INTRODUCTION Mod es of HIV Transmis sion 1 Analysis of HIV Prevention Response and Modes of HIV Transmission: The UNAIDS-GAMET Supported Synthesis Process Authors: M. Colvin1, M. Gorgens-Albino2, S. Kasedde1 Affiliations: (1) UNAIDS Regional Support Team, Eastern and Southern Africa, (2) GAMET 1. INTRODUCTION From June 2007 to July 2008 UNAIDS and GAMET led a five-country Modes of Transmission (MoT) process. A process evaluation was undertaken of the process, and an impact evaluation is planned at a later stage, once countries have disseminated the results of the study. The primary motivation for initiating the Modes of Transmission (MoT) process was the recognition that, in many countries, there is a lack of alignment between programmatic and financial HIV prevention needs and the prevailing prevention responses. Significant resources continue to be invested into a variety of biomedical and behavioural prevention interventions that are not systematically evaluated for their impact or quality. At the same time, efforts at addressing underlying social norms that hinder the capacity of individuals to prevent HIV infection or to deliver services consistent with human rights and service standards remain weak, inconsistent or completely absent . In short, there is a need to “know your epidemic” and “know your response”, and make better policy decisions about how to improve the HIV prevention response. The broader aim of the MoT process was to build capacity within countries and the region to be able to undertake similar studies in the future as part of HIV response reviews. Furthermore, the intention was to build capacity to be able to “synthesize” this information, interpret it and propose recommendations and policy interventions. It is hoped that, if this initial round of the synthesis work were to be fruitful, the methods and approaches will be integrated into the ongoing HIV-related evaluation and planning processes within these countries and others in the region. The direct objectives are for the 5 participating countries to produce national HIV synthesis reports that will, over the coming months, feed directly into existing policy development initiatives in the various countries. 2 Modes of HIV Transmis sion INTRODUCTION INTRODUCTION Mod es of HIV Transmis sion 3 2. BACKGROUND TO THE MOT PROCESS 4. RESULTS OF PROCESS EVALUATION a) MOT rationale: The rationale for the MoT process in each of the a) Overall comments: countries was: First and foremost, it is apparent from country reports, country meetings, 1. To understand better the heterogeneity of the HIV epidemic, where and the recent survey of stakeholders, informal interactions and the final among whom new cases of HIV are occurring and what the drivers of the Regional Review Meeting held in July 2008, that the MoT process has been a epidemic are. worthwhile initiative. No individual or organization has suggested that the MoT 2. To describe and understand better the extent and reach of the various HIV concept or its implementation so far was seriously flawed. interventions and programmes. 3. To determine the degree of alignment between HIV prevention resource Each country and those involved within countries have all suggested that this is allocation and where and how HIV transmission is occurring. a useful process that needs to be repeated in the future. 4. To make recommendations for adjustment of policies and practices in order to ensure optimal targeting and resourcing of a focused and relevant The key factors identified by country and regional participants in this evidence informed national HIV prevention strategy. success were: b) MOT methods: Each country undertook an analysis based on 4 components: 1. Extensive international and in-country consultation. 1. Epidemiological review: analysis of national behavioural, biological, 2. The rationale for the MoT process was well constructed and well motivated. socioeconomic and demographic data to identify and explain the factors 3. Adequate financial and human resources were committed to the process. involved in driving the local epidemic. 4. The NACs within each country played a key role in mobilizing support and 2. Incidence modeling: use of national HIV and STI prevalence and behavioural technical expertise. data to determine the likely distribution of HIV infections in the adult 5. Process was driven by in-country Technical and Policy teams rather than only population (aged 15 – 49 years) based on modes of HIV transmission. by consultants. 