Download Know Your Epidemic: Most-at-risk Population

Know Your Epidemic:
Most-at-risk Population
INTEREST Workshop, 15 Dakar May 2013
Vivian Black, Director Clinical Programmes
Wits Reproductive Health & HIV Institute
The situation at a glance
• In the world today there are 34 million people living
with HIV
• In 2011, 1.7 million people died of AIDS
• In the same year there were 2.5 million new infections.
• In order to address HIV, it is vital that we understand
the HIV epidemic and target interventions to give the
greatest returns for any investments made.
• The most-at-risk populations are an important group to
target
UNAIDS; 2012
Structure of the talk
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Know your epidemic
MARP – principals
Sex-workers
MSM
Injecting drug users
Way forward
Net gain of 800 000
Deaths
New infections
Improvements
• 8 million people on ART
• 80% coverage in
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Botswana
Namibia
Rwanda
Swaziland
Zambia
• South Africa had 1.7 million people on ART in 2011, 2
million currently
• Scale up of initiations increased in past 2 years
• 14 million lives have been saved by ART
UNAIDS; 2012
Improvements
• Incidence of HIV is decreasing with 700 000
fewer infections in 2011 vs. 2001
• Africa has reduced new infections by 1/3 since
2005.
UNAIDS; 2012
Improvements
• 500 000 fewer deaths in 2011 compared to
2005
– South Africa 100 000, Zimbabwe 90 000
– Botswana 71% reduction in AIDS deaths
UNAIDS; 2012
UNAIDS; 2012
UNAIDS; 2012
Concerns
• 50% of people do not know their HIV status
• Shortfall of 6 million people on ART
• HIV associated mortality has increased in:
Eastern Europe,
Central Asia,
Middle East,
North Africa
• Prevention is weak
• Most-at-risk populations remain marginalised
UNAIDS; 2012
Most-at-risk population
• In countries with generalised HIV epidemics,
trends among the most-at-risk populations
may be missed
• Although the HIV pandemic is slowing overall,
infections among MARP continue to increase
• MARP remain an important part of the HIV
burden, including in settings where sex work,
and MSM are criminalised
Beyrer C et al, JAIDS 2011
Alary M et al, AIDS 2013
Avahan
Ng M. et al, Lancet 2011
Avahan
• Interventions include:
– Safe-sex counselling by peers
– Clinic services including for STI
– Condoms
– Needle and syringe exchange
– Community mobilisation and advocacy
Ng M. et al, Lancet 2011
Thilakavathi S. et al, BMC Public Health, 2011
Avahan
• Assessment of population-level effect, 2003-2008
• Mixed effect multilevel regression model used to
determine effect
• Among different provinces in the South, greater
funding was associated with lower HIV
prevalence (p<0.05)
• Estimated 100 178 (95%CI: 25897-207-713) HIV
infections averted
Ng M. et al, Lancet 2011
Female Sex Workers
Sub Saharan Africa
Sex Workers
• In Sub-Saharan Africa 0.7-4.3% of women
engage in transactional sex
• Around 1/3 access prevention interventions
• Fewer access HIV treatment and care
• In South Africa there are an estimated 153 000
SW with an HIV prevalence of 60%
• SW contributes to 20% of new infections
Chersich FM, et al, JIAS 2013
SANAC , 2013
HIV prevalence among FSW in low &
middle-income countries 2007-2011
Baral S et al, Lancet Infect Dis 2012
Female Sex Work
• Criminalisation and stigmatisation increases
risk of HIV infection by limiting options to
negotiate safer sex.
• Supporting SW in accessing condoms, safer
work environments, and interventions
targeting behavioural and structural factors
reduce HIV and STI infections.
