Title: Overview of the HIV Epidemic in Eastern and Southern Africa: Are we on track to achieve the HLM 2015 targets? Implications for CSO mobilisation & Capacity Building"

1. Overview of the HIV Epidemic in Eastern and
Southern Africa:
Are we on track to achieve the HLM 2015
targets? Implications for CSO mobilisation &
Capacity Building"
Dr. Mbulawa Mugabe, Deputy Director,
UNAIDS Regional Support Team for Eastern and Southern Africa

2. 34 million people living with HIV, 2011

3. 2015 targets in the UN Political Declaration 2011
1 2 3 4 5
Halve sexual Halve infections Eliminate new HIV 15 million Halve tuberculosis
transmission among injecting infections among people on HIV deaths among
drug users children and halve treatment people living with
AIDS-related HIV
maternal deaths
6 7 8 9 10
Close the global Eliminate gender Eliminate stigma Eliminate Eliminate parallel
resource gap and inequalities and and discrimination travel related systems, for stronger
achieve annual sexual violence restrictions integration
investment of and increase
US$ 22-24 bn capacities of
women and girls

4. Reduce sexual transmission of HIV by
50%
• In 2011, there were approximately 2.2 million new infections
in adults globally; 1 million of them were in ESA.
• Decline in New Infections from 2001 to 2011:
– 7 countries in ESA achieved over 50%
– 4 countries achieved 26-49%
– 2 countries achieved 10-25%
– 3 countries remained stable
– 1 country showed an increase
• All countries need to achieve 50% decline from 2009 to 2015

5. % Change in Incidence 2001 – 2009
% Change in
Country 2001 Prevalence 2001 Incidence 2011 Prevalence 2011 Incidence
Incidence 2001-11
Malawi 13.8 1.74 10.0 0.49 -72
Botswana 27.0 3.48 23.4 1.00 -71
Namibia 15.5 2.39 13.4 0.77 -68
Eritrea 1.1 0.08 0.6 0.03 -67
Zambia 14.4 1.89 12.5 0.80 -58
Rwanda 4.1 0.31 2.9 0.15 -53
Zimbabwe 25.0 2.11 14.9 1.05 -50
South Africa 15.9 2.42 17.3 1.43 -41
Swaziland 22.2 4.11 26.0 2.60 -37
Kenya 8.5 0.66 6.2 0.45 -32
Mozambique 9.7 1.63 11.3 1.13 -31
Sudan South 2.6 0.41 3.1 0.33 -21
Angola 1.7 0.26 2.1 0.21 -19
Lesotho 23.4 2.67 23.3 2.47
-7
Tanzania 7.2 0.62 5.8 0.59 -5
Madagascar 0.3 0.04 0.3 0.04 10
Uganda 6.9 0.69 7.2 0.84 21
Comoros na na na na nd
Mauritius na na na na nd
Ethiopia na na na na nd
Seychelles na na na na nd
Source: UNAIDS Estimate 2012

6. Priority Actions: Sexual Transmission
• Assist countries identify who is getting infected / who is at risk of
infection (KYE/R)
• Prioritize relevant, effective, and impactful prevention strategies for
different populations (IF)
• Advocate for the scale up of Basic High Impact Program Activities:
1. Increase # of people on ARVs (effect on transmission)
2. Scale up male circumcision as a priority
3. Behavior change programmes
4. Programmes for key populations (almost no data for MSM, sex
work, IDU in region)
5. Condom promotion & distribution (Condom use at last sex in
Lesotho – 34%)
• Make smart investments that combine programs with critical
enablers to exploit synergies

7. Estimate of Number of Adults 15-49 yrs. VMMC needed to reach
80% coverage / country (PEPFAR Data)

8. Estimate Number of VMMC done / country as of October 2011
(PEPFAR Data)

9. Estimate Number of VMMCs needed to prevent one HIV
infection (PEPFAR Data)

10. Reduce HIV transmission among people
who inject drugs by 50%
Country Number of IDUs with HIV Gender Distribution M/F
Kenya 64,500 89/11
South Africa 33,500 73/27
Tanzania 22,000 N/A
Mauritius 19,000 N/A
Source: compiled from academic sources that are not comparable
• Practically no data for IDU (and other key populations) in the region
• Country Action: Prioritize collection of data on IDU in the region

