Progress on the Acceleration of Health Sector HIV Prevention in the WHO African Region

Innocent Ntaganira
Assimawe Pana
Erica Kufa
Abdikamal Alisalad
Rui Gama Vaz
Rufaro Chatora

Division of AIDS, Tuberculosis and Malaria
World Health Organization, Regional Office for Africa

Corresponding Author:
Innocent Ntaganira
Email: Ntaganirai@afro.who.int

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ABSTRACT

In 2005, the WHO Regional Committee for Africa called upon countries to accelerate HIV prevention and to declare 2006 as the Year of Acceleration of HIV Prevention in the African Region. The strategy document that was developed by WHO Regional Office was adopted by the Region's ministers of health in August 2006. The strategy proposed targets to be met by 2010, in line with universal access targets, in areas of HIV testing and counselling; prevention of motherto- child transmission of HIV; prevention and control of sexually-transmitted infections; blood safety, and access to comprehensive prevention, treatment and care. Specifi cally, it was envisaged that, by 2010, all districts will provide HIV testing and counselling services; 100% safe blood and blood products will be ensured; at least 80% of pregnant women attending antenatal care will access prevention of mother-to-child transmission of HIV services; at least 80% of patients with sexually-transmitted infections will access comprehensive STI management; at least 80% of people living with HIV/AIDS will have access to comprehensive prevention, treatment and care services; and condom use in high-risk sexual encounters will reach at least 60%. This paper describes the progress made in accelerating key health sector HIV prevention interventions in the Region toward these targets and issues that should be taken into consideration for moving forward the HIV prevention agenda in the health sector.





RÉSUMÉ

En 2005, le Comité régional de l'OMS pour l'Afrique a invité les pays à accélérer la prévention du VIH et à déclarer 2006 comme étant l'Année de l'accélération de la prévention du VIH dans la région africaine. Le document stratégique qui a été mis au point par le Bureau régional de l'OMS a été adopté par les ministres de la santé de la région africaine en août 2006. La stratégie a proposé des objectifs à atteindre d'ici à 2010, conformes aux objectifs d'accès universels, dans les domaines du dépistage du VIH et des conseils, de la prévention de la transmission mère-enfant du VIH, de la prévention et du contrôle des infections sexuellement transmissibles, de la sécurité du sang, et de l'accès à la prévention d'ensemble, aux traitements et aux soins. Plus précisément, il était prévu que, d'ici à 2010, tous les districts fournissent des services de dépistage du VIH et de conseils, du sang et des produits sanguins sécurisés à 100%, que des produits sanguins soient fournis, qu'au moins 80% des femmes enceintes fréquentant les consultations prénatales aient accès aux services de prévention de la transmission mère-enfant du VIH; qu'au moins 80% des patients atteints d'infections sexuellement transmissibles soient globalement gérés pour ces maladies; qu'au moins 80% des personnes vivant avec le VIH / SIDA aient accès aux services complets de prévention, de traitements et de soins, et que l'utilisation du préservatif lors de rencontres sexuelles à hauts risques atteigne au moins 60%.Ce document décrit les progrès réalisés dans la région africaine en accélérant les interventions-clé de prévention du VIH dans le secteur de la santé en vue d'atteindre ces objectifs ainsi que les enjeux qui devraient être pris en considération pour faire avancer le programme de prévention du VIH dans le secteur de la santé.

