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Fast-Tracking the response in

Eastern and Southern Africa
– on what do we focus and how?

HIV Epidemic Overview 2018

Dr. Amala Reddy, Senior Strategic Information Adviser
UNAIDS Regional Support Team Eastern and Southern Africa
at Champions High Level Political Roundtable,
18 September 2018
Outline
•  Overview of the Eastern and Southern Africa (ESA) HIV
epidemic (Global Report 2018)
•  Progress and gaps in the ESA epidemic and response
–  Status of epidemic control
–  New infection trends in countries
–  Testing and treatment progress
•  People left behind
–  Key populations – FSW, MSM, TG, PWID
–  AGYW
•  Age, gender and human rights issues
•  Gaps in the epidemic response and barriers to access services
Overview
of the Eastern and Southern Africa (ESA)
HIV epidemic
Overview of the HIV Epidemic in
Eastern and Southern Africa in 2017

HIV prevalence (15-49 yr): 6.8% [5.9 – 7.7%]
People living with HIV: 19.6 million [17.5 – 22 million]
Data not shown Children (0-14 yr) 1.2 million [0.88 – 1.4 million]
Women (15+ yr) 11.2 million [10.1 – 12.5 million]
Young people (15-24 yr) 2.1 million [1.1 – 3.0 million]

New HIV Infections: 800 000 [650 000 – 1 000 000]
AIDS-related deaths: 380 000 [300 000 – 510 000]

Coverage of ART: 66% [52 – 77%]
Coverage of PMTCT 93% [73 – >95%]

People receiving ART: 12.9 million [11.4 – 13.4 million]
Mothers receiving PMTCT: 871 000

Source: Prepared by RST ESA SI Hub based on UNAIDS Estimates 2018
Antiretroviral treatment coverage has increased steadily,
with major progress in averting deaths from AID-related illness,
and preventing new infections
Estimated number of new HIV infections, AIDS-related deaths,
and people on ART, Eastern and Southern Africa, 1990 - 2017

12.9 million

4.3 million

-30%
800 000
- 42%
380 000

Source: Prepared by RST ESA SI Hub based on UNAIDS Estimates 2018
Epidemic transition metrics defined by expert group:

•  Existing: Incidence rate per 1,000 uninfected (SDG indicator)

•  % reduction in new infections from 2010 baseline (HLM target)
–  (new infections2017 – new infections2010) / new infections2010
•  % reduction in AIDS deaths from 2010 baseline (HLM target)
–  (AIDS deaths2017 – AIDS deaths2010) / AIDS deaths2010
•  Ratio of Incidence to Prevalence (IPR)
–  New infections / people living with HIV
•  Ratio of Incidence to Mortality (IMR)
–  New infections / total deaths to HIV population
ESA with an IPR of 0.04 [0.03 – 0.05] is the one region
rapidly moving towards IPR benchmark of 0.03

The average number of
new HIV infections per
each person living with
HIV. When the ratio of
incidence: prevalence is
maintained below 0.03
(incidence and/or mortality
declining) the epidemic will
decline over time Target value 0.03

Source: UNAIDS 2018 estimates.
All 4 epidemic transition metrics for ESA:
Mozambique, South Africa, and U.R. Tanzania accounted for more
than half of new HIV infections and deaths from AIDS-related
illness in 2017

Distribution of new HIV infections and AIDS-related
deaths by country, ESA, 2017

Source: UNAIDS 2018 estimates.
15 priority countries in Eastern and Southern Africa accounted
for >98% of new infections, AIDS-related deaths and PLHIV in 2017.
About one-third of new infections occur in South Africa
Women Young people Children
New HIV AIDS-related Peope Adult prevalence
Country (15+) living with (15-24) (0-14)
infections deaths living with HIV (15-49)
HIV living with HIV living with HIV

South Africa 270 000 110 000 7 200 000 4 200 000 700000 280 000 18,8
Mozambique 130 000 70 000 2 100 000 1 200 000 250000 170 000 12,5
U. R. Tanzania 65 000 32 000 1 500 000 810 000 170000 120 000 4,5
Kenya 53 000 28 000 1 500 000 860 000 180000 110 000 4,8
Uganda 50 000 26 000 1 300 000 750 000 160000 95 000 5,9
Zambia 48 000 16 000 1 100 000 630 000 130000 72 000 11,5
Zimbabwe 41 000 22 000 1 300 000 740 000 140000 77 000 13,3
Malawi 39 000 17 000 1 000 000 590 000 120000 71 000 9,6
Angola 27 000 13 000 310 000 190 000 36000 27 000 1,9
Ethiopia 16 000 15 000 610 000 350 000 76000 62 000 0,9
Lesotho 15 000 4 900 320 000 180 000 34000 16 000 23,8
Botswana 14 000 4 100 380 000 210 000 35000 9 000 22,8
South Sudan 14 000 12 000 180 000 98 000 20000 13 000 2,4
Namibia 7 400 2 700 200 000 110 000 19000 12 000 12,1
Eswatini 7 000 3 500 210 000 120 000 23000 13 000 27,4
ESA region 800 000 380 000 19 600 000 11 200 000 2100000 1 200 000 6.8