3. Prevention Response Review: analysis of the scope and scale of the key 6. High level expertise and experience in doing synthesis work brought into the prevention interventions implemented in the country and the prevention process by GAMET. policy and strategic information environments. , 4. Response review: analysis of the degree of alignment of national prevention Each of these factors is further outlined below. resources with the priorities highlighted by this evidence b) Participatory approach to planning: Based on these 4 analytic components, each country prepared a synthesis Key to the success of the process was the extensive consultation process report featuring recommendations for prevention policy and programmatic that preceded the launch of the MoT in the 5 countries. The UNAIDS-led action to ensure a stronger and more effective national prevention strategy. initial consultations were primarily with UN agencies and other international organizations such as the World Bank, CDC and SADC. At these meetings, The analysis and synthesis process in some countries, also aimed to facilitate high-level presentations were made which provided a clear and strong the formation or strengthening of technical and policy leadership mechanisms rationale for the need for such work to be undertaken. for prevention. Subsequently, clear criteria were established for choosing appropriate countries to participate in the MoT process. Consultations then shifted to Towards the end of the country processes, a process evaluation was obtaining support from the NACs and other role players within the selected conducted. countries. Although the consultation process took several months to complete, it 3. PROCESS EVALUATION METHODOLOGY did ensure that the MoT process was accepted and received support from international and national role players. The process evaluation involved two parts: a) Country team survey (stakeholder survey) completed by each country team. Having secured support for the MoT process from the various NACs, the next b) Key respondent Interviews conducted by an independent researcher. step was to bring on board the various in-country stakeholders. In general, Data was collected from 21 participations involved in the MoT process using a this process of inclusion was successful. However, in some countries it was semi-structured interview. Respondents included government representatives, perceived that the MoH was not sufficiently engaged and, in some cases, that country consultants, UNAIDS representatives in the 5 countries and members academic institutions did not play a very active role. In one country however, of the regional team that supported the country analyses. leading experts from academic institutions, WHO, CDC and the Medical Research Council were engaged to serve as a peer-review team to support the Data was then analysed using qualitative content analysis1. Such analysis allows HIV incidence modeling and this mechanism, proved extremely valuable in for similarities and differences between respondents to be analysed, rather ensuring quality of the analysis. than individual specifics issues and circumstances to be highlighted. As such the process evaluation provided by this analysis, gives an ‘overview’ and is used The central role played by the NACs in most countries was critical to the to identify salient themes that emerge from the data. success of the MoT process. In Uganda, Kenya and Swaziland the NACs were key to mobilizing support within each country and in setting up the 1 Flick (1998) An Introduction to Qualitative Research. Sage Publications: London technical and policy teams. In Lesotho, the NAC committed substantial 4 Modes of HIV Transmis sion INTRODUCTION INTRODUCTION Mod es of HIV Transmis sion 5 technical resources of its own to ensure coordination and technical support required in this process. to the process to counter initial setbacks due to key staff turnover and limited availability of consultants to form the core MOT team. Responses of respondents to the stakeholder survey in regards to the guidelines and templates was mixed. Most found the documents useful but c) Significant financial and human resources committed to the a few found them not so useful. One junior researcher was dismissive of the MoT process: guidelines as being too complex and difficult to use. The entire process has been well supported in terms of the provision of funding and in terms of organizational and technical support and this has f) Organisational support: clearly contributed to the success of the MoT process. UNAIDS initiated this MoT process and took primary responsibility for assisting with coordination on a regional and in-country basis. The UNAIDS Regional Support for the MoT process was provided in the following areas: Support Team for Eastern and Southern Africa provided the regional support through their Johannesburg office and hired a coordinator for the duration • Financial support from UNAIDS and GAMET. of the study. In-country organizational support was provided by the country • Provision of Lead Epidemiologists in 4 countries by GAMET and supervision UNAIDS team. by GAMET. • In-country and inter country coordination provided by UNAIDS. Feedback from the stakeholders survey was very positive about the level • Establishment of a Regional Technical Team coordinated by UNAIDS. of support from UNAIDS and GAMET. Contact between countries was • Regular technical support and inter-country teleconferences and monthly mediated through monthly reports produced by the coordinator and through regional reports. teleconferences. • Basic standard “Terms of Reference” for consultants that were adapted as necessary by countries. Most respondents to the stakeholders survey believed that there was sufficient • Standard methods, guidelines and templates. ownership of the process by the countries. However, a few respondents • Process orientation and training workshops held in country. thought that the process was essentially being driven by UNAIDS and GAMET. • Limited in-country “mentoring” support. 