1. 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 Huerga MSF-OCB Operational Research Day 2014

2. 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

3. 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)

4. 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

5. 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

6. Study Procedures

7. Results: who participated? Women, n (%)351862.3 Age, median years (IQR)2619-40 Never married, n (%)423475.0 Secondary education, n (%)280649.7 Rural area, n (%)471183.4 Student/unemployed, n (%)414673.4 Moved residency, n (%)76113.5 Table: Participants’ socio-demographic characteristics 2377 HH visited –> 6688 individual eligible –> 5649 (84.5%) included

8. 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)

9. HIV incidence: How many new infections per year? WomenMenTotal /100 PY(95%CI)/100 PY(95%CI)/100 PY(95%CI) 15-29 years3.2(1.4-4.9)1.0(0.0-1.9)2.1(1.1-3.2) 30-59 years0.1(0.0-1.7)0.2(0.0-2.0)0.1(0.0-1.4) Overall2.0(0.7-3.2)0.8(0.0-1.6)1.4(0.6-2.3) PY: person-year

10. 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)

11. 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

12. 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) Public sector

13. 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)

14. Cascade of care Of all HIV positive, 49% had no detectable virus, and hence were not transmitting HIV.

15. 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

16. 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?

17. 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 Acknowledgements MSF 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