Monitoring and evaluation and research on
HIV/AIDS in Africa:
What do tell us and what more is needed?
Kevin R O’Reilly
World Health Organization
Geneva, Switzerland
00002-E-1 – 1 December 2002
Key points M & E tells us:
z
Epidemic in Africa is stabilizing
– why?
– Future?
z
prevention and care must be inextricably bound together
z
better surveillance, research and M & E is needed for definitive
(or clearer) answers
00002-E-2 – 1 December 2002
Global Distribution of 42 million People
Living with HIV in 2002
Sub-Saharan Africa
South & Southeast Asia
East Asia & Pacific
Latin America
Eastern Europe & Central
Asia
Caribbean
North America
Western Europe
North Africa & ME
00002-E-3 – 1 December 2002
The Global Distribution of Prevalence (Old +New) is still very
similar to the Global Distribution of Incidence (New)
Prevalence
00002-E-4 – 1 December 2002
Incidence
Trends in Number of People Living with HIV
infection 1980 - 2002 by WHO Region
30,000,000
25,000,000
AFRO
EURO
AMRO
WPRO
SEARO
EMRO
20,000,000
15,000,000
10,000,000
5,000,000
00002-E-5 – 1 December 2002
02
20
00
20
98
19
96
19
94
19
92
19
90
19
88
19
86
19
84
19
82
19
19
80
0
What is future if epidemic is stabilizing?
z
Reasons for stabilization
z
Treatment may increase the number of people living with
HIV/AIDS
z
prevention must not be neglected and even increased
– pool of young people (likely to be infected) is large
00002-E-6 – 1 December 2002
Age in years
Projected population structure with
and without the AIDS epidemic, Botswana, 2020
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Males
Females
Projected population
structure in 2020
Deficits due to AIDS
140 120 100 80
60
40
20
0
20
40
60
Population (thousands)
Source: US Census Bureau, World Population Profile 2000
00002-E-7 – 1 December 2002
80 100 120 140
What do M & E tell us about prevention
efforts?
z
Estimates of additional needs in prevention
z
Example of further needed synergy between prevention and care
00002-E-8 – 1 December 2002
Estimated global need for testing and
counseling, 2003
z
For prevention of mother to child transmission: 46 million
z
For access to treatment: 37 million
z
For prevention: 101.1 million
z
Grand total: 184.1 million
00002-E-9 – 1 December 2002
Four-pronged Strategy for MTCT
Prevention
Prong 1:
Prong 2:
Prong 3:
Prevention
of HIV in
women,
especially
young
women
Prevention
of
unintended
pregnancy
in HIV
infected
women
Prevention of
transmission
from HIV
infected
woman to her
infant
00002-E-10 – 1 December 2002
Prong 4:
Care for
infected
women,
their
infants and
families
UNGASS goal
By 2005, reduce the proportion of infants infected with
HIV by 20%
By 2010, reduce the proportion of infants infected with
HIV by 50%
00002-E-11 – 1 December 2002
Problems inherent in UNGASS goals
z
Implied emphasis on Prong 3
z
little attention to Prongs 1 and 2
z
simple modelling shows the difficulty of reaching the goals with
Prong 3 alone
00002-E-12 – 1 December 2002
Reaching the goal with Prong 3
z
To reach goal for 2005 (20% decrease)
– a. ANC coverage must be 90%
– b. acceptance of VCT must be 70%
– c. acceptance of NVP must be 75%
z
To reach goal for 2010 (50% decrease)
– a-c must be 100%
(since effectiveness of NVP is 47%)
00002-E-13 – 1 December 2002
Condom use among men with non-regular partners over time
in selected sub-Saharan African countries: 1994-2000
60
Malawi
Tanzania
50
%
Uganda
Zambia
40
30
20
1994
1995
1996
1997
1998
Source: Macro International (1994-2000) Demographic Health Surveys; Measure Evaluation
00002-E-14 – 1 December 2002
1999
2000
HIV prevalence and reported consistent condom use
among female sex workers, Abidjan, Côte d'Ivoire, 1992-1998
HIV prevalence
Reported consistent condom use
% HIV seropositive
80
80
60
60
40
40
20
20
0
0
1992
1993
Source: Ghys PD et al. (2002) AIDS
00002-E-15 – 1 December 2002
1994
1995
1996
1997
1998
% consistent condom use
100
100
Casual sex and condom use
by educational status, Mozambique
Respondents reporting
the behaviour (%)
60
casual sex in the past year
condom use at last casual sex
50
40
30
20
10
0
0-2
3-6
7-9
10+
Number of years respondent spent in school
Source: Agha S, et al. The promotion of safer sex among high-risk individuals in
Mozambique, Population Services International, USA, 1999
00002-E-16 – 1 December 2002
Percentage of sexually experienced girls
in South Africa who say …
“I have been forced to have sex.”