5. CONCLUSION d) Importance of establishing in-country technical and policy teams: Within each country a Technical Working Group (TWG) of local experts was In conclusion, this has been a very successful process and collaboration set up and tasked with the responsibility of supervising the consultants and between UNAIDS, GAMET and all 5 countries. The process set out to provide assisting with the data collection, analysis and report writing. It is clear that an improved these TWGs played a significant role in providing support to the consultants. understanding of the epidemic and response in the 5 countries and to provide evidence based recommendations for strengthened and more focused In an attempt to ensure that the MoT process will filter into the ongoing HIV prevention. The abstracts presented here highlight the high quality of the prevention planning activities in each country, a Policy Advisory Group was analysis and the success of the country processes. established or existing structures were used for this function. It remains to be seen whether the MoT process will actually impact on policy. e) Provision of technical assistance to countries: Technical assistance was provided through several channels. Most obviously, funding was provided to be able to hire consultants and GAMET provided epidemiologists to four of the countries. One of the biggest challenges to countries was the difficulty in contracting high quality consultants. The reality is that in many countries there are not many high-level researchers/consultants who are available for relatively short term contracts at short notice. The Regional Technical Team was a useful resource. The team assisted in developing guidance documents and templates, facilitating workshops, providing direct in-country technical assistance and reviewing country outputs. One regional training workshop on using the HIV incidence model was held in December and many country-level workshops were held. However, some respondents noted in the process evaluation interview that the required technical assistance was not always available and this limited the in-country mentoring. While workshops were helpful in building some aspects of required capacity more intensive and sustained in-country mentoring was KENYA Mod es of HIV Transmis sion 7 METHODS SYNTHESIS OF HIV EPIDEMIC AND RESPONSE FINDINGS The study was conducted (December 2007 – July 2008) by a team of three Kenya-based consultants, Approximately half of the prevention resources are going and co-ordinated by UNAIDS-Kenya M&E Adviser towards counselling and testing or PMTCT, while youth- and the Head of the Strategic Research & Monitoring oriented programmes claim less than 5% of prevention Unit of NACC. The study was supervised and guided resources, and government funding aimed at most-at- by a Kenya MOT Technical Team (KMoTTT) through risk groups, such as sex workers and their clients, MSM regular meetings, reviews and updates. The Kenya team and IDUs are negligible or non-existent. While there are underwent training in applying the UNAIDS incidence funds for behaviour change and communication, there model, reviewed data sources, consulted with experts is hardly any funding aimed at mobilizing communities. at both the national and international levels, and The amount of total funding available at the national level Analysis of HIV Prevention Response worked closely with the National AIDS Control Council for prevention activities has fallen to less than 25% of the (NACC), UNAIDS and the Global AIDS Monitoring and total HIV & AIDS funding since 2005. and Modes of HIV Transmission: Evaluation Team (GAMET) from the World Bank. Regular consultations were held with the Regional Coordinating Kenya Country Synthesis Team and monthly updates sent. RECOMMENDATIONS • Review national AIDS strategy KNASP to focus FINDINGS: HIV EPIDEMIC AND prevention strategies towards most at-risk populations. Supported and funded: RESPONSE SYNTHESIS • Research to understand and monitor geographical and UNAIDS, GAMET (World Bank) and Kenya Government community variations, MSM and IDU communities, From both the epidemiological analysis and the factors affecting behaviour change. modelling, it is clear that heterosexual transmission is • Operationalise the new national circumcision policy. the most prominent mode of transmission in all areas of This should also be supported by an approach that Kenya, but that this represents several different