Lesotho Modes of Transmission ( MoT ) Study Prevention Reference Group Meeting

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Lesotho

Modes of Transmission (MoT) Study

Prevention Reference Group Meeting

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Outline of Presentation

IntroductionOverview of HIV prevalence in LesothoKey MOT Study questions

Components of the MOT study

Methodology employed

Know Your Epidemic (KYE)

Know your response (KYR)

KYE & KYR Synthesis

Key Recommendations


Introduction

Multi-country study in five countries – Lesotho, Kenya, Mozambique, Swaziland and UgandaPurpose: To check whether the response matches

the magnitude of the epidemicTo establish where the bulk of HIV

infections will come from in the next year Study undertaken by NAC, MOHSW and supported by UNAIDS & World Bank


Overview of HIV Prevalence in Lesotho (cont.)


Key questions the MoT study aims to answer

1. Are HIV prevention policies based on the

latest available evidence and global best

practice?

2. Do HIV prevention policies & programs

respond to the key drivers?

3. Is funding for HIV prevention allocated to

where it is most needed?


1.Incidence data (modelled) 2. Epidemiological

review

3. Prevention policies, response and strategic info

review

4. Review of resources for

prevention

“Know your epidemic”

“Know your response”

Components of the MoT Study:


Methodology (KYE & KYR)

1. Incidence modelling: UNAIDS model, prior use in several countries, 1-day modelling workshop

2. Epidemiological review: desk review of data (published, unpublished, national and sub-regional);

3. Prevention review: checklists for KIs on policy context & SI, use of programme activity monitoring databases + structured interviews with HIV implementers for assessment of HIV activities

4. Review of prevention resources: Review of NASA 2005/06 - 2007/08 report, focus on prevention spending, some further analysis


1.Incidence data (modelled) 2. Epidemiological

review



PREVALENCE PATTERNS:Age and sex-related heterogeneity

Women have a higher burden of infection than men • Women are 40% more likely to be HIV positive• 57% of PLHIV are female“Two peaks” in females, high prevalence in older males • Female prevalence rises extremely steeply among young

women and shows a first “peak” among women in their late 20s and reaches its highest level in women in their late 30s (fig)

• Male prevalence peaks at 30-34 years and is higher than female prevalence for adults in their 40s

• Trends in ANC clients: drop in young women, rise in older women


HIV prevalence patterns (cont.) (2004)

Source: LDHS 2004

8

25

39 4043

29

17

2

11

24

41 3934

28

0

10

20

30

40

50

15-19 20-24 25-29 30-34 35-39 40-44 45-49

WomenMen


Heterogeneity by education status

Probability of being HIV positive decreases with increasing education (“education is protective”) *Education strongly predicts preventive behaviours like condom use, delayed sexual debut, HTC uptake and knowledge about AIDS *ANC: Prevalence drop in more educated women

* multivariate analysis by Corno & de Walque 2007


From 2003-2007: Largest HIV prevalence drop in ANC clients with tertiary education, smallest drop in those with primary education

Source: MOHSW ANC surveillance 2003, 2005, 2007

27 32 26 243026 182626

0

5

10

15

20

25

30

35

40

Primary High school Tertiary

HIV

prev

alenc

e

2003

2005

2007

-31%-4% -19%


Homogeneity• All districts, both sexes, and most age groups

had HIV prevalence above 15% in the 2004 DHS (except females 15-19 and males 15-24)

• Women and men in all wealth, education and migration strata analysed have a HIV prevalence of at least 15%

• All but one ANC sentinel site reported HIV prevalence above 15% in 2007


Applying the UNAIDS Incidence Model

Calcification by main HIV exposure/mode of transmission eg. MSM; IDU, SW, CSW- Gaps in most of the data

Nationally representative data on multiple partner frequencies: 2004 DHS, 2007 CIET KAP


Distribution of new infections (DHS multiple partnership data)

0.000.000.490.621.753.02

0.5216.49

15.2761.80

0.000.040.00

0 10 20 30 40 50 60 70

Injecting Drug Use (IDU) Partners IDU

Sex workers Clients

Partners of ClientsMSM

Female partners of MSMMultiple Partnerships (MP)

Partners MPOne partner last 12

No risk Medical injectionsBlood transfusions

Ris

k gr

oup

Percent

Incidence model (using DHS 2004) multiple partners: 21.1% (M), 7.6%(F)

Largest group (0.5 mio) – 62%.