Baral C et al, Lancet Infect Dis 2012
Limiting exposure to HIV in SubSaharan Africa
Condom promotion
Limiting exposure to HIV in SubSaharan Africa
Knowledge of HIV status
Chersich FM, et al, JIAS 2013
Reduce transmission efficacy in SubSaharan Africa
• Treating STI
Chersich FM, et al, JIAS 2013
Reduce transmission efficacy in SubSaharan Africa
• Antiretroviral therapy – no studies have been
conducted to increase access to ART in SSA
• Treatment is prevention
Chersich FM, et al, JIAS 2013
MSM
MSM
• Among the first groups to be identified as
being infected with HIV
• Early behavioural interventions had successes,
but were not sustained.
• Re-emerging epidemics among MSM are
occurring in high income countries
Sullivan PS, et al, Lancet 2012
HIV infection among MSM in low &
middle income countries
• Odds ratio for MSM being infected compared
to the general population depended on
background country HIV prevalence OR =19.3
• Very low prevalence countries (≤ 0.5%)
• Low prevalence countries (≤ 1.%)
• Medium/high prevalence (≤5%/>5%)
Baral S, et al, PloS One 2007
OR = 58.4
OR = 14.4
OR = 9.6
MSM in Africa
• Marked homophobia, discrimination
• Scarcity of interventions and information
• MSM sub epidemics are being reported from
across Africa and Asia
Baral S, et al, PloS One 2012
MSM in Africa
Botswana, Malawi and Namibia
• 537 MSM recruited
• A mean of 1-1.5 female and 3-4 male sexual
partners in preceding 6 months
• Disclosure of sexual orientation to HCW <25%
(<10% in Malawi)
• Almost half of MSM use internet to find partners
• Men experienced rape, blackmail and police
violence
Baral S, et al, PloS One 2012
MSM in Africa
Botswana, Malawi and Namibia
• Only 3% of 389 MSM practiced safe anal sex
• Less than a quarter were aware of their HIV
status
• Younger MSM were less likely to be HIV
infected – prevention programmes will be
beneficial
Baral S, et al, PloS One 2012
Categories of HIV prevention intervention
for MSM and their effect on UAI and HIV
incidence
Sullivan PS, et al, Lancet 2012
Modelled estimates of proportion of infections averted
in 10 years after provision of HIV prevention packages
to MSM
Sullivan PS, et al, Lancet 2012
Injection Drug Users
Injection Drug Users
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Between 11 & 21million IDU in the world.
HIV prevalence is high. (>20% in 25 countries)
High risk of transmission risk
High risk sexual behaviour
Other infections
Baral S, et al, PloS One 2007
Injection Drug Users
Interventions
• Needle syringe programmes
• Opioid substitution / therapy programmes
• ART
Injection Drug Users
Interventions
• Needle-syringe exchange programmes
Country
Needles/IDU/year
Australasia
202
Central Asia
92
Western Europe
59
Latin America
0.3
Middle East & North Africa
0.5
Sub Saharan Africa
0.1
Average WW
Mathers B, et al, Lancet 2010
22 (1 every 17 days)
Mathers B, et al, Lancet 2010
Opioid substitution and therapy
programmes
Methadone maintenance
treatment
20
41
Buprenorphine
maintenance
6
70
No
interventions
Mathers B, et al, Lancet 2010
ART and IDU
• Data weak
Country
ART/100 HIV+ IDU
Western Europe
89
Australasia
22
Chile
<1
Kenya
<1
Pakistan
<1
Russia/Uzbekistan
<1
Average WW
4
Mathers B, et al, Lancet 2010
The law and IDU
• 11 countries in Asia have laws to detain IDU
• Over 400 000 IDUs detained in China, Vietnam
and Thailand
• In 2003 in Thailand “government sponsored
war on drugs” resulted in declines in
participation clinical trials and prevention
programmes, while infections continued.
Mathers B, et al, Lancet 2010
Wolfe D, Cohen J, JAIDS 2010
Way forward
• Clear that MARP need to be aggressively
targeted and managed
• Understanding MARP epidemics in different
settings is important, including in countries with
generalised epidemics
• Targets should be set and indicators monitored to
ensure adequate implementation of combination
prevention interventions
• Barriers to reaching MARPS should be addressed
Thank you
Acknowledge:
• Brian Williams
• Francois Venter
• Andrew Black
• PEPFAR