HTC Plus

For effective HIV Prevention, Treatment & Care for Young People

Becoming a Plus Activist

Prepared by Rick Olson UNICEF Senior HIV Specialist (Prevention & Adolescents) Eastern & Southern Africa Regional Office ICASA Pre Youth Conference Cape Town 05 Dec. 2013

Some Progress

3.5 Billion Google Results

AIDS: 350 Million Google Results

Normal human behaviour

but with conseqences

Penicillin Cures 1st Patient in 1942

The United States produces 2.3 million doses in time for D-Day the invasion of Normandy - spring 1944

Global estimated incidence of syphilis, 2005

Total number of cases

303 000
Total number of cases

43 000
Female 9 040 Male 34 234
Total number of cases

Female 150 888 Male 152 011

587 000
Female 287 292 Male 299 966

Total number of cases

1 052 000
Female 517 819 Male 533 778

Total number of cases Total number of cases

2 350 000
Female 1 151 222 Male 1 198 596
Total number of cases

2 847 000
Female 1 449 089 Male 1 398 137

3 496 000
Female 1 527 061 Male 1 969 653
Total number of cases

10 680 000
Female 5 092 414 Male 5 586 377

Reduction in New Infections Among Children, Adolescents & Young People

The 16th International Conference on AIDS & STIs in Africa, Addis Ababa

Getting to Zero Burden of new Infections among Young People

(UNICEF Administrative Geographical Areas)

52

% of new infections among young people 15-24

23

2.5

2.9

4.4

4.9
Latin America & Caribbean

5.7
South Asia West & Central Africa East & Southern Africa

Central & Eastern Middle East & North East Asia & Pacific Europe & Africa Commonwealth of Independant States

Trends in HIV Prevalence in Females 15-19 year

9 8 7 6 5 4 3 2 1 0 03 to 05 DHS 08 to 10 DHS 6.2 Kenya 7.9

3.7
3

4.2 4.1 4.2 2.7

Malawi Zimbabwe

Lesotho

The 16th International Conference on AIDS & STIs in Africa, Addis Ababa

Which young people are most at risk of HIV infection? Need for Disaggregated Data? HIV Prevalence by Age Bands
Get ahead of the virus with females 15-17
Males 15-17
Males 23-24 Females 15-17 Females 23-24 19.1 9.1 3 2.7 1.4 Swaziland (07) 31.6 43.3

5.7 1.7

8.3

7.2 1 2 0.6 2

2.8

4.6 3.4

7.5

6.2

Kenya (08)

Tanzania (07)

Malawi (10)

Lesotho (09)

Females 15-24 Some HIV Prevalence Variations

(Recent DHS & AIS)

Never Married Females

Married

Widowed/Divorced

49.6

19 10.3 5.6 1.3 3.8 5.5 12.9 8.4 5.2 15.7 9.2

Tanzania (2010)

Malawi (2010)

Zimbabawe (2011)

Lesotho (2009)

Relationship Context Transition among Females 15 -24

(DHS Data)
Never Married
90 80 70 60 50 40 30 20 10 0
18.4 9 1.3 2.8 27.7 23.4 14.2 9.6 2.7 23.2 25 11.9 16.3 1 4.5 80.3 73.8 63.3

Married or Living Together

76.2

Divorced, Separated or Widowed

82.7

74.1 63.1 55.4 40.1

Percentage of Females 15, 17 and 19 years of Age who have started Childbearing (DHS Data)
70 60 50 40 30 20 20.3 13.9 3.3 0 2.7 16.5 63.5 58.6

15

17

19
36.2 40.8 41 44.3 44.5 47.8

54.6

34.6

28.7

19.2
14 1.9 3

20.7 5.2

22.4

25.5

20.1 5.8

21.7

10 0

2.1

4.2

3.9

1.9

3.5

Trends - % of 19 year olds who have started Childbearing

80 70 60 67.9 63.5 45.6 43.7 41.2 Rwanda Kenya Malawi Zimbabwe Lesotho 20.3 12.8

50
40 30 20 10 0

47.8 41 36.2

03 to 05 DHS

08 to 10 DHS

Priority Results for Young People Eastern & Southern Africa - Baselines
% of Young People 15-24 with Comprehensive Knowledge
Regional Average:

% of Young People 15-24 with multiple partners who reported condom use at last sex
Regional Average:

% of Young People 15-24 who have had an HIV test and received results in the past 12 months
Regional Average:

Females: 34% Males: 40%

Range among Females: High: Namibia 62% Low: Mozambique 23%

Females: 34% Males: 45%

Range among Females: High: Namibia 74% Low: Madagascar 3%

Females: 22% Males: 14%

Range among Females: High: Lesotho 58% Low: Ethiopia 5%

Trends in % Comprehensive Knowledge Females 15-24 55 50 45 40 35 30 25 36 45 44 52 48 42 39 34 65 60 55 50 45 40 35 30 25 20 15

Trends -% of Sexuality Active Females aged 15-19 who used a condom at last sex - Increasing use but not consistent use
62.3 50.2 46 38.7 36.9 24.7 2004/05 Kenya Malawi 2009/10 Tanzania Lesotho 45.4 41.8

26
20 2003-05
Mozambique Tanzania Lesotho Zimbabwe

20
15

2009-11
Malawi

HIV Prevalence, Condom Use & Comprehensive Knowledge Poorest & Wealthiest Females 15-24 (AIS/DHS)

13.5

Prevalence

66 9.4
35 35 52

8.1 62 3.2 27
17

10 56 5.2 23 32 23 48
Zambia Wealth

4.6

Condom Use high risk

44 3 27 26 52 27
Tanzania Poor (3.6) Tanzania Wealth

23 55

33

Ever had Sex high risk

26
Lesotho Poor (13.6)
Prevalence Females 15-24

48
Lesoth Wealth

Comprehensive Knowledge

33
Malawi Poor (5.2)

24
Malawi Wealth Zambia Poor (8.5)

Follow the Money - HTC to HTC Plus - a Programming Platform for adolescent sensitive HIV prevention programming
UNAIDS and UA Data

Scale-up of HTC Sites

Lesotho Zimbabwe Zambia Malawi 1689

# of HIV Tests
Lesotho Zimbabwe Zambia Malawi
1726762

Malawi 11-12 #Q 1.2 Million

33% males 35% non pregnant females 32% pregnant females

1612388

1218 772 310 216 56 14 50 2001 2004 2010 806

1318975

213000 40806

288000

18380

235295

2000-1 2011

2004

2010

Tanzania 2010 2193 Sites 2.1 million Tests 840,000 young people

Average # of tests per day per site

Zambia = 2.1, Tanzania = 2.6, Lesotho = 2.9, Zimbabwe = 3.6 , Malawi = 6.1

The 16th International Conference on AIDS & STIs in Africa, Addis Ababa

Opportunity to reduce vulnerability through integrated services HTC Plus

Trends -% of Females aged 15-19 who have ever tested for HIV Kenya Tanzania Malawi Lesotho Zambia 51 43.1 35.2 29.3 27.8 9.7 7 6.8 6.5 2004/05 2009/10

% of these females clients are accessing testing in ANC are these services meeting the needs of adolescent girls? In HTC individuals have undertaken some sort of risk assessment have put a behaviour in to practice [with the testing behaviour indicator showing the largest increase in population based trend data] - but are positive and negative adolescent clients getting relevant post-test services??

The 16th International Conference on AIDS & STIs in Africa, Addis Ababa

Trends - % of Sexually Active Females 15-19 who have gone for an HIV Test in the past 12 months
(DHS Data)

[Against condoms use at last sex among the proportion who where sexually active in 2010]

Tested 2004/05

Tested 2009/11

Sex in Last 12 Months

69.3 59.4 48.5

35.3

35.4 26.9 17.2 5.7

39.6

25.5

26.9

15.2
4.7 8

4.1

4.2

5.6

4.6

Kenya

Tanzania

Zimbabwe

Lesotho

Malawi

Rwanda

Large % of these adolescent females clients are accessing testing in ANC are these services meeting the needs of adolescent girls? In HTC individuals have undertaken some sort of risk assessment have put a behaviour in to practice [with the testing behaviour indicator showing the largest increase in population based trend data] - but are positive and negative adolescent clients getting relevant post-test services?

Young people are using HIV Testing Services and new evidence says we need to make them more effective!!
(See: The role of voluntary counseling and testing (VCT) in changing risk behaviors related to HIV - Fonner VA,
Denison J, Kennedy CE, O'Reilly K, Sweat M. September 12, 2012 - Cochrane Review Group on HIV/AIDS)

Malawi 42% of HTC clients are in the 1524 age range

ESAR 2010 Around 25,000 HTC sites

Approximately

Zimbabwe 38% of HTC clients are in the 15-24 age range

37 million HIV tests

(60% of clients are females)

14 million
could have been young people!
(Was it an adolescent and youth sensitive service?)