situations, takes cultural challenges of the communities BACKGROUND including both casual and long-term partnerships and into consideration. assorted degrees of transactional alliances, all hinging • Revise policies and laws that hinder provision of services In recent years, with the HIV & AIDS epidemic on the concept of multiple concurrent partnerships to MSMs, IDUs, FSWs etc well-established, but with treatment programs now as a primary driver of the epidemic. The epidemic • Intensify couple-based HIV prevention programs, in place, questions have arisen as to whether those is heterogeneous, with marked regional variations. including discordant couple counselling and prevention groups who have traditionally been at risk are still the MOT modelling confirms that 80% of new infections are for positives. source of new infections. The importance of “knowing due to heterosexual sex (including in fishing communities). • Scale up, revitalize and initiate programs among your epidemic” (KYE) has become evident, and Kenya IDUs, clients of sex workers and MSM (at least in the most-at-risk populations became part of the exercise, along with UNAIDS and major urban centres) are also significant contributors to • Capacity to design and implement prevention the World Bank, to initiate a series of epidemiologic new infections. programmes at the district level needs to synthesis studies in the country. HIV epidemiological and be strengthened. incidence modelling data are synthesised to obtain an Geographic and special population variations are • Improve access to research results, and interpretation of epidemiological synthesis (‘KYE’ synthesis), while the HIV influenced by prevalent behaviours and cultural those research results into understandable knowledge prevention review and resources data are synthesised practices, most notably male circumcision and multiple that most implementers can utilise in planning, to obtain an HIV response synthesis or “knowing your concurrent relationships. management and monitoring. response” (KYR) synthesis. The two syntheses are then • Increase spending on most-at-risk populations, compared to understand the gaps in HIV prevention The modelling has allowed not only the gathering programmes to change social norms in the community, programming, leading to recommendations as to how the of incidence data, but also the disaggregation and and on prevention programmes for prevention response can be improved. categorization of most-at-risk groups and regions. with positives. 8 Modes of HIV Transmis sion KENYA LESOTHO Mod es of HIV Transmis sion 9 NEXT STEPS • Recommendations from the MoT to be reviewed by the Kenya National Prevention Task Force and findings to be shared at the upcoming Kenya National Prevention Summit (September 2008) and key strategic directives obtained. • Consolidated recommendations from the National Prevention Summit, together with detailed recommendations from the MoT Study presented at the Mid-term Review of the KNASP (Oct. 2008) as part of influencing policy based on evidence gathered by the MoT. • Prioritise and initiate research to address data gaps recommended by the MoT study. • Review the current synthesis of the MoT using the new findings from the Kenya AIDS Indicator Survey (2007), (not yet launched when this report was submitted to the July 2008 Regional Peer Review Meeting held Analysis of HIV Prevention Response in Johannesburg). • UNAIDS and WB to determine ways in supporting and Modes of HIV Transmission: NACC to institutionalise the MoT synthesis into an annual exercise. Lesotho Country Synthesis FUNDING AND TECHNICAL SUPPORT Authors: M. Khobotlo1, R. Tshehlo1, J. Nkonyana2, M. 1. UNAIDS – funded the study in Kenya by paying for two Ramoseme2, M. Khobotle1, M. Hildebrand3, consultants and for all the training exercises and the A. Chitoshia3, N. Fraser4 contributed towards the National Prevention Summit while providing full technical support through out the Affiliations: (1) NAC, (2) MOHSW, (3) UNAIDS, (4) GAMET study period. 2. World Bank Global AIDS Monitoring and Evaluation Team (GAMET) – Provided technical support for quality assurance and provided one consultant to the study team in Kenya. BACKGROUND 3. National AIDS Coordinating Authority (NACC) – supported all regular in-country meetings by providing Lesotho’s hyperendemic situation has been characterized, venue, secretariat support and documentation, as well but there is a suspected poor match of prevention as opening access to information and data gathering. priorities with epidemic dynamics. There has been little focus on incidence and recent new evidence has not been seen side-by-side. The reduction of new infections in adults and children is an absolute priority, and the MOT study will help to define the future HIV prevention response in Lesotho. METHODS Know your epidemic (KYE) involved literature review of published and unpublished materials from Lesotho and the region, and application of UNAIDS incidence model (limited by availability of data on HIV prevalence and behaviour on risk populations). Know your response (KYR) involved data collection and analysis on policy context, strategic information 10 Modes of HIV Transmis sion LESOTHO MOZAMBIQUE Mod es of HIV Transmis sion 11 and prevention interventions through key informant KEY RECOMMENDATIONS interviews and district review meetings on prevention. Synthesis of KYE-KYR was done using GAMET synthesis 1) Strengthen commitment on implementation of existing process. The process was coordinated by NAC in policies by capacitating collaboration with a steering committee (‘core team’), providers and ensure quality services; supported by reference teams on M&E and Prevention. 