Yes
39%
“I am afraid of saying no to sex.”
Agree
33%
No
61%
7%
Agree
55%
Disagree
39%
6%
“There are times I don't want to have sex
but I do because my boyfriend
Insists on having sex.”
Source: Kaiser Family Foundation/KLA (2000) South African National Youth Survey
00002-E-17 – 1 December 2002
Disagree
60%
Number of reported rapes and convictions
in Botswana, 1984 to 1997
1400
reported rapes
1200
convictions
Number
1000
800
600
400
200
0
1984
85
86
87
88
89
Source: Emang Basadi Women’s Association, Botswana, 1998
00002-E-18 – 1 December 2002
90
91
92
93
94
95
96
1997
Condoms per man per year
Condom gap in sub-Saharan
African countries in 1999
Six countries
with highest
condom
procurement
rate
30
25
20
Average condom procurement of top 6 countries = 16.9
15
10
Additional condoms needed to get all
countries to the level of 16.9 = 1.9 billion per year
5
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
Countries in sub-Saharan Africa, ordered by condom procurement rate
Source: Shelton JD, Johnston B (2001) Condom gap in Africa: evidence from donor agencies and key infromants,
British Medical Journal
00002-E-19 – 1 December 2002
00002-E-20 – 1 December 2002
Global estimates for adults and children
end 2002
z
People living with HIV/AIDS
42 million
z
New HIV infections in 2002
5 million
z
Deaths due to HIV/AIDS in 2002
00002-E-21 – 1 December 2002
3.1 million
Adults and children estimated to be living
with HIV/AIDS as of end 2002
North America
980 000
Caribbean
440 000
Latin America
1.5 million
00002-E-22 – 1 December 2002
Eastern Europe
Western Europe & Central Asia
570 000 1.2 million
East Asia & Pacific
North Africa
1.2 million
South
& Middle East
& South-East Asia
550 000
6 million
Sub-Saharan
Africa
29.4 million
Australia
& New Zealand
15 000
Total: 42 million (3.2 mln children)
HIV Prevalence (% of adults 15-49)
by Sex and Region in 2002
Australia & NZ
East Asia & Pacific
North Africa & ME
Men
Western Europe
Women
EEurope & Central Asia
Latin America
South & Southeast Asia
North America
Caribbean
Sub-Saharan Africa
0
00002-E-23 – 1 December 2002
2
4
6
8
10
Estimated number of adults and children
newly infected with HIV during 2002
North America
45 000
Caribbean
60 000
Latin America
150 000
00002-E-24 – 1 December 2002
Western Europe
30 000
North Africa
& Middle East
Eastern Europe
& Central Asia
250 000East Asia & Pacific
270 000
South
83 000
Sub-Saharan
Africa
3.5 million
Total: 5 million
& South-East Asia
700 000
Australia
& New Zealand
500
(0.8 mln children)
Global Distribution of 5 million Newly
HIV Infected People in 2002
Sub-Saharan Africa
South & Southeast Asia
East Asia & Pacific
Latin America
Eastern Europe & Central
Asia
Caribbean
North America
Western Europe
North Africa & ME
00002-E-25 – 1 December 2002
Estimated adult and child deaths
from HIV/AIDS during 2002
North America
15 000
Caribbean
42 000
Latin America
60 000
00002-E-26 – 1 December 2002
Western Europe
8 000
Eastern Europe &
Central Asia
25 000
North Africa
& Middle East
37 000
Sub-Saharan
Africa
East Asia & Pacific
45 000
South
& South-East Asia
440 000
2.4 million
Total: 3.1 million
Australia
& New Zealand
<100
Global Distribution of 3.1 million Adult and Child
Deaths from HIV/AIDS in 2002
Sub-Saharan Africa
South & Southeast Asia
East Asia & Pacific
Latin America
