HIV/AIDS Situation in Mauritius
Dr. A. Saumtally
Grants Manager, Global Fund National AIDS Secretariat
Adults and children estimated to be living with HIV in 2008
33.4 million (31.1–35.8 million) North
America
1.4 million
Caribbean
240 000
Eastern Europe
& Central Asia
Western
Europe
Latin
America
2.0 million
1.5 million
850 000
East Asia & Pacific
850 000
South
North Africa
& Middle East & South-East Asia
310 000
3.8 million
Sub-Saharan
Africa
22.4
million
Total: 39.5 (34.1-47.1)
million
Oceania
59 000
HIV INFECTIONS AND TRANSMISSION SOURCES GLOBALLY
IDU
Heterosexual
SW
MSM
IDU
SW
IDU
MSM
Heterosexual
Types of HIV/AIDS Epidemic
High Risk Group
IDUs, SWs, MSM, Seafarers
Migrant population Soldiers, Police officers
Pregnant women
Low Prevalence
All groups < 5 %
< 1 %
Concentrated
Any group > 5%
< 1 %
Mauritius
Generalised Epidemic
IDUs: 47.4% (2009)
SWs: 28.9% (2010)
MSM: 8.1% (2010)
Seafarers: 6.7% (2008)
No Reference
0.48%
(2010)
> 1 %
Situation in Mauritius
From 1987 to end of December 2010
• Detected cases of HIV/AIDS: with 4844 Mauritians (3905 males and 939 females). • Sex ratio male to female is 4.3 : 1
• Deaths due to HIV/AIDS reported : 484
• 28 children of age 1 to 14 years: 6 died, 7 on ART • Roughly an average of 540 new infections yearly since 2006
Nombre Cumulatif de Nouveaux Cas de VIH Détectés
4000
3500
HIV cases detected since 1987
3000
FEMALE
MALE
2500
2000
1500
1000
500
0
92
93
94
95
96
97
98
99
2000
2001
2002
2003
2004
2005
2006
2007
2008
Distribution of detected cases
2009 UNAIDS estimate: The Prevalence is 0.97% (0.6 –
1.9%) equivalent to 7800 (6,000 – 12,000) people
No. of people
No. of off track people (Approx)
7800 – 4800 = Detected cases
As at Feb. 2011 4844
3000
(2000 – 7000)
Registered cases 3000
at the Day Care Including Centres for HIV
Prisoners Compliant to follow‐up
CHALLENGE
2500
(4800‐3000)
1800
500
Total = 5300
Probable Reasons
Not informed or not aware of HIV
Not feel concerned
Not interested (IDUs) *
Fear to do a test (Stigma)
Fear to know the status
Don’t want to attend Public Services
Denial
Results not given
Not interested (IDUs, CSWs)
Stigma and Discrimination
Stigma and Discrimination
Urgent need for early diagnosis and treatment ** HIV Testing
• The VCT services have been decentralized: – 2005: all regional hospitals
– 2006: in private clinics
– February 2009:
• extended to all Area Health Centres and peripheral Hospitals. • Mobile screening services include a component of HIV and AIDS.
• National Strategy has been elaborated
• Guidelines have been finalised to allow NGOs to perform Rapid Tests where results are obtained after only 15 minutes • Tests carried out annually: about 89000
– 45000(Blood donors)+ – 15000(ANC) + – 27000(pre‐op/migrants/ PITC/ prison) + – 2000 VCT From 1987 to end of December 2011
• Age Groups:
– 15 to 24 years represent 18.5%; (1/5)
– 25 to 39 years represent 54.6% (1/2)
• Mode of contamination:
– 74.5 % through injecting drug use – 17.8 % heterosexual transmission
Pattern of HIV among 15-24 years olds
19
8
19 7
88
19
8
19 9
9
19 0
91
19
9
19 2
93
19
94
19
95
19
96
19
9
19 7
98
19
9
20 9
00
20
0
20 1
02
20
0
20 3
04
20
05
20
06
20
07
cases
1000
900
800
700
600
500
400
300
200
100
0
years
Total reported HIV/AIDS
cases
15-24 years old HIV/AIDS
cases
Evolution of HIV epidemic in Mauritius: 1987-2007
1000
900
800
700
cases
600
500
400
300
200
100
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
0
years
Total reported HIV/AIDS cases
Injecting drug transmission
Heterosexual transmission
The observed sharp rise of reported HIV/AIDS cases in Mauritius is most likely due to increased HIV testing particularly among IDU in various institutions (prison, rehabilitation centres, outreach
services)
New detected cases according to sex
No. of new detected cases of HIV
1000
% of new detected cases of HIV accoding to sex
% F
900
% M
800
88.4 88.5
700
83.9 82.8
600
500
64
79.6
74.2
74.7
25.8
25.3
76.2
61.8 60.2
400
300
36
200
38.2 39.8
100
16.1 17.2
20.4
23.8
11.6 11.5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Female
Male
Total
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Cas de VIH positifs répertoriés par district
1% 1%
3% 3% 2%
2%
3%
1%
Black River
Flacq
12%
Grand Port
Moka
Pamplemousses
P.Wilhems
18%
54%
P.Louis
R. du Rempart
Rodrigues
Savanne
Unknown
Mapping of HIV cases in Mauritius
Sources : AIDS Unit, MOH & QL, 2008
AntiRetroviral Treatment ‐ 2002
No. Of Patients (Apxt)
No. of people initiated on Antiretroviral Treatment
New protocol: Increase the Based on Lymphocytes T threshold of CD4 to 350 (WHO)
CD4 cout <300/mm³
900 Death recorded
100
Adherent patients
650
Lost to follow‐up
150
No. of resistant cases
New Caese on ART
Remarks
3
Increasing no. yearly
(150 Last year)
Diagnosed at a too late stage of the disease
Non‐AIDS Related = IDU
Stigma and Discrimination
IDUs activities???