2) Integrate “partner reduction” as a key element of HIV Capacity building of local stakeholders included NAC, prevention into all future MOHSW, other government ministries, NUL & NGOs on policies, strategies and guidelines; Analysis of HIV Prevention Response use of incidence model and synthesis writing. 3) Fast-track the process of creating the policy context for a scale-up and and Modes of HIV Transmission: standardization of male circumcision (including traditional FINDINGS: HIV EPIDEMIC AND sector as appropriate); Mozambique Country Synthesis RESPONSE SYNTHESES 4) Strengthen research and evaluations alongside interventions in order to understand Population prevalence stabilized at 23.2%; excess “what works” in Lesotho; mortality in adults and children combined with reduced 5) Revise content of prevention messages to address Authors: Donald Whitson GAMET fertility leads to stagnant population growth. Estimated underlying social norms Roberta Horth UNAIDS annual HIV incidence in adults in 2007 at 1.7% (down regarding multiple concurrent partnerships; Sandra Gonçalves KULA from 3.6% in 1995); incidence in children halved in the 6) Introduce a harmonized planning system at district level last 8 years to 0.17%. Incidence modeling suggests that for all prevention casual sex contributes 65% of all new infections in adults, implementers to ensure synergistic action and longer-term and that 23% of new infections arise through sex with continuity of interventions; BACKGROUND a single marital or cohabiting partner. There may be a 7) Institutionalise MOT as a planning tool. considerable number of new infections in MSM, but there The first National HIV/AIDS Strategic Plan 2000/2002 was is a lack of local data. Key determinants of epidemic first elaborated in response to alarming data from sentinel are high frequency of multiple partners (24% of adults NEXT STEPS surveillance sites that prevalence was high and increasing. with a partner have other concurrent partners, trend is This led also to the establishment of the National AIDS decreasing), unprotected sex especially among longer- 1) Finalizing of synthesis report Council (CNCS) tasked with leading and coordinating the term partners, and low male circumcision (only about 15% 2) Dissemination of findings country-wide national response. The NSP was later revised, resulting of men circumcised). 3) Preparation of policy briefs in the current NSP (PEN II) 2005-2009, which adopted a 4) Translation into policy and programme fully multisectoral approach to combating the spread Lesotho has created enabling policy environment of the disease. In 2008, the process of revision of the for prevention, but there is a need to improve PEN will begin. According to the 2007 ANC sentinel operationalisation of policy commitments. National HIV FUNDING AND TECHNICAL SUPPORT surveillance data, the epidemic appears to be stabilizing and AIDS Bill and the Child Welfare Bill to be passed, BCC in the Central and Northern regions, but appears to strategy in draft form, but comprehensive prevention UNAIDS, GAMET, NAC, MOHSW, BOS still be rising in the South, reaching alarming levels. A strategy lacking. PMTCT and HCT interventions have Prevention Reference Group, headed by the Minister of been scaled-up. The majority of interventions focus on Health, was established in 2008, and is currently reviewing changing knowledge, attitudes and beliefs. Main target best practices for prevention, which, together with the audiences are youth and general population. According results of the MOT study will be incorporated into the to NASA prevention expenditure is at 13% of total AIDS revised NSP. expenditure 2007/08. METHODS SYNTHESIS OF HIV EPIDEMIC AND The Modes of Transmission Study in Mozambique is RESPONSE FINDINGS being undertaken in coordination with a similar exercise, Data Triangulation, led by the CDC and University of Multiple partnerships, sexual networks and underlying California San Francisco. A joint DT/MOT coordinating social norms not adequately addressed in policies committee was formed to oversee both processes and and programmes. Scale-up of male circumcision is at ensure that the two are coordinated to the greatest planning stage. Distribution of free condoms fluctuates. advantage. The epidemiologic review was carried out in Some prevention interventions