Malawi - 5 Districts in Malawi - sex breakdown among adolescent 10-19 who have tested for HIV

The 16th International Conference on AIDS & STIs in Africa, Addis Ababa

Zambia Reason Females 15-19 Dont Test (2009 BSS)

Need for Treatment Literacy, Stigma Reduction and Psycho-Social Support Interventions 70 60 50 40 30 23.9 12 10 23.7 27.5 57.8

20

0
Not at Risk Fear of Results Fear of Stigma

Old/New

VMMC

Tanzania Example - 750,000 young people testing per year 100 condoms per young person would need 75 million condoms a year in HTC!

The Plus
Malawi HTC 5 District Data

75% of HIV positive adolescents were

referred to additional services But only 2% of HIV

negative adolescents
were referred to other services

Trends in AIDS Related Deaths among Children, Adolescents & Young Adults

15-19 year olds have the worst pre-ART retention (ICAP Data 2011 M. Lamb)
60% Proportion lost to follow-up in pre-ART phase one year after enrollment into care (blue bars) Proportion lost to follow-up one year after ART initiation (orange bars) 50%
Based on 50,203 young people 16% of all ICAP Patients in 4 countries & 123 clinics

40%

30%

pre-ART ART

20%

10%

0% 11-14 years 15-19 years 20-24 years 25-29 years

*Among patients enrolling April 2008-March 2010. Loss to follow-up is defined as patients not known to have died or transferred without a visit in the last year of data collection (pre-ART) or the last 6 months of data collection (ART). Patients LTF are censored 3 months after their last visit (pre-ART) or 15 days after their last visit (ART).

2011

Body Wasting the new fear factor?

Continuum of HIV prevention for Sexually Active Adolescents & Young Adults

HTC Utilization Sexual Intercourse with condom use Sexual Intercourse without condom use Sexual Intercourse with condom use

Access to HTC when condom use inconsistent Transition to Adulthood ->

At a minimum - on-going through multiple channels age relevant communication
on positive sexual health & development, risk avoidance options, consistent condom use, HIV testing and counseling services and ART benefits ->

Condoms requirements as per HTC guidelines

Malawi (2012)
1.7 million Tests 20 condoms per clients 34 million condoms but only 31 million condoms distributed (free & social marketed ) in all services

Zambia (2012)
2.1 million test 30 condoms per clients 60 million condoms -> but only 46 million distributed (free & social marketed ) in all services

Estimated Population of Young People 15-24 and Male Condom Supply

(In Millions Free & Social Marketed) Young People 15-24 Male Condom Distribution
400

180

111 90 32 0.3 7.2 Swaziland (08) 0.47 Namibia (08-09) 0.48 5.5

29.5
0.43 Botswana

18.3 2.2 Rwanda (09)

22.3 2.6 Zambia (11)

31 3 Malawi (11) 3.1 8.6 8.3 10.7 South Africa

Lesotho (08)

Zimbabwe Tanzania Kenya (10) (11) (10)

Advocacy with MOH HTC Committees -> Post-Test Support Services Minimum Mix ART HIV + At-Risk Ado HTC Expert Client ALHIV

Teen Club Community

PTC Health Based Services Youth Groups Community

HIV -

For Post Test Support Services

Adherence Reminders for PLHIV

Appointment Reminders via SMS

Follow-up & Tracking

Building a Support System

PYP

PYP

PYP

Building a Support System

PYP

PYP

PYP

Vertically Infected Adolescents in Care in Uganda Some Findings

(Source: Sample 732 ages 15-19 Sexual & reproductive health needs of adolescents perinatally infected with HIV in Uganda Birungi, et al, Frontiers, 2008)

In a sexual relationship Disclosed their status to sexual partner Always use a contraceptive method Involved with a pregnancy

47 48 35 42
Males Females

45 16 41 40

58

20

60

80

Expanding the Post Test Support System

NYP NYP

PYP

PYP

NYP
Condom distribution site

NYP
NYP PYP NYP NYP

HTC Plus Activism

Quality Youth Sensitive HTC post-test counselling experience for both negative & positive clients condom demonstration & promotion and referral to other services information & contacts for community based support services Quality Post Test Support Services community level referral and follow-up care and support services for positive young people HIV prevention support for negative young people

Making them work!

Thank you!

It always seems impossible until its done.

-Nelson Mandela