11. Eliminate new infections among children and
reduce AIDS-related maternal deaths
• Global – approximately 330,000 babies were born with HIV in 2011;
55% or 180 000 were in ESA
• Nearly 90% of all new HIV infections among children globally occur
in 22 countries – 21 of those countries are in Africa, and 14 are in
ESA
• Global Plan aims to reduce new infections in infants by 90% from
2010 levels, by 2015; requires achieving >90-95% coverage for high
quality PMTCT services in priority countries

12. Percentage Coverage of PMTCT Services 2011 (excluding SD Nevirapine)
Countries 2 - 49%
Countries 50 - 79%
Countries >80%
• ESA coverage for PMTCT services in 2011 was 72%
• PMTCT coverage in five is low

13. Priority Country Actions: Implement the Global
Plan on EMTCT
1. Frame it – Develop an EMTCT Plan
2. Advocate for it – Leadership, communication
3. Do it – Implementation (4 prongs)
4. Account for it – M&E, shared responsibility
Almost all countries have developed emtct plans – follow up
on implementation;
CARMMA is bring launched across countries in the region –
follow up on implementation

14. Reach 15 million PLHIV with ART by 2015
• # of persons living with HIV in ESA 2011 – 17.1m
• # of persons eligible for ART using CD4 350 guidelines – 8.1m
• # of persons on ART 2011 – 5.2m (64% coverage)
• Unmet need for ART – 2.9m
• Epidemiological projections shows that if the 15x15 target is met
by 2015, 80% of those in need of ART will be receiving therapy
Source: UNAIDS & WHO Estimates, 2010

15. Estimated ART Coverage (CD4<350) 2011
Countries <50%
Countries 50 - 79%
Countries >80%
Source: WHO Data 2012
• 5 countries Rwanda, Botswana, Namibia, Swaziland and Zambia have achieved > 80% coverage; consider treatment for
prevention

16. Priority Country Actions: 15x15
• Increase ART Demand:
– Promote testing campaigns for early diagnosis and commencement of
therapy
– Push for Treatment for Prevention especially in countries that have
achieved high ART coverage (e.g. Botswana)
• Improve Supply:
– simplify the way HIV treatment is currently provided (e.g. fixed dose
combination ARVs for children in Uganda; CD4 testing devices at select
clinics in Mozambique reduced test time from 27 days to 1 day)
– decentralize provision of services (e.g. shift from hospitals to health
centers and from clinical officers to nurses in Malawi)
• Better Intelligence:
– forecasting on medicines and commodities to prevent stock outs

17. Reduce TB deaths in PLHIV by 50%
• TB is a leading killer of people living with HIV causing one
quarter of all deaths. People living with HIV and infected with
TB are 20 - 30 times more likely to develop active TB disease,
compared to people without HIV.
• In 2010 there were an estimated 1.1 million new cases of HIV-
positive new TB cases globally; approximately 60% occurred in
ESA
• In 2010, about 350 000 people died of HIV-associated TB
globally. Almost 250 000 deaths were in ESA
Source: WHO Report 2011: Global Tuberculosis Control
Data for ESA extrapolated

18. HIV Prevalence (Percent Estimate) in New TB Cases, 2009
< 25%
25 – 50%
50 – 83%
Source: WHO 2010
In South Africa, Lesotho, Swaziland, Namibia, Botswana, Zimbabwe, Zambia, Mozambique, Malawi &
Uganda, more than 50% of new TB patients are HIV positive

19. Priority Actions in TB/HIV Epidemics
• Ensure that TB burden reduction in people living with HIV is
sufficiently addressed in NSPs
• Mobilize partners to provide the technical support to countries
assisting them to scale-up HIV and TB responses (WHO is lead
agency)
• Advocate for HIV programmes in countries to effectively
implement TB prevention, treatment, care and support (service
integration)
• Social movement building and activism for PLHIV & TB.