Couple discordancy, Low condom use, ?Secret partners

Multiple partner behaviours: 32%


Distribution of new infections (CIET multiple partnership data)

0.000.000.470.591.682.89

0.5031.04

27.6535.15

0.000.040.00

0 10 20 30 40 50 60 70

Injecting Drug Use (IDU) Partners IDU

Sex workers Clients

Partners of ClientsMSM

Female partners of MSMMultiple Partnerships (MP)

Partners MPOne partner last 12 months

No risk Medical injections

Blood transfusions

Ris

k g

rou

p

Percent

Incidence model (using CIET 2007)multiple partners: 32% (M), 10%(F)

Only 296,000 individuals – 35%

Multiple partner behaviours: 59%


Risk Factors for New Infections

individual level community level structural level

Low male circumcisionMultiple concurrent sexual partnersInconsistent condom useCommercial sex

Social normsGender roles & discriminationLabour & migrationAlcohol abuse

Labour & migration Sexual & physical violence Income inequality


3. Prevention policies, response and strategic info

review

4. Review of resources for

prevention



HIV prevention programmes

• Mass media: 11 programmes: mostly targeting both males and females of all ages (the ‘general population’); few focus on specific age groups or target sub-population;

• BCC: 23 programmes (15 national); mostly directed at 12-35 old males and females; some at in-school youth and students; youth in churches and communities;

• Condoms: 9 programmes incl. MOHSW (free distribution) and PSI (socially marketed condoms);

• HTC: MOHSW is the main implementer; key messages relating to KYS campaign;

• PMTCT: provided in all districts in Government and CHAL facilities;

• Male circumcision: services in health facilities & traditional setting• Blood safety: consistently 100% screening• PEP: services strengthened, now available at district-level


KYR Synthesis

Strong policy environment for HIV prevention, but there is need to scale-up operationalisation of policy commitments.Male Circumcision Policy & Strategy to be developedM&E systems are in place & functional, but there is shortage of data on high risk sub-populations Most prevention programmes focus on: Interventions affecting Knowledge, Attitudes and Beliefs. Risk reduction component (mainly condom distribution) Biological/Biomedical Interventions that Reduce HIV Infection and

Transmission Risk (PMTCT,PEP etc.) Youth & OVC in & out of school; general population; workplace Key Messages - Behaviour change; HTC; life skills; awareness;

ABC; positive living; condom use; sexual violence Coverage is often country-wide except for a few programmes


Incidence data (modelled) Epidemiological

review

Prevention policies, response and strategic info

review

Review of resources for

prevention



Epidemic Epidemic and and

Response Response SynthesisSynthesis


1) Are HIV prevention policies based on current best evidence & practice?

Prevention strategies regarding HCT, PMTCT, treatment of STIs and blood safety are covered by national policies and emulate international best practices.

Male circumcision is not addressed by the existing policies and no MC strategy is available.

The National BCC Strategy has been informed by the findings of this among other studies conducted in Lesotho.

Promotion of abstinence and delayed sexual debut in adolescents needs to take into account societal changes such as delayed marriage, as well as the “catch-up” phenomenon.


2) Do HIV prevention policies & programmes respond to the key drivers of the epidemic?

Low male circumcision - MC policy and programme yet to be developed Multiple and concurrent partnerships - MCPs are highly prevalent, but not explicitly addressed in communication programmes Migration, intimate partner violence & income inequality – not adequately addressed policy and programmes asstructural drivers by Prevention activities are not well targeted to priority populations (discordant couples, migrant couples, out-of-school youth, sex workers etc.)


3) Is funding for HIV prevention allocated to where it is most needed?

According to the NASA 2006/07, only 11% of funding was spent on HIV prevention

There are great fluctuations in annual spending per intervention category and ‘communication for social and behaviour change’ received only 2% of prevention funding in 2006/07

HCT interventions - received considerable funding

PMTCT - received considerable funding

Expenditure on positive prevention was small, possibly due to a lack of a clear programme


Actual Spending based on NSP categories for 2005/06, 2006/07 and 2007/08

19%28%

18%

15%

11%

9%

31%

38%57%

35%22% 16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2005/06 2006/07 2007/08

Impact Mitigation

Treatment, Care &Support

Prevention

Mgt,Coordination &Support


Key Recommendations

1. Strengthen the commitment on implementation of existing policies; 2. Partner reduction as a key element of HIV prevention needs to be

integrated into all relevant prevention strategies and programmes;3. Fast-track the process of creating policy framework for a scale-up of

male circumcision (including harnessing traditional sector as appropriate);

4. Strengthen research and evaluation along side interventions in order to understand what works;

5. Revise content of prevention messages to address underlying social norms regarding Casual Sex & MCP;

6. Players at the district level to have a harmonised planning system which ensures synergy and sustainability of interventions; and

7. Institutionalise MOT study as a planning tool.


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Lesotho Modes of Transmission ( MoT ) Study Prevention Reference Group Meeting

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