High incidence of HIV in young women despite

High incidence of HIV in young women despite high ART coverage and viral load suppression Results from a population-based survey in Kwa. Zulu -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 <500 CD 4 PMTCT B+ Male circumcision

Study Procedures

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) 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 age 20 -24: 42% - 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)

When did they start ART? • Time since ART initiated: 31. 0 m (IQR: 12. 4 -61. 0) • Year range ART initiated: 1992 -2013 Start MSF project

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 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)

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% 50 49. 3% 40 30 20 10 0 Diagnosed Linked to care Initiated on ART Remained on ART Virally supressed

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 -30 y – 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