Stopped Rx when feeling well
Half of patients diagnosed in AIDS Stage */**
Undiagnosed no. of people infected
No. of people in need of ARVs (CD4 <350 /mm³)
CHALLENGE
5000
10 ‐15% =
500 ‐ 750
Where are they?
Not Diagnosed yet.
Attending hospitals
in the AIDS Stage
Urgent need for early diagnosis and treatment
HIV Prevalence in Pregnant Women
15‐45 Yrs
15‐24 Yrs
0.67
0.52
0.48
0.42
0.38
0.34
0.33
0.3
0.27
0.33
0.26
0.17
0.07
0.04
2000
0.09
0.07
0.09
0.08
0.11
0.1
0.04
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Paediatric HIV Cases
New detected cases
Death Registered
Living with HIV
2000
7
0
7
2002
2
2
7
2005
4
1
10
2006
2
0
12
2007
3
0
15
2008
4
1
18
2009
6
0
24
2010
6
2
28
Total
34
6
28
Rodrigues island
Mode of Infection for the detected cases per year
6
5
4
IDU
3
HTS
MTCT
2
1
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Thank you Introduction of Harm reduction strategies
November 2006
• Needle ‐Syringe Exchange Programme
• Methadone Substitution Therapy
Needle ‐Syringe Exchange Programme
• November 2006: Introduction of the NEP by NGOs with the support of the Ministry. • December 2006: Enactment of HIV and AIDS Act – (WHO‐ local consultant; UNHCR; UNDP) allowing NEP
• May 2007: Financial support to NGOs(allowance to social worker + material) to carry out NEP. (around 600 clients reached by NGOs to date: 8 sites)
• As at May 2008: Two mobile caravans have been made available and staff of the Ministry also carries out the NEP • As at December 2010: MOH is covering 35 sites and NGOs 9 sites touching about 5600 clients around the island
• Challenge was to enhance Quality of these services: • Training in psycho‐social support for service providers and Peer Educators
• Opening of drop‐in centres : one‐stop shop allowing more interaction between client and provider
Methadone Substitution Therapy (MST)Programme
• 21 November, 2006: Introduction of MSTProgramme at the National Detoxification Centre. • 10 March 2008: Opening of National Methadone Substitution Therapy Centre (Female). • Currently about 3844 clients (of whom 237 females) have been induced on Methadone Substitution Treatment.
• MST initiation on an outpatient daycare basis is available at Mahebourg Hospital & Ste Croix
• Dispensing MST Units: 16 in all including
– 1 is operational at each of the 5 Regional hospitals, – 1 at Brown Sequard Mental Health Care Centre, and – 1 at Bouloux AHC (ex:NDCCI)
HIV STRUCTURE
Envelope Proteins
Envelope
gp120
gp41
Matrix Protein
p17
Core Proteins
p24
RNA
RT
Integrase
Protease
NEW
VIRUS
INFECTING
VIRUS
HIV
RNA
INTEGRASE
REVERSE
TRANSCRIPTASE
Insertion
in Host
Genome
REVERSE
TRANSCRIPTION
D. S.
HIV
DNA
HIV
mRNA
INTEGRATION
HIV
LIFE
CYCLE
PR
RIBOSOMES
SE
S. S.
HIV
DNA
HIV
precursor
proteins
O
TE
A
HIV
RNA
ASSEMBLY
HIV
RNA
HIV LG. PROTEINS
Diagnostic Techniques
PMTCT prophylaxis
• Dec 1999: – Prophylaxis PMTCT by monotherapy: AZT
– Provision of artificial milk for 2 years free of user cost
• April 2004: Combined triple therapy started • Target:
• Combined therapy with indetectable viral load at week 34 : normal delivery given higher modbidity with caeserean section
• Challenges
• From 69% in 2009, 81 % compliance reached in 2010 though difficult client tracing
• Non‐compliance to PMTCT prophylaxis mainly among IDUs and SWs
• PMTCT prophylaxis now starting at 14 wk of pregnancy instead of 26 wk