are underfunded, e.g. BCC three stages, beginning with a national 2007 Annotated interventions (3% of total prevention expenditure). Lack Bibliography compiled by the Ministry of Science and of understanding whether certain interventions work, e.g. Technoloy 2) The DT team complemented this with a impact of KYS campaign and social mobilisation. further in-country search for grey literature and published and unpublished studies. The MOT then commissioned 12 Modes of HIV Transmis sion MOZAMBIQUE SWAZILAND Mod es of HIV Transmis sion 13 a search of grey literature in seven provinces. The first dedicated to reducing multiple concurrent partnerships in round of Data Triangulation chose a research question adults. Male circumcision is under study by the Prevention focusing on identifying the key drivers of the epidemic Reference Group, but as yet there are no policies or in order to provide the greatest amount of synergy with programs in place. the MOT process. The first DT synthesis workshop was held together with the MOT inception workshop. This was followed by an Incidence Model Workshop in June 2008. SYNTHESIS OF HIV EPIDEMIC AND During this workshop, participants discussed and decided RESPONSE FINDINGS on values to use for the input variables for the model based on national and regional data and estimates. Current evidence points to partner reduction and circumcision as the most effective strategies for The MOT team commissioned a private consulting firm to reducing HIV transmission, with increasing condom use undertake a Review of Prevention Policies and Programs. in selected populations at risk. The current prevention The team traveled to seven provinces to gather data about response, which focuses on youth, abstinence, testing prevention programs from private and public entities, and counseling, condoms in the general population, NGOs and the CNCS databases in each province, and and STI diagnosis and treatment, is unlikely to reduce interviewed policymakers about policies and programmes. heterosexual transmission. There is an urgent need for These, together with a review of the PEN II, provided further information on factors characterizing multiple input into a Prevention Review paper. This paper, together concurrent partnerships, potential acceptability of male with the results of the 2008 NASA report provided the circumcision, and to define the population of IDUs and Analysis of HIV Prevention Response basis for a comprehensive review of prevention policies, MSM in order to target programs. programmes, and financial resources. A final synthesis and Modes of HIV Transmission: workshop was held July 23, 2008 to present the findings and draw conclusions and make recommendations for the RECOMMENDATIONS Swaziland Country Synthesis upcoming review of the PEN. The revision of the PEN should include specific strategies for reducing multiple concurrent partners, policies and FINDINGS: HIV EPIDEMIC AND strategies regarding male circumcision, and targeting Authors: S. Mngadi1, N. Fraser2, T. Lapidos3, H. RESPONSE SYNTHESES adults, both men and women. Specific condom promotion Mkhatshwa3, T. Khumalo3, S. Tsela1, N. policies and programs that focus on risk groups, including Nhlabatsi4, H. Odido5, M. Gorgens-Albino2 The 2007 ANC sentinel survey report indicates that mobile populations, sex workers and others should be national HIV prevalence in pregnant women has reached considered. The definition of mobile populations should Affiliations: (1) NERCHA, (2) GAMET, (3) In-country 16% and is leveling off. However, this masks significant be broadened to include the sedentary populations with consultant, (4) MOHSW, (5) UNAIDS regional differences. The epidemic in the North is leveling whom they interact. off at a lower prevalence of 9%, the Central Region has peaked at about 18%, but the South has reached 21% and is still rising. The incidence model predicts that 23% of NEXT STEPS BACKGROUND incidence is the direct result of casual partnerships, with another 48% of new cases occurring in people in steady The results will be presented to the Prevention Reference Given the high HIV prevalence in Swaziland, reducing partnerships, with 68% of heterosexual transmission Group for inclusion in policy revisions for prevention new HIV infections is an absolute priority. The Swaziland occurring in adults over 25 years of age. Sex work programs. In addition, they will form the basis for the National Multisectoral AIDS Strategic Plan 2006 - 2008 contributes directly and indirectly to another 19% of new revision of the prevention policies in the PEN beginning in is currently under review: the MOT study will help define infections, and 3% of new cases result from injection drug 2008. A wealth of new data will become available in 2009, the future HIV prevention response in Swaziland by use, 5% in men who have sex with men, and 2% result including the results of the AIDS indicator Survey, BSS+ providing key evidence on the sources of new infections from medical injections. Factors