1. Stop AIDS! Keep the promise Lesotho Modes of Transmission (MoT) Study Prevention Reference Group Meeting

2. Powered to Conquer HIV and AIDS Outline of Presentation Introduction  Overview of HIV prevalence in Lesotho  Key MOT Study questions Components of the MOT study Methodology employed Know Your Epidemic (KYE) Know your response (KYR) KYE & KYR Synthesis Key Recommendations

3. Powered to Conquer HIV and AIDS Introduction Multi-country study in five countries – Lesotho, Kenya, Mozambique, Swaziland and Uganda Purpose:  To check whether the response matches the magnitude of the epidemic  To establish where the bulk of HIV infections will come from in the next year Study undertaken by NAC, MOHSW and supported by UNAIDS & World Bank

4. Powered to Conquer HIV and AIDS Overview of HIV Prevalence in Lesotho (cont.)

5. Powered to Conquer HIV and AIDS Key questions the MoT study aims to answer 1.Are HIV prevention policies based on the latest available evidence and global best practice? 2.Do HIV prevention policies & programs respond to the key drivers? 3.Is funding for HIV prevention allocated to where it is most needed?

6. Powered to Conquer HIV and AIDS 1.Incidence data (modelled) 2. Epidemiological review 3. Prevention policies, response and strategic info review 4. Review of resources for prevention “Know your epidemic” “Know your response” Components of the MoT Study:

7. Powered to Conquer HIV and AIDS Methodology (KYE & KYR) 1.Incidence modelling: UNAIDS model, prior use in several countries, 1-day modelling workshop 2.Epidemiological review: desk review of data (published, unpublished, national and sub-regional); 3.Prevention review: checklists for KIs on policy context & SI, use of programme activity monitoring databases + structured interviews with HIV implementers for assessment of HIV activities 4.Review of prevention resources: Review of NASA 2005/06 - 2007/08 report, focus on prevention spending, some further analysis

8. Powered to Conquer HIV and AIDS 1.Incidence data (modelled) 2. Epidemiological review “Know your epidemic”

9. Powered to Conquer HIV and AIDS PREVALENCE PATTERNS: Age and sex-related heterogeneity Women have a higher burden of infection than men Women are 40% more likely to be HIV positive 57% of PLHIV are female “Two peaks” in females, high prevalence in older males Female prevalence rises extremely steeply among young women and shows a first “peak” among women in their late 20s and reaches its highest level in women in their late 30s (fig) Male prevalence peaks at 30-34 years and is higher than female prevalence for adults in their 40s Trends in ANC clients: drop in young women, rise in older women

10. Powered to Conquer HIV and AIDS HIV prevalence patterns (cont.) (2004) Source: LDHS 2004

11. Powered to Conquer HIV and AIDS Heterogeneity by education status Probability of being HIV positive decreases with increasing education (“education is protective”) * Education strongly predicts preventive behaviours like condom use, delayed sexual debut, HTC uptake and knowledge about AIDS * ANC: Prevalence drop in more educated women * multivariate analysis by Corno & de Walque 2007

12. Powered to Conquer HIV and AIDS From 2003-2007: Largest HIV prevalence drop in ANC clients with tertiary education, smallest drop in those with primary education Source: MOHSW ANC surveillance 2003, 2005, 2007 -31%-4%-19%

13. Powered to Conquer HIV and AIDS Homogeneity All districts, both sexes, and most age groups had HIV prevalence above 15% in the 2004 DHS (except females 15-19 and males 15-24) Women and men in all wealth, education and migration strata analysed have a HIV prevalence of at least 15% All but one ANC sentinel site reported HIV prevalence above 15% in 2007

14. Powered to Conquer HIV and AIDS Applying the UNAIDS Incidence Model  Calcification by main HIV exposure/mode of transmission eg. MSM; IDU, SW, CSW- Gaps in most of the data  Nationally representative data on multiple partner frequencies: 2004 DHS, 2007 CIET KAP

15. Powered to Conquer HIV and AIDS Incidence model (using DHS 2004) multiple partners: 21.1% (M), 7.6%(F) Largest group (0.5 mio) – 62%. Couple discordancy, Low condom use, ?Secret partners Multiple partner behaviours: 32%

16. Powered to Conquer HIV and AIDS Incidence model (using CIET 2007) multiple partners: 32% (M), 10%(F) Only 296,000 individuals – 35% Multiple partner behaviours: 59%

