Mbongolwane & Eshowe HIV Impact in Population Survey

Report
High incidence of HIV in young women
despite high ART coverage and viral
load suppression
Results from a population-based survey in
KwaZulu-Natal, South Africa
Helena Huerga
MSF-OCB Operational Research Day 2014
Background
• South Africa highest number of people with HIV and
on ART in the world
• MSF working in South Africa since >10 years
• Kwazulu-Natal (KZN): project “Bending the Curves”
– Aim to reduce HIV/TB incidence and morbi-mortality
– Gradually implemented since 2011
Background
Good understanding of HIV epidemic in a community
essential to define strategies of intervention
HIV+ at health facilities
(partial view of community)
HIV surveys in population
(overall view of community)
Objectives
Primary: To assess ART coverage
Secondary:
– To estimate HIV incidence & prevalence
– To assess viral load suppression
– To assess HIV testing coverage and access to HIV care & ART
– To assess access to PMTCT and male circumcision coverage
Methods
• Design: cross-sectional study
• Population:
– Aged 15-59 years
– Living in Mbongolwane / Eshowe
• Survey area:
– Pop: 115,000 hab.
– Rural, urban and farms
– 2 hospitals & 10 ART clinics
• MSF project:
– HIV testing in community
– Linkage to care
–
–
–
–
Support to MOH on ART
Early ART <500CD4
PMTCT B+
Male circumcision
Study
Procedures
Interview head
of household
Household
questionnaire
Interview eligible
individuals
Individual
questionnaire
duel
HIV test
HIV rapid test
(finger prick)
Blood collection
(phlebotomy)
Interview HIV
positive / Test
not done
Laboratory tests
- GCVL Durban
- Groote Schuur
Cape Town
- NICD Joburg
Positive
Discordant
Not done
Negative
3 tubes
3 tubes
1 tube
Questionnaire HIV care & ART
CD4 count
DBS cards
Viral load
Genotyping
Storage
ELISA HIV test
Positive
Plasma
separation
Negative
ARV levels
Incidence testing
- Biorad
- LAg
NAAT for acute
infection
Results: who participated?
2377 HH visited –> 6688 individual eligible –> 5649 (84.5%) included
Table: Participants’ socio-demographic characteristics
Women, n (%)
3518
62.3
26
19-40
Never married, n (%)
4234
75.0
Secondary education, n (%)
2806
49.7
Rural area, n (%)
4711
83.4
Student/unemployed, n (%)
4146
73.4
Moved residency, n (%)
761
13.5
Age, median years (IQR)
HIV prevalence: How many were HIV-positive?
Overall: 25.2% (95%CI: 23.6-26.9)
- Women: 30.9% (95%CI: 29.0-32.9)
Women age 30-39: 56%
- Men: 15.9% (95%CI: 14.0-18.0)
70
60
50
40
%
Women
30
Men
20
10
0
15-19
20-24
25-29
30-34
35-39
Age group
40-44
45-49
50-54
55-59
HIV incidence: How many new infections per year?
Women
Men
Total
/100 PY
(95%CI)
/100 PY
(95%CI)
/100 PY
(95%CI)
15-29 years
3.2
(1.4-4.9)
1.0
(0.0-1.9)
2.1
(1.1-3.2)
30-59 years
0.1
(0.0-1.7)
0.2
(0.0-2.0)
0.1
(0.0-1.4)
Overall
2.0
(0.7-3.2)
0.8
(0.0-1.6)
1.4
(0.6-2.3)
PY: person-year
ART coverage: How many in need of treatment
were on ART?
Overall: 75.0% (95%CI: 72.0-77.8)
- Women: 78.5% (95%CI: 75.8-81.0)
- Men: 63.9% (95%CI: 56.7-70.5)
89% successfully treated with ART
(VL<1000 copies/ml)
Women age 20-24: 42%
140
100
80
No ART
60
ART
40
20
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
0
Women
Number of ART eligible
CD4 <350 ; PMTCT B
120
55-59
When did they start ART?
• Time since ART initiated: 31.0 m (IQR: 12.4-61.0)
• Year range ART initiated: 1992-2013
Year of ART initiation
40
Start MSF project
35
30
37,1
25,5
25
% 20
16,7
12,5
15
10
8,3
5
0
Before 2006
2006-2007
2008-2009
2010-2011
2012-2013
HIV testing: who tested where?
HIV testing: 81.4% (95%CI: 79.8-82.9)
- Women: 88.4% (95%CI: 86.8-89.9)
- Men: 69.8% (95%CI: 67.2-72.4)
Place of HIV test overall
0.6%
18.9%
Time since test: 6 months (IQR: 3-16)
Number of tests: 3 times (IQR: 2-4)
Individuals aware of HIV status
1.9%
78.6%
3.3% 0.1%
2.0%
Public sector
Public sector
Private sector
MSF
Other
Public sector
94.7%
Who was already aware of their HIV infection?
Awareness: 75.2% (95%CI:72.9-77.4)
- Women: 77.7% (95%CI: 75.1-80.1)
Women & men 20 -24 y: 43.1% & 83.3%
- Men: 67.3% (95%CI: 62.0-72.1)
250
150
Not aware
100
Aware
50
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
0
Women
Number of HIV positive
200
55-59
Cascade of care
100
Of all HIV positive, 49% had no detectable
virus, and hence were not transmitting HIV.
% of all HIV positive
90
80
74.8%
65.4%
70
57.1%
60
52.1%
49.3%
Remained on
ART
Virally
supressed
50
40
30
20
10
0
Diagnosed
Linked to care
Initiated on
ART
Discussion
• KZN survey:
– ART coverage and VL suppression relatively good
– Overall moderate incidence in a high HIV prevalence area
– High incidence in young women
– Impact on the HIV epidemic but gaps in cascade of care
• Limitations: cross-sectional design in mobile population
• Strengths: survey in population, inclusion rate
Discussion
• Recommendations:
– Maintain quality and go further to enlarge eligibility criteria
– Develop strategies to test, link and treat young people 20-30y
– Include interventions for prevention focused on young women
• Implications on the operations:
– HIV population based surveys are critical to define strategies
– Change orientation of MSF intervention in KZN after survey?
Acknowledgements
Mbongolwane & Eshowe
study participants and
communities
South Africa survey team
Malika Bouhenia
Radoslav Antonov
Nomsa Nzama
Godwin Dube
Field teams
MSF South Africa
Gilles Van Cutsem
Ruggero Guilliani
Mathew Reid
Emilie Venables
Emilie Wang
MSF SAMU South Africa
Tom Ellman
Eric Goemare
Emmanuel Fajardo
Carole Metcalf
NICD Johannesburg
Adrian Puren
MSF Brussels
Marc Biot
SACEMA Stellenbosch
Alex Welte
Epicentre Paris
Jihane Ben Farhat
David Maman
Serge Balandine
Jean-François Etard
Global Laboratory Durban
Madurai Lorna
Bronwyn Pitam
Collin Pillay
University of Cape Town
Jennifer Norman

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