that most influence and others. UNAIDS is planning to sponsor subsequent and the current alignment between the epidemic and the transmission are male circumcision (highly protective), rounds of DT/MOT revision in 2009 that will allow the prevention response. multiple concurrent partnerships and mobile populations incorporation of this new information and revision of the engaging in risky sex. A significant amount of transmission recommendations. occurs among discordant couples. The high prevalence of METHODS sexually transmitted infections is another important factor. FUNDING AND TECHNICAL SUPPORT Know your epidemic (KYE): Desk review of local and The current prevention response is oriented toward international published and grey literature, application prevention in youth, counseling and testing, condom National AIDS Coordinating Authority, UNAIDS, GAMET,, of UNAIDS incidence model (application of incidence social marketing and STI diagnosis and treatment. CDC/University of California San Francisco and the joint model in Swaziland limited by availability of data on While there are programs targeting mobile populations, DT/MOT Coordinating Committee. risk populations, HIV prevalence and sexual behaviour very few target sex workers and their clients, and none data); Know your response (KYR): Data collection on target MSM or IDUs. Few resources or programs are policy context, strategic information and prevention 14 Modes of HIV Transmis sion SWAZILAND UGANDA Mod es of HIV Transmis sion 15 interventions through key informant interviews, using standard MoT data collection tools. Synthesis of KYE-KYR: using GAMET synthesis process. Local epidemiologist, prevention consultant and sociologist to support process coordinated by NERCHA; implementation supervised by steering committee (the ‘core team’), use of findings ensured by ‘policy team’. Multi-stakeholder effort regarding data provision and review process. Capacity building through workshops especially on incidence modeling and synthesis writing. FINDINGS: HIV EPIDEMIC AND RESPONSE SYNTHESES Population prevalence stabilized at 26% leading to negative population growth and life expectancy of just 37 years. Estimated annual HIV incidence in 2008 of 3% (down from 6% in 1999). In 2008, approximately 72% of adult HIV incidence in individuals aged 25+, about 62% Analysis of HIV Prevention Response of adult HIV incidence in females, and about 19% of all new infections in children aged 0-14. Transmission mainly and Modes of HIV Transmission: through heterosexual contact between longerterm partners and partners aged 25+, condom use higher among non-regular and commercial partners than regular Uganda Country Synthesis partners. Key determinants of epidemic are low male circumcision (8%), high frequency of multiple partners (which have cultural resonance, but show early signs of KEY RECOMMENDATIONS decline) and probably oscillating short-term migration by Authors: 1Wabwire-Mangen F, 2Odiit M, 3Kirungi W, men and women. 1) Put in place policies and strategies in order to build a 4 Mwijuka B, 4Kaweesa DK, 2Wanyama J, 2Harper M. prevention/social change movement at community level Prevention benefits from mostly supportive policy context, 2) Ring-fence a considerable proportion of the AIDS Affiliations: 1 Makerere University, School of Public Health, but there is some clash with traditional law, and key budget for prevention (not below 20%) Kampala Uganda; policies on gender, male circumcision, sexual offences 3) Strengthen the legislative environment 2 UNAIDS Country Office, Uganda; and domestic violence bill remain in draft form. Prevention 4) Fast-track processes required to launch large-scale 3 Ministry of Health, Republic of Uganda; interventions scaled up, many focusing on changing male circumcision (adoption of policy and strategy, 4 In-country Consultant knowledge, attitudes and beliefs. Main targets are implementation of MC plan) youth and general population; lack of targeting of older 5) Target steady couples with tailored integrated adults, and sex-specific targeting. Prevention third most prevention and sexual health programs important NASA spending category (17%). 6) Accompany innovative and key interventions by research in order to understand “what works” BACKGROUND SYNTHESIS OF HIV EPIDEMIC AND Since the identification of the first AIDS cases in Uganda RESPONSE FINDINGS NEXT STEPS in 1982, HIV has spread throughout the country resulting into a severe, mature, and generalized epidemic. The Not enough messages address partner reduction, sexual 1) Finalizing of synthesis report by epidemic in Uganda has evolved into a heterogeneous networks and social norms, although first results of MCP GAMET/NERCHA/UNAIDS epidemic affecting different population sub-groups. It is campaigns are promising. A strategy and implementation 2) Dissemination of findings by NERCHA probable that the risk factors and drivers of the epidemic plan for male circumcision have been developed. Risk of 3) Preparation of policy brief (actor to be defined) may have changed over time as evidenced, for instance, infection in discordant couples, positive prevention, and 4) Translation into policy and programme by Policy Team, by the occurrence of a significant proportion of new vulnerability through migration not addressed adequately. NERCHA & stakeholders infections among discordant couples in union rather than Spending on prevention may need to be increased in with casual partnerships as was the case early on in the view of protecting the 74% of the population who are epidemic. There is therefore a need to conduct a study HIV negative. Lack of understanding whether “collective FUNDING AND TECHNICAL SUPPORT that will describe the current drivers of the epidemic, action” approaches and peer education work, and how the modes of transmission of HIV in Uganda, identify they should be changed to maximum benefit. UNAIDS, GAMET, NERCHA the source of new infections and review the allocation of prevention resources. 16 Modes of HIV Transmis sion UGANDA METHODS SYNTHESIS OF HIV EPIDEMIC AND RESPONSE FINDINGS We used the standard Modes of Transmission methodology as described in the UNAIDS/GAMET The synthesis shows as mismatch between the guidelines. In brief, we conducted a review of the epidemiology, policies & programs and resource epidemiology of HIV in Uganda, applied the UNAIDS allocation. Despite the evidence of the risk factors and incidence model to predict the distribution of new drivers of the epidemic, there are no policies targeting infections, used the MoT prevention review tool to MARPS, circumcision and the contextual factors. There are describe the current prevention policies and programs no programs or funding targeting concurrent partnerships and reviewed the current allocation of resources for HIV or marital or co-habiting partnerships especially prevention. Finally, the GAMET synthesis process was discordant couples. Funding is not targeted to prevention used to assess whether prevention policies, programs with positives but rather to ART and care. and resources are aligned to the populations in need. The study was implemented by a team of 4 national experts coordinated by the UAC and the UNAIDS Country RECOMMENDATIONS Office with technical support from UNAIDS RST. A national • Institutionalize MoT in NAC and MoH operations Technical Steering Committee provided oversight and a • Strengthen capacity for the conduct and utilization group of epidemiologists and modelers peer reviewed of MoT the process. • Encourage evidence-based planning and programs • Re-align prevention effort to where the new infections are occurring and to the populations most in need FINDINGS: HIV EPIDEMIC AND RESPONSE • Develop repository for strategic information on SYNTHESES national response • Strengthen routine sources of program data eg HMIS, The epidemiology review indicates that the previously • Conduct sero-behavioral surveys for MARPs heralded decline in prevalence from a peak of 18% in 1992 • Conduct MoTs regularly after every AIS i.e every 3 years to 6.1% in 2002 may have ended. There is stabilization of prevalence between 6.1 and 6.5% in some ANC sites 1 and even a rise in others. This is accompanied by deterioration NEXT STEPS in behavioral indicators especially an increase in multiple concurrent partnerships. There has also been a shift in • Finalize synthesis process and report the epidemic from single casual relationships to long- • Consult NAC and MoH on best strategy for term stable relationships. Incidence modeling reveals in-country dissemination that 43% of new HIV infections are among monogamous • Disseminate to the National Prevention Policy Steering relationships while 46% are among persons reporting Committee meeting in September multiple partnerships & their partners. Commercial sex • Present a discussion paper during the Joint AIDS workers, their clients and partners of clients contribute Review in September 10% of new infections. MSMs and IDUs contribute less • Plan to contract out development of communication than 1%. There has also been a shift in concentration of strategy for GRIPP the epidemic from younger to older individuals with the highest prevalence for men (9.9%) being among 35 – 39 year olds while for women (12.1%) it is among 30 – 34 year FUNDING AND TECHNICAL SUPPORT olds. Furthermore, the high burden of HSV-2 of 44% has fueled the epidemic. Uganda AIDS Commission, Ministry of Health, UNAIDS Country Office, UNAIDS RST The prevention review revealed that policies exist for and World Bank-GAMET many of the prevention programs implemented in Uganda. Significantly, there are no policies for media and IEC, behavior change interventions, male circumcision and interventions for MARPs. The key stakeholders in the prevention response include government, non- governmental and civil society organizations. Only 31% of the US $249 million was toward prevention while the bulk of funding (53%) went towards care and treatment. Program support and mitigation both took 8% each.