HIV prevalence > 10%

Source: Prepared by RST ESA SI Hub based on UNAIDS Estimates 2018
Since 2010 there has been significant progress in controlling new
HIV infections among adults in several
countries – but other countries lag behind
Percentage change of new HIV infections among adults
in Eastern and Southern Africa, 2010-2017

Source: Prepared by RST ESA SI Hub based on UNAIDS Estimates 2018
Antiretroviral treatment coverage of children (0-14 y) has
more than doubled (25% to 59%) and new infections and deaths
have been reduced by around half between 2010 and 2017
Estimated number of new HIV infections and AIDS-related deaths among children,
and children on ART, Eastern and Southern Africa, 1990 - 2017

Source: Prepared by RST ESA SI Hub based on UNAIDS Estimates 2018
2018 estimates indicate less decline in new infections among
children in eastern and southern Africa between 2010 and 2017
(44%) than previously estimated – only 6 countries have more than
50% reduction
Percentage change of new HIV infections among children
in Eastern and Southern Africa, 2010-2016

Madagascar
- 44%

Source: Prepared by RST ESA SI Hub based on UNAIDS Estimates 2017
There has been good progress with 81% of PLHIV who know their
status, about two-thirds are accessing antiretroviral therapy (66%)
and about half are virally suppressed (52%)

HIV Testing and Treatment Cascade, 2017

15.9 million people
12.9 million people

10.3 million people

Source: UNAIDS special analysis, 2018
Uneven country progress on PMTCT, adult and children antiretroviral
coverage indicates the need for better outreach and integrated services
PMTCT coverage ART coverage ART coverage
Country (Effective regimen) (Children 0 - 14 years) (Adults 15+ years)

ESA REGION 93 59 66
Zimbabwe >95 89 84
Namibia >95 76 85
Eswatini 90 75 86
Botswana 90 68 84
Rwanda 92 76 83
Uganda >95 68 73
South Africa >95 58 61
Zambia 92 64 76
Malawi 92 63 71
Lesotho 90 61 74
Mozambique 86 51 55
U.R. Tanzania 85 34 68
Kenya 76 82 75
Ethiopia 59 34 75
Eritrea 39 35 65
Comoros 30
Angola 34 14 27
South Sudan 60 9 14
Madagascar 11 4 7
Estimates not published < 50% 50 – 79% 80 – 94% ≥ 95%

Source: Prepared by RST ESA SI Hub based on UNAIDS Estimates 2018
Steady increases in HIV resources have enabled massive
expansion in responses. Both domestic and international funding
($10.6 billion in 2017) have increased to $500 million more than
the target for 2020

HIV resource availability by source, 2000-2017, and projected resource needs by 2020, ESA
$ 10.6 billion $ 10.1 billion

11 %

39 %

42 %

Source: UNAIDS 2018 resource availability and needs estimates.
Renewed commitment to
Combination Prevention and Treatment Access is urgent
for populations left behind …
Sex workers, People who inject drugs and Men who have sex with
men and their partners contribute 17% of new infections in ESA
Distribution of new HIV infections, by population group,
Eastern and Southern Africa, 2017
In many countries HIV prevalence among
female sex workers and men who have sex with men is very high!
HIV prevalence among key populations, latest surveillance, Eastern and Southern Africa

Source: Prepared by RST ESA SI Hub based on GAM 2018. Data from surveys 2014 – 2017,
Exceptions: Botswana, Uganda, Seychelles 2013 and Kenya 2011
In countries with available data the HIV prevalence among
people who inject drugs and prisoners can be very high too!
HIV prevalence among key populations, latest surveillance, Eastern and Southern Africa

Source: Prepared by RST ESA SI Hub based on GAM 2017. PWID data from surveys in 2017, except for
Kenya 2011, U.R. Tanzania 2015 and Madagascar 2016. Prisoners data from surveys in 2016 – 2017.
There is high HIV prevalence among female sex workers in most
countries with data, yet condom use is below the recommended value
in half. Knowledge of HIV status has reached the target in 3 out of 5 of
the few reporting countries.
HIV prevalence, condom use with last client and knowledge of HIV status
among FSW in ESA
100
90
80
71,9
69,6
70
61,9 60
60 57,7 56,2
48,8
50 45,8
%

40 34,2
29,3 28
30 24,3
21,3
20 15
10,4
10 8
5,7 5,5 4,6
0

Source: Prepared by RST ESA SI Hub based on GAM 2018
There is high HIV prevalence among men who have sex with men in
most countries with data, yet condom use and knowledge of HIV status
are below the recommended value in the majority
HIV prevalence, condom use with last client and knowledge of
HIV status among MSM in ESA

Source: Prepared by RST ESA SI Hub based on GAM 2018
There is high HIV prevalence among men who have sex with men in
most countries with data, yet condom use and knowledge of HIV status
are below the recommended value in the majority
HIV prevalence, condom use with last client and knowledge of
HIV status among MSM in ESA