SUMÁRIO

Em 2005, o Comité Regional da OMS para a África apelou aos países para acelerar a prevenção do VIH e declarar 2006 como o Ano da Aceleração da Prevenção do VIH na Região Africana. O documento estratégico desenvolvido pelo Escritório Regional da OMS foi adoptado pelos Ministros de Saúde da Região em Agosto de 2006. A estratégia proposta prevê o alcance dos objectivos propostos até 2010, tendo em conta as metas relativas ao acesso universal nas áreas de testagem e aconselhamento relacionados com o VIH; prevenção da transmissão materno-fetal do VIH; prevenção e controlo de infecções sexualmente transmissíveis; segurança transfusional e acesso à prevenção, tratamento e cuidados integrados. Foi especifi camente defi nido que, até 2010, todos os distritos disponibilizarão serviços de testagem e de aconselhamento relacionados com o VIH e que a segurança transfusional e dos produtos de sangue serão assegurados a 100%; pelo menos 80% das mulheres grávidas que recebem cuidados pré-natais terão acesso aos serviços de prevenção da transmissão materno-fetal do VIH; pelo menos 80% dos pacientes com infecções sexualmente transmissíveis (IST) terão acesso a uma gestão integrada das IST; pelo menos 80% das pessoas infectadas pelo VIH/SIDA terão acesso a serviços compreensíveis de prevenção, tratamento e cuidados assistenciais e que a utilização de preservativos em encontros sexuais de alto risco terá atingido pelo menos 60%. Este relatório descreve o progresso obtido na aceleração das intervenções chave na prevenção do VIH no sector da saúde na Região em direcção a estas metas bem como aspectos a ter em consideração de modo a prosseguir com a agenda da prevenção do VIH no sector da saúde.


In 2005, the WHO Regional Committee for Africa called upon countries to accelerate HIV prevention and to declare 2006 as the Year of Acceleration of HIV Prevention in the African Region. The Regional Committee also requested WHO to develop a strategy for acceleration of HIV prevention in the health sector, provide the necessary technical support to countries, help mobilize additional resources and monitor implementation. The strategy document1 that was developed by WHO Regional Offi ce was adopted by the Region's ministers of health in August 2006.

The strategy proposed targets to be met by 2010, in line with universal access targets, in areas of HIV testing and counselling; prevention of mother-to-child transmission (PMTCT) of HIV; prevention and control of sexually-transmitted infections (STIs); blood safety, and access to comprehensive prevention, treatment and care. Specifically, it was envisaged that (by 2010) all districts will provide HIV testing and counselling services; 100% safe blood and blood products will be ensured; at least 80% of pregnant women attending antenatal care will access PMTCT services; at least 80% of patients with sexuallytransmitted infections will access comprehensive STI management; at least 80% of people living with HIV/AIDS will have access to comprehensive prevention, treatment and care services; and condom use in high-risk sexual encounters will reach at least 60%.

Methods

Country-reported data for districts and health services were used in assessing progress toward the targets. The data are available in the WHO Regional Office HIV/AIDS database. Published estimates as well as data from UN-based sources, including the 2008 and 2009 universal access reports, were also used to assess Sprogress for some targets. Progress was assessed by comparing the most recent Regional averages with earlier averages. The Regional averages used in assessing progress are weighted averages, where the population sizes of individual countries are used as weights, particularly for population-based surveys.

This paper has been reviewed by a technical panel at the WHO Regional Office for Africa. It was also presented to Ministers of Health of the WHO African Region at the 59th session of the Regional Committee.

This paper describes the progress made in accelerating key health sector HIV prevention interventions in the Region toward these targets and issues that should be taken into consideration for moving forward the HIV prevention agenda in the health sector.

Challenges

Sub-Saharan Africa is making steady progress in accelerating HIV prevention. According to new data in the 2009 epidemic update(2), new HIV infections have been reduced globally by 17% over the past 8 years, with most progress in sub-Saharan Africa. The number of new infections in sub-Saharan Africa is approximately 15% lower than in 2001.

Scaling up access to HIV testing and counselling is the gateway to prevention, treatment and care services, and is critical to the achievement of universal access to HIV prevention, treatment and care. In just one year (2007-2008), the total number of health facilities providing HIV testing and counselling (HTC) services increased by 50%. Over 17 million people aged 15 and above received the services in Sub-Saharan Africa in 2008.(3)

Countries are implementing various models of HTC, from the traditional voluntary counselling and testing to the new concept of provider initiated HIV testing and counselling, which is aimed at increasing uptake of HTC and improving access to health services for people living with HIV(4).

