high incidence of hiv in young women despite high art coverage and viral load suppression results...
TRANSCRIPT
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 HuergaMSF-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
BackgroundGood 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
StudyProcedures
Interview head of household
Interview eligible individuals
Household questionnaire
Individual questionnaire
duel HIV test
Discordant Not done
Negative Positive
Blood collection (phlebotomy)
Laboratory tests - GCVL Durban
3 tubes 3 tubes 1 tube
ELISA HIV test
Positive Negative
CD4 count DBS cards Viral load Genotyping Storage
NAAT for acute infection
Interview HIV positive / Test not done
Questionnaire HIV care & ART
Incidence testing - Biorad - LAg
ARV levels
- NICD Joburg
- Groote Schuur Cape Town
Plasma separation
HIV rapid test (finger prick)
Results: who participated?
Women, n (%) 3518 62.3
Age, median years (IQR) 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
Table: Participants’ socio-demographic characteristics
2377 HH visited –> 6688 individual eligible –> 5649 (84.5%) included
HIV prevalence: How many were HIV-positive?
Overall: 25.2% (95%CI: 23.6-26.9)
Women age 30-39: 56%
- Women: 30.9% (95%CI: 29.0-32.9)
- Men: 15.9% (95%CI: 14.0-18.0)
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-590
5
10
15
20
25
30
35
40
45
50
WomenMen
Age group
%
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 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)
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
0
20
40
60
80
100
120
140
No ARTART
Num
ber o
f ART
elig
ible
CD4
<350
; PM
TCT
B
When did they start ART?
8,3
12,5
16,7
25,5
37,1
0
5
10
15
20
25
30
35
40
Before 2006 2006-2007 2008-2009 2010-2011 2012-2013
%
Year of ART initiation
• 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)
Time since test: 6 months (IQR: 3-16)
Number of tests: 3 times (IQR: 2-4)
78.6%
2.0%
18.9%0.6%
Place of HIV test overall
Public sectorPrivate sectorMSFOther
Public sector
94.7%1.9%3.3% 0.1%
Individuals aware of HIV status
Public sector
Who was already aware of their HIV infection?
Awareness: 75.2% (95%CI:72.9-77.4)
Women & men 20 -24 y: 43.1% &
83.3%- Women: 77.7% (95%CI: 75.1-80.1)
- Men: 67.3% (95%CI: 62.0-72.1)
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
Wom
en
Men
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
0
50
100
150
200
250
Not awareAware
Num
ber o
f HIV
pos
itive
Cascade of care
0
10
20
30
40
50
60
70
80
90
100
74.8%
65.4%57.1%
52.1% 49.3%
% o
f all
HIV
pos
itive
Of all HIV positive, 49% had no detectable virus, and hence were not transmitting HIV.
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?
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
NICD Johannesburg Adrian Puren
University of Cape Town Jennifer Norman
SACEMA Stellenbosch Alex Welte
Global Laboratory Durban Madurai Lorna Bronwyn Pitam Collin Pillay
AcknowledgementsMSF SAMU South Africa Tom Ellman Eric Goemare Emmanuel Fajardo Carole Metcalf
MSF Brussels Marc Biot
Epicentre Paris Jihane Ben Farhat David Maman Serge Balandine Jean-François Etard