesotho Malawi Mauritius Namibia Rwanda Seychelles Swaziland Tanzania Uganda Zambia Zimbabwe

2007

2009

Universal Access Targets 28% 95% 100% 49% 43% 75% 80% not reported 80% not reported 30% 35% 4% not reported 90% 61% 30% 41% 50% 50%

not reported 17% 34% (2004) 31% not reported not reported 4% 4% (2004) 21% not reported not reported not reported not reported

25% (2004) not reported 19% (2006) 18% not reported not reported 17% not reported

Madagascar 7% (2003)

Mozambique not reported 22% 13% (2005) not reported 100% (2006) not reported 75% not reported 41%

South Africa 67%

51% (2006) 16% 11% (2006) not reported 16% not reported 31% (2006) 21%

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Prevention In the 2001 Declaration of Commitment on HIV/AIDS, recognizes HIV prevention as "the mainstay of the response" and commits countries to implement comprehensive, evidence-informed strategies to reduce the number of people newly infected with HIV. New HIV infections have fallen by nearly 20% in the last 10 year. In 2009, there were 2.6 million new infections, down from 3.1 million in 1999. 31% of new HIV infections occurred in 10 countries of southern Africa - Angola, Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. Five countriesBotswana, South Africa, United Republic of Tanzania, Zambia, and Zimbabweshowed a significant decline in HIV prevalence among young women or men in national surveys. Ethiopia, South Africa, Zambia and Zimbabwe have reduced new infections by 25% from 2001 to 2009. Universal Access indicators: 1. Prevention of mother-to-child transmission (PMTCT)4 The percentage of HIV-positive pregnant women who received treatment to prevent transmission of the virus to their child increased from 35% in 2007 to 53% in 2009. Sub-Saharan Africa, which accounts for nearly 90% of all pregnant women living with HIV in low- and middle-income countries, has made the most progress in the past four years. In 2009, 54% of pregnant women living with HIV in sub-Saharan Africa received antiretroviral drugs to prevent transmission of HIV to their children - up from 15% in 2005. Between 2004 and 2009, AIDS-related deaths among children in southern Africa declined by 26%, from 120,000 to 90,000. Overall in the ESA region approximately 69% of HIV+ pregnant women are now being tested for HIV and receiving some form of PMTCT, but access varies greatly by country. With UNAIDS aiming at the virtual elimination of MTCT by 2015, there is considerable work to be done in the region but many countries are reaching Universal Access targets set for 2010. As of December 2009, six countries in the region (Botswana, Mozambique, Namibia, Swaziland, Tanzania, and Uganda) had already achieved 2010 Universal Access targets for prevention of mother-to-child transmission. An additional seven countries (Angola, Eritrea, Kenya, Lesotho, Malawi, South Africa, and Zambia) were approaching 2010 targets by the end of 2009.

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2007 data: UNICEF, WHO, UNAIDS, Towards Universal Access, 2008: 2009 data based on UNAIDS/WHO estimates

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Universal Targets 28% 97% 100% 78% 80% 90% 80% 15% 65% 95% 46% 75% 83% not reported 90% 80% 50% 21% 70% 80% Access

Country Angola Botswana Comoros Eritrea Ethiopia Kenya Lesotho Malawi Mauritius Namibia Rwanda Seychelles

2007 9% >95% 0% 7% 7% 69% 32% 32% 31.7% 64% 60% not reported 67% 32% 34% 47% 29%

2009 19% >95% not available (<100 people on treatment) 34% not available 73% 64% not available 58% not available 70% 88% 65% not reported 88% 88% 70% 53% 69% 56%

Madagascar 1.6%

Mozambique 46%

South Africa 57% Swaziland Tanzania Uganda Zambia Zimbabwe

2. Coverage of HIV testing and counselling5 Coverage of HIV testing and counselling is usually calculated on the percentage of people who received an HIV test in the 12 months preceding the survey relative to those who had ever received a test. The percentage of people tested in the 12 months preceding the survey varies among countries in eastern and southern Africa. Only in Botswana have more than 50% of people undergone HIV testing in the last year and counselling and obtained their result. In Lesotho, Malawi, Uganda, and Angola, less than 10% of people know their current HIV status from a recent test.