20. Global Investment of US$22-24b / year in
low and middle income countries
• By 2010, Africa had mobilised close to US $ 8bn from both International and Domestic Sources
• The increase in domestic resources is smaller than that of international resources
•Advocate for implementation of the African Union Roadmap

21. Share of care and treatment expenditure originating from
international assistance, African countries, 2009–2011
Source: Global AIDS Response Progress Reporting
country reports (most recent available).
• Most countries in SSA are more than 50% dependent on international sources for treatment;

22. HLM Target 7:Eliminate Gender Inequalities & GBV and Increase Women and Girls’
Capacity to Protect Themselves from HIV
Countries % women who think % of men who think Criminalisation of Legislative
IPV is justified IPV is justified (2 Marital Rape Environment:
Domestic Sexual
Angola ?? ?? ?? ?? ??
Botswana ?? ?? No ?? ??
Comoros ?? ?? ?? No Yes
Eritrea 71% ?? ?? ?? ??
Ethiopia 81% 52% Yes No No
Kenya 53% 44% No Yes Yes
Lesotho 37% Yes No Yes
Madagascar 32% 30% ?? No Yes
Malawi 28% 16% ?? ?? ??
Mauritius ?? ?? Yes Yes Yes
Mozambique 36% ?? Yes Yes No
Namibia 35% 41% Yes No
Rwanda 48% ?? ?? Yes Yes
Seychelles ?? ?? Yes No No
South Africa ?? ?? Yes Yes Yes
South Sudan ?? ?? ?? ?? ??
Swaziland 38% 41% ?? No Yes
Tanzania 54% 38% Yes Yes No
Uganda 70% 60% No Yes Yes
Zambia 62% 49% Yes Yes Yes
Zimbabwe 49% ?? Yes Yes Yes

23. HLM Target 7:Eliminate Gender inequalities & GBV and increase women and girls’ capacity to protect
themselves from HIV
Issues Challenges Opportunities Areas for Scaled up Action
1. Eliminate Gender • Prevention: Women & • Treatment is prevention – could • Scaling up the
Inequality in HIV girls still the majority of reduce HIV infections in women & participation of men in
Prevention and Treatment PLHIV & gap not narrowing; progress though limited is being prevention and treatment
made with microbicide research programmes
• Treatment: Poor men’s • Increasing programmes to
health seeking behaviour engagement men – eg: men’s
groups, scaling up of MC & couples
• Treatment outcomes: counselling
Programmes focus on
coverage & not outcomes. • Increasing global platforms • Focus on HIV/SRH&R
Cervical cancer killing focusing on cervical cancer in particularly for WLHIV
WLHIV WLHIV and stronger HIV/SRHR
linkages
2. Eliminate GBV • Paucity of GBV prevalence • Increasing legislative instruments
data to protect women & girls from
• Deeply entrenched societal violence; •Scaling up community
attitudes towards women • Increasing programmes to engage driven prevention of
& girls men & traditional & religious violence initiatives
• Weak GBV enforcement leadership in eliminating GBV
3. Increase Women’s & • Women’s lower economic • Free education, increased • Sustain gains in girls
girls capacity to protect empowerment heightens women’s participation in decision education and eco
themselves from HIV vulnerability; making & expansion in micro- empowerment of women
credit facilities
• Sexuality education still a • Scaling up advocacy with
challenge & levels of • Increased advocacy in the area of traditional & religious
knowledge among young sexuality education leaders & school bodies
women still low