17. Powered to Conquer HIV and AIDS Risk Factors for New Infections individual levelcommunity levelstructural level Low male circumcision Multiple concurrent sexual partners Inconsistent condom use Commercial sex Social norms Gender roles & discrimination Labour & migration Alcohol abuse Labour & migration Sexual & physical violence Income inequality

18. Powered to Conquer HIV and AIDS 3. Prevention policies, response and strategic info review 4. Review of resources for prevention “Know your response”

19. Powered to Conquer HIV and AIDS HIV prevention programmes Mass media: 11 programmes: mostly targeting both males and females of all ages (the ‘general population’); few focus on specific age groups or target sub-population; BCC: 23 programmes (15 national); mostly directed at 12-35 old males and females; some at in-school youth and students; youth in churches and communities; Condoms: 9 programmes incl. MOHSW (free distribution) and PSI (socially marketed condoms); HTC: MOHSW is the main implementer; key messages relating to KYS campaign; PMTCT: provided in all districts in Government and CHAL facilities; Male circumcision: services in health facilities & traditional setting Blood safety: consistently 100% screening PEP: services strengthened, now available at district-level

20. Powered to Conquer HIV and AIDS KYR Synthesis Strong policy environment for HIV prevention, but there is need to scale-up operationalisation of policy commitments. Male Circumcision Policy & Strategy to be developed M&E systems are in place & functional, but there is shortage of data on high risk sub-populations Most prevention programmes focus on: Interventions affecting Knowledge, Attitudes and Beliefs. Risk reduction component (mainly condom distribution) Biological/Biomedical Interventions that Reduce HIV Infection and Transmission Risk (PMTCT,PEP etc.) Youth & OVC in & out of school; general population; workplace Key Messages - Behaviour change; HTC; life skills; awareness; ABC; positive living; condom use; sexual violence  Coverage is often country-wide except for a few programmes

21. Powered to Conquer HIV and AIDS Incidence data (modelled) Epidemiological review Prevention policies, response and strategic info review Review of resources for prevention “Know your epidemic” “Know your response” Epidemic and Response Synthesis

22. Powered to Conquer HIV and AIDS 1) Are HIV prevention policies based on current best evidence & practice? Prevention strategies regarding HCT, PMTCT, treatment of STIs and blood safety are covered by national policies and emulate international best practices. Male circumcision is not addressed by the existing policies and no MC strategy is available. The National BCC Strategy has been informed by the findings of this among other studies conducted in Lesotho. Promotion of abstinence and delayed sexual debut in adolescents needs to take into account societal changes such as delayed marriage, as well as the “catch-up” phenomenon.

23. Powered to Conquer HIV and AIDS 2) Do HIV prevention policies & programmes respond to the key drivers of the epidemic? Low male circumcision - MC policy and programme yet to be developed Multiple and concurrent partnerships - MCPs are highly prevalent, but not explicitly addressed in communication programmes Migration, intimate partner violence & income inequality – not adequately addressed policy and programmes as structural drivers by Prevention activities are not well targeted to priority populations (discordant couples, migrant couples, out-of- school youth, sex workers etc.)

24. Powered to Conquer HIV and AIDS 3) Is funding for HIV prevention allocated to where it is most needed? According to the NASA 2006/07, only 11% of funding was spent on HIV prevention There are great fluctuations in annual spending per intervention category and ‘communication for social and behaviour change’ received only 2% of prevention funding in 2006/07 HCT interventions - received considerable funding PMTCT - received considerable funding Expenditure on positive prevention was small, possibly due to a lack of a clear programme

25. Powered to Conquer HIV and AIDS Actual Spending based on NSP categories for 2005/06, 2006/07 and 2007/08

26. Powered to Conquer HIV and AIDS Key Recommendations 1.Strengthen the commitment on implementation of existing policies; 2.Partner reduction as a key element of HIV prevention needs to be integrated into all relevant prevention strategies and programmes; 3.Fast-track the process of creating policy framework for a scale-up of male circumcision (including harnessing traditional sector as appropriate); 4.Strengthen research and evaluation along side interventions in order to understand what works; 5.Revise content of prevention messages to address underlying social norms regarding Casual Sex & MCP; 6.Players at the district level to have a harmonised planning system which ensures synergy and sustainability of interventions; and 7.Institutionalise MOT study as a planning tool.

27. Powered to Conquer HIV and AIDS