Source: Prepared by RST ESA SI Hub based on GAM 2018
Insufficient attention is given to key populations despite extremely
high prevalence. An estimated 1 million sex workers need services
but programme coverage is low in many countries

Estimated size of sex worker populations by country, Percentage of sex workers who reported receiving at
ESA, 2014-2017 least 2 prevention services in the past 3 months, ESA,
2014-2017

Source: 2018 Global AIDS Monitoring
Countries need to design programmes that appropriately address
the needs of different age groups of adolescent girls and young
women
Countries with more new infections among
50,000 adolescent girls 15-19 years than 20-24 years, 2017
40,000
30,000
20,000
10,000
0

Countries with more new infections among
20000 adolescent girls 20-24 years than 15-19 years, 2017
15-19 yr 20-24 yr
15000

10000

5000

0

15-19 yr 20-24 yr
In 10 countries laws and policies that require parental
consent to access SRH services discourage adolescent
girls from accessing services they need to stay healthy
Clearly, young people need to learn about HIV prevention
In most countries less than half surveyed have correct and comprehensive
knowledge about HIV prevention; young women generally have less
knowledge
Young people (15-24 years) comprehensive knowledge of HIV prevention

Source: UNAIDS Global AIDS Update 2018
Stigma and discrimination continue to work against
reaching epidemic transition.
Measures of HIV-related stigma and discrimination are
under discussion to accompany epidemic transition
markers
HIV-related stigma is declining across ESA, but remains
high in several countries
Percentage of men and women (15 -49 y) who would
not by vegetables from a shopkeeper living with HIV,
ESA, 2000-2016

Comoros Ethiopia

Eswatini
Intimate partner violence experienced by ever-married women or
partnered women is also declining, but remains unacceptably high,
ranging from 15 – 30% in surveys, 2014 – 2016
Percentage of ever-married women or partnered
women (15 -49 y) who experienced physical/ or sexual
violence by an intimate partner in past 12 months,
ESA, 2000-2016

Rwanda

Uganda
U.R. Tanzania

Malawi

S. Africa
Discrimination in health-care settings still occurs,
especially towards key populations
Percentage of PLHIV who experienced Percentage of key populations who reported having
discrimination in health-care settings, countries avoided health-care services in the past 12 months due
with available data, ESA, 2013-2016 to stigma and discrimination, countries with available
data, ESA, 2014-2017
Human rights-related issues continue to hinder the response

a

a Determined / differs at sub-national level
•  Source: UNAIDS Global QAIDS Update 2018
Human rights-related issues continue to hinder the response

Source: Prepared by RST ESA SI Hub based on 1. UNAIDS RST ESA Country profiles On HIV, Human Rights and the Laws for
People Living with HIV, Key Populations and Vulnerable Groups in Eastern & Southern Africa, March 2015; 2. http://
www.aidsinfoonline.org/kpatlas/#/home; and 3. http://ilga.org/
Recommendations
Substantial progress in ESA towards epidemic transition by reducing new
infections and scaling-up treatment hides disparities in individual
countries.
Renewed commitment to combination prevention to address sources of
new infections needs to be matched by removing underlying barriers
•  Invigorating combination prevention approaches is critical to success in
reducing new infections.
–  Among specific populations based on age, gender or those at higher risk
who are stigmatized or discriminated against
–  Focus on locations and populations in most need
•  Adolescent girls and young women are particularly vulnerable to HIV infection
and programs to reduce inequalities, harmful gender norms, and other
underlying social, economic and structural drivers are required.
•  Community and key population involvement in the HIV response is imperative
if we want to sustain our progress in prevention, care and treatment.
Thank you!

Acknowledgement:
Overview Slide Set prepared by
UNAIDS RST ESA Regional SI Hub
September 2018
based on
UNAIDS Global AIDS Update 2018
IPR interpretation

Definition: The ratio of new HIV infections to number of people living with HIV
Benchmark: 0.03
Strengths: Identifies an epidemiological relevant shift in the epidemic.
Limitations: This metric cannot be disaggregated by sex, age or key population as the
metric reflects an entire epidemic including transmission across
population groups.
Interpretation: The average number of new HIV infections per each person living with
HIV. When this ratio is maintained below 0.03 (incidence and/or mortality
declining) the epidemic will decline over time.

The benchmark was chosen based on models that suggest that the mean life expectancy for a
person living with HIV is 30 years. If over an individual’s life time they passed infection on to
only one person, the replacement or transmission rate would be 1/30 or 0.03. This is closely
linked to the basic epidemiological concept of incidence = prevalence / duration. The mean life
expectancy of a PLHIV of 30 years is based on an average of all PLHIV, whether on ART or
not. This value is still under discussion.
IMR interpretation

Definition: The ratio of new HIV infections to the total number of
deaths among the HIV population (not AIDS deaths)
Benchmark: 1
Strengths: Identifies a point at which HIV related health care costs
will diminish
Limitations: Requires to be interpreted together with a measure of
low mortality among people living with HIV or high ART
coverage (otherwise IMR<1 could be attained in the
presence of high mortality)
Interpretation: When this value is less than one, the size of the
population living with HIV decreases, lowering costs of
antiretroviral therapy and services.