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Global Report on the AIDS Epidemic, 2008 and 2010

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Country Angola Botswana Comoros Eritrea Ethiopia Kenya Lesotho 2007 2009 Universal Access Targets 95% 60% 100% 27% men 26% women 75%

5% total (2006) 9% total 7% male (2006) 6% male 4% female (2006) 12% female not reported not reported 6% 2% (2005) 14% (2003) not reported not reported not reported not reported

23% male 3 million 29% female (2008) 80% 6% men 10% women 75% 18% 9.6% 22% men 35% women 26% not reported 75% 50% 50% 5% 25% 85%

2% total (2005) 5% male(2005) not reported 6% female (2005) not reported not reported 6% (2008) 12% total 9% male 14% female not reported

Madagascar 8%6 Malawi Mauritius 11% 2% (2004)

Mozambique 2% (2004) 23% total 18% men 29% women

Namibia

Rwanda Seychelles

11% total (2005) 11% male (2005) not reported 12% female (2005) 100% (2006) 16% total 9% male 22% female 36% not reported 25% (2008) not reported 19% (2008)

South Africa 90% (2006) Swaziland Tanzania Uganda Zambia Zimbabwe

10% male (2006) 20% 12% female (2006) 15% 7% (2006) not reported not reported

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National Survey, 2008

3. Young women and men aged 15-24 who can correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions7 The HIV epidemics are sustained primarily through sexual transmission of infection to successive generations of young people. Sound knowledge of HIV and AIDS is an essential prerequisite for adoption of behaviours that reduce the risk of HIV transmission. In eastern and southern Africa, the drop in HIV prevalence seen over the last eight years can be partly attributed to changes in behaviour among young people, which is a testament to the importance of sound knowledge of HIV and AIDS. Country Angola Both sexes (15-24) 2007 Both sexes (15-24) 2009 23% total 25% male 21% female 28% (2003) not reported not reported 24% (2005) 33% male (2005) 21% female (2005) 19% male (2004) 27% female (2004) 80% male (2005) 58% female (2005) 28% total 32% male 25% female 42% total 39% male 45% female not reported 77% total 77% male 78% female not reported not reported 55% male 48% female 57% male 54% female not reported not reported 34% male 36% female not reported

Botswana Comoros Eritrea

Ethiopia Lesotho Kenya

46% total Madagascar 45% male 45% female Malawi Mauritius 42% total 42% male 42% female 22% (2004)

28% total (2004) Mozambique 39% female (2004) 25% male (2004) Namibia 63% total 62% male

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UNGASS Country Progress Reports, 2008; Global Report on the AIDS Epidemic, 2008 and 2010

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Country Both sexes (15-24) 2007 Both sexes (15-24) 2009 65% female Rwanda 52% total (2005) 54% male (2005) 51% female (2005) 20% total 20% male 21% female not reported

Seychelles

not reported 29% total 30% male 27% female 52% (2007) 40% total 42% male 39% female not reported

South Africa not reported Swaziland Tanzania 52% not reported 33% total 38% male 32% female 35% total 37% male 34% female 45% total 46% female 44% male

Uganda

Zambia

not reported

Zimbabwe

53% female

4.Percentage of young men and women who have had sex before age 158 The proportion of young men and women who report their first sex before the age of 15 has remained constant over time in eastern and southern Africa. Only in Lesotho (from 21% in 2005 to 8% in 2007) and Ethiopia (from 41% in 2005 to 12% in 2007) has the proportion reporting first sex before age 15 decreased. In Mauritius, the proportion increased from just 2% in 2007 to 7.3% in 2009. Country Angola 2007 32% total 36% males 28% females 7% (2005)9 10% (1996) 2009 30% total 37% males 23% females 4% total (2008) 5% male (2008) 3% female (2008) not reported Universal Access Targets not reported

Botswana Comoros

1% not reported

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UNGASS Country Progress Reports, 2008; Global Report on the AIDS Epidemic, 2008 and 2010 9 UNGASS Country Progress Report, 2008

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Country 2007 16% male (1996) 8% female (1996) Eritrea Ethiopia 27%10 not reported 10% not reported 20% male 10% female 13.5% male 7.5% female 27% male 18% female not reported 12% total (2005) 2% male (2005) not reported 16% female (2005) 21% total (2003) 22% male 29% male (2003) 11% female 14% female (2003) 8% total (2005) 12% male (2005) not reported 6% female (2005) 2009 Universal Access Targets

