Olive Shisana

A Comparison of South African National HIV Incidence Estimates: A Critical Appraisal of Different Methods.

Background The interpretation of HIV prevalence trends is increasingly difficult as antiretroviral treatment programs expand. Reliable HIV incidence estimates are critical to monitoring transmission trends and guiding an effective national response to the epidemic. Methods and Findings We used a range of methods to estimate HIV incidence in South Africa: (i) an incidence testing algorithm applying the Limiting-Antigen Avidity Assay (LAg-Avidity EIA) in combination with antiretroviral drug and HIV viral load testing; (ii) a modelling technique based on the synthetic cohort principle; and (iii) two dynamic mathematical models, the EPP/Spectrum model package and the Thembisa model. Overall, the different incidence estimation methods were in broad agreement on HIV incidence estimates among persons aged 15-49 years in 2012. The assay-based method produced slightly higher estimates of incidence, 1