Figure 1: Numbers of PLAs on ART amd ART coverage, 2004-2008, sub-Saharan Africa

Mother-to-child transmission is responsible for about 20% of all new HIV infections in sub- Saharan Africa. In 2008, over 600,000 HIV-positive pregnant women reportedly received antiretrovirals (ARVs) for the prevention of mother-to-child transmission of HIV, resulting in 45% coverage and an increase of 17% since 2007. Among 43 countries that reported in 2008, the median number of facilities per country that offer PMTCT services is 156.(5) Botswana has reached the 80% target and other countries including Kenya, Namibia, Rwanda, South Africa and Swaziland are moving towards the target.

In 2007, WHO and UNAIDS recommended that safe male circumcision (MC) be added to the arsenal of effective HIV prevention interentions , particularly in countries in eastern and southern Africa with high HIV prevalence rates and low male circumcision rates. Since then, countries including Botswana, Burundi, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia and Zimbabwe have taken concrete steps to scale up MC. Actions taken included situation analyses, development of policies, strategies and plans, training of service providers, and provision of MC services.

The scale up of antiretroviral therapy (ART) is expected to have a significant impact on the reduction of new HIV infections in the African Region. At the end of 2008, an estimated 6.7 million HIV-infected people were in need. Of these, about 3 million HIV-infected people received ART, resulting in 43% coverage, compared with 33% in 2007. The number of health facilities providing ART also increased by 51% in just one year. The bulk of this achievement comes from eastern and southern African countries, which have the highest rates of HIV infection.(6)

In 2007, 40 countries reported that 100% of the blood used for transfusion was screened for HIV; this compared with 98% in 2004.(7) Eleven countries(8) are implementing specific programmes(9) to strengthen infection prevention and control. However, reports indicate that 50% of medical injections administered in developing countries were given with reused, non-sterilized equipment.(10)

Demographic and Health Surveys (DHS) carried out between 2005 and 2008 indicate that condom use for the last high-risk sexual encounter among people aged 15-49 years ranged from 26% to 71% for males and 14% to 47% for females, with a median of 45% for males and 26% for females. Condom use among 15-24-year-olds engaging in high-risk sex increased in 10 out of 14 countries(11) with trend data. The DHS surveys also show that comprehensive knowledge of HIV/AIDS among people aged 15-49 remains very low (ranging from 6.9% to 58.9 % in women and 18.6 % to 57.5 % in men), despite very high levels of awareness (ranging from 79% to 99.9% in women and 87.7% to 99.9% in men).

The Way Forward

HIV prevention is firmly on the agenda of countries and development partners and encouraging progress is being made in accelerating health sector HIV prevention in the African Region.

However, much more needs to be done: An estimated 2 million new HIV infections were reported in 2008; as the DHS indicated, comprehensive knowledge of HIV/AIDS is low. Less than 20% of people living with HIV know their status and coverage of services among populations at high risk remains low.

Challenges also include weak health systems to support scaling up of effective HIV prevention interventions, as well as addressing multiple and concurrent sexual partnerships, which continue to be among the main drivers of the HIV epidemic in the African Region.

Virtual elimination of HIV transmission from mother to child is possible. There is a need to ensure that all pregnant women are systematically screened for HIV and ARVs for PMTCT are systematically provided to all HIV-infected pregnant women and their infants.

Accelerated scaling up of HIV testing and counselling, scaling up of ART service provision together with timely initiation of treatment, and scaling up of safe male circumcision in areas of high HIV prevalence, are likely to significantly contribute to the reduction of new HIV infections in the African Region.

There is a need to do more to address unsafe sex; the need for more outspoken leadership on issues of concurrent multiple sexual partnerships which continue to drive the HIV epidemic in sub-Saharan Africa. There is also a need for the African leadership to create the necessary environment for addressing the needs of key populations, including sex workers, if any impact is to be made on the course of the epidemic.

ACKNOWLEDGEMENTS

We acknowledge the contribution of WHO staff who reviewed this paper as well as Ministers of Heath and their offi cials who shared their country experiences with us.

REFERENCES