24. HL HLM Target 8: Eliminate stigma & discrimination against PLHIV
thru laws & policies that protect human rights fundamental freedoms
Countries Existence of a National % Reported Stigma by Laws Criminalising HIV Laws Criminalising key
Stigma Index PLHIV transmission populations
MSM Sex Work
Angola* No N/A Yes Yes Yes
Botswana No N/A No Yes Yes
Comoros No N.A No Yes Yes
Eritrea No N/A ?? Yes Yes
Ethiopia Yes Indicate the level no Yes No
Kenya Yes Indicate the level Yes Yes Yes
Lesotho* No N/A Yes Yes Yes
Madagascar No N/A Yes No No
Malawi Yes N/A Contradictory Yes No
Mauritius On going N/A No Yes Yes
Mozambique No No Yes Yes No
Namibia No No No Yes No
Rwanda Yes 20% no No Yes
Seychelles No N/A no Yes Yes
South Africa On-going N/A no No Yes
South Sudan No No ?? ?? ??
Swaziland Yes Indicate the level No Yes Yes
Tanzania Yes Indicate the level Yes Yes Yes
Uganda* No No Proposed in bill Yes Yes
Zambia Yes 36% Yes Yes Yes
Zimbabwe On-going N/A Yes Yes Yes

25. HLM Target 8: Eliminate stigma & discrimination against PLHIV
thru laws & policies that protect human rights fundamental freedoms
Issues Challenges Opportunities Areas for Scaled up
Action
Eliminate Stigma & • More than half the Increased All countries to
Discrimination countries in the region treatment access conduct Stigma Indices
have not measured and positive health
levels of Stigma outcomes/longivity
of life for PLHIV Scale up access to
• Where Stigma Index justice programmes
reports have been for PLHIV and
conducted, undertake concerted
recommendations are campaigns with
not being implemented community leaders
Promote Laws and • There are few countries Increasingly, NSPs Concerted advocacy is
Policies that protect in the region with laws make required to remove
the rights and that fully promote and commitments to punitive laws
fundamental protect the rights of rights based
freedoms of PLHIV PLHIV responses Ensure all NSPs include
actions to address the
• Technical Capacity to needs of Key
address this area is populations & other
inadequate vulnerable groups

26. HLM T Target 9: Eliminate HIV-Related Restriction on
Entry, Stay and Residence
• Only Two Countries in the ESA Region Criminalise
stay and entry for PLHIV.
• Intensify advocacy for a “final push” for the removal
of these restrictions
Country Criminalisation of Entry for Criminalisation of Stay &
PLHIV Residence for PLHIV
Comoros No Yes
Mauritius No Yes
Source: Making the Law work for the HIV Response, July 2010

27. Strengthen integration of the AIDS response
in global health and development efforts
• Integration means different things to different people; need to use a
standardized definition such as the health systems framework based on the 6
WHO building blocks
• No indicators yet on how to measure the integration of HIV into the general
health and development sphere in a country. No indicators developed for 2012
country reporting.
• UNAIDS part of the EU/UNFPA/UNAIDS Collaboration supporting the
integration of HIV and SRHR in seven Southern African countries.
• UNAIDS Participating in Experts Meeting to develop indicators for Integration of
HIV and SRHR at policy and service delivery levels; may shed light on
monitoring of this HLM target.

28. 1. Sexual Prevention: Evidence & Prioritisation: Gather more evidence on
where infections are coming from and prioritise high impact interventions;
2. IDU: Evidence generation, political support & Implementation of harm
reduction programmes;
3. EMTCT: Familiarise yourselves with your country emtct plans, provide
community based monitoring of implementation;
4. Treatment: Promote testing (especially of men), advocate for simpler
innovations in testing and treatment, treatment is prevention and treatment
outcomes not just coverage;
5. HIV/TB: Service Integration
6. Money: 15% campaign, domestic funding , local manufacture (AU road map
7. Gender: Scale up men’s engagement & work with community structures to
end GBV
8. Stigma & Discrimination: Country Stigma index reports, evidence on key
populations and HIV, political support and concerted action of advocacy to
remove punitive laws
9. Travel, stay and residence: advocacy for removal in 2 countries, monitor
others;
10. Integration: advocacy for service integration and contribution to indicator
exercise

29. VISION
ZERO NEW HIV INFECTIONS.
ZERO DISCRIMINATION.
ZERO AIDS-RELATED DEATHS.