Kenya

Lesotho

36% total (2006) 9% male Madagascar 33% male (2006) 18% female 39% female (2006) Malawi 15% total 14% male 15% female not reported

Mauritius

2% total (2004) 7% total (2008) 3% male (2004) 10% male (2008) 1% female (2004) 5% female (2008)

2%

28% total (2005) 25% total Mozambique 26% male (2005) 25% male 28% female (2005) 25% female Namibia 12% total 18% male 7% female not reported

not reported 15% male 6% female

Rwanda Seychelles

9% total 7% total (2005) 13.1% male 13% male (2005) 5.1% female 14% female (2005) not reported not reported

70% (2012) not reported not reported 3% male 3% female

8% total (2005) 9% total (2008) South Africa 5% male (2005) 11% male (2008) 12% female (2005) 6% female (2008) Swaziland 6% total 5% male 7% female not reported

Tanzania

11% (2005) 10% total (2008) 10% male (2005) 11% male (2008) 7% 13% female (2005) 10% female (2008)

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National Survey, 2008

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Country Uganda 2007 2009 Universal Access Targets 7%

15% total (2006) 12% male (2006) not reported 16% female (2006) 15% total 16% male 14% female not reported

Zambia

not reported

Zimbabwe

5% total (2006) not reported 5% male (2006) 5% female (2006)

not reported

National Commitment Universal Access indicator: Amount of national funds disbursed by governments in low and middle income countries (in US$ million)11 After decades of increasing funding being made available to developing countries to respond to HIV, the recent global economic turndown has put the brakes on donor aid. A total of US$ 15.0 billion was available for the AIDS response in 2009, US$ 10 billion short of what is needed in 2010. In low and middle income countries, domestic resources account for over half of all AIDS-related investments. In low income countries, however, 88% of all spending on AIDS comes from international funding. Botswana, Kenya, Lesotho, Malawi, Mozambique and Zimbabwe - 6 out of 16 countries in eastern and southern Africa - appear to be spending less on the AIDS response than might be expected given their disease burden and government resources. Substantial additional resources will be required to support a robust and sustainable HIV response in the coming years. Based on the country-defined targets for 2010, it is estimated that an investment of US$ 25.1 billion (US$ 18.9 billion-US$ 30.5 billion) will be required for the global AIDS response in 2010 for low- and middle-income countries. Of this total, nearly US$ 11.6 billion will be required for HIV prevention and US$ 7 billion for treatment. In Eastern and Southern Africa, an investment of US $ 5.3 billion will be required for the AIDS response in the region. Of these, US $ 800 will be required for HIV prevention and nearly US $ 3 billion for treatment.

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Global Report on the AIDS Epidemic, 2008 and 2010

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Total reported Total reported Universal domestic public domestic public Access and international Domestic and international Domestic Targets expenditure public (%) expenditure public (%) million million million USD USD(2007) USD(2009) 31,766 339,868 not reported 14,457 not reported 659,866 53,737 (2007) 75.8% 67.3% not reported 5.9% not reported 11.2% 37.2% (2007) 45.3% 1.8% not reported 3.5% not reported 5.5% 83.9% 77% 39.6% (2007) not reported 13% not reported 1.3% 24.839 not reported not reported 13.661 not reported 687.258 81.315 (2008) not reported 103,907 not reported not reported not reported 110.8 (2008) 0,575 2,088,000 not reported not reported not reported not reported 39,548 64.6% not reported not reported 8.9% not reported 14.2% 56.9% (2008) not reported 1.4% not reported not reported not reported not reported 80.4% 72.7% not reported not reported not reported not reported 19.5% not reported 180.7 107.7 not reported not reported 10% of budget 5% of budget 10.1 not reported not reported not reported not reported 12.7 not reported 12.7 billion not reported not reported not reported 15 not reported

Country

Angola Botswana Comoros Eritrea Ethiopia Kenya Lesotho

Madagascar 11,954 Malawi Mauritius 106,722 not reported

Mozambique 144,946 Namibia Rwanda Seychelles not reported 110,812 0,573

South Africa 1,694,000 Swaziland Tanzania Uganda Zambia Zimbabwe 49,477 (2007) not reported 296,650 not reported 27,344