Eastern Europe & Central
Asia
Caribbean
North America
Western Europe
North Africa & ME
00002-E-27 – 1 December 2002
About 14 000 new HIV infections a day in 2002
z
More than 95% are in developing countries (70%
are in Africa)
z
2000 are in children under 15 years of age (9 out
of 10 are in Africa)
z
About 12 000 are in persons aged 15 to 49 years,
of whom:
— almost 50% are women
— about 50% are 15–24 year olds
00002-E-28 – 1 December 2002
Strategies for reaching UNGASS goals
zRapid
scaling up of ANC, VCT, NVP
zexploration
00002-E-29 – 1 December 2002
of other prongs
New infections (millions)
Projected new adult HIV infections with and without a timely
implementation of a comprehensive interventions package
6.0
5.0
4.0
3.0
2.0
1.0
0.0
2000
2002
2004
2006
2008
Year
No intervention
00002-E-30 – 1 December 2002
Timely intervention
2010
Projected new HIV adult infections according
to timing of implementation of a comprehensive
interventions package, 2002-2010
No intervention
Timely intervention
Delayed intervention
0
10
20
30
40
Total Infections (millions), 2002-2010
00002-E-31 – 1 December 2002
50
Percentage of women who are mothers
or pregnant by the end of their teens, 1990-1998
Percentage
of women
80
60
40
0
B
e
C nin
am
er
oo
n
C
A
C R
om
C
ôt oro
e
s
d'
Iv
oi
G re
ha
na
K
en
M
ad ya
ag
as
ca
r
M Ma
oz li
am
b
N iqu
am e
ib
i
N a
ig
e
N r
ig
e
R ria
w
an
Se da
ne
ga
To l
g
U o
ga
n
Za da
m
Zi bi
m a
ba
bw
e
20
Source: Demographic and Health Surveys, various countries
00002-E-32 – 1 December 2002
HIV prevalence (%)
HIV prevalence rate among teenagers
by age in Kisumu, Kenya
35
30
25
20
boys
girls
15
10
5
0
15
16
17
18
Age in years
Source: National AIDS Programme, Kenya, and Population Council, 1999
00002-E-33 – 1 December 2002
19
Leading causes of disease burden
in Africa, 2000
25.0
20.6
20.0
% of
Total
15.0
10.1
10.0
8.6
6.3
6.1
4.5
5.0
3.6
2.8
1.8
1.9
0.0
HIV/AIDS
Lower
respiratory
infections
Malaria
Diarrhoeal
diseases
Perinatal
conditions
Maternal
conditions
Measles
Other
unintentional
injuries*
Tuberculosis
* Unintentional injuries aside from traffic accidents, poisoning, falls, fires and drowning
Source: The World Health Report 2001, WHO
00002-E-34 – 1 December 2002
Pertussis
Estimated and projected deaths at ages 15-34,
with and without AIDS in South Africa: 1980-2025
Deaths (Thousands)
2,000
1,600
Without AIDS
With AIDS
1,200
800
400
0
1980-1985 1985-1990 1990-1995 1995-2000 2000-2005 2005-2010 2010-2015 2015-2020
Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision.
00002-E-35 – 1 December 2002
2020-2025
HIV prevalence rate among 13 to 19-year-olds
Masaka, Uganda, 1989 to 1997
HIV prevalence (%)
5
Girls
4
Boys
3
2
1
0
1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97
Source: Kamali et al. AIDS 2000, 14: 427-434
00002-E-36 – 1 December 2002
HIV prevalence rate among pregnant
15 to 19-year-olds, Lusaka, Zambia, 1993 to 1998
1993
1994
1998
HIV prevalence (%)
35
30
25
20
15
10
5
0
Chelstone
Chilenje
Kalingalinga
Clinic
Source: Ministry of Health, Zambia, 1999
00002-E-37 – 1 December 2002
Matero
Prevalence in 15-24 years old first time testers
Kampala, Uganda
HIV Prevalence (%)
30
Males
25
Females
20
15
10
5
0
1992
1993
Source: Uganda National AIDS Programme
00002-E-38 – 1 December 2002
1994
1995
1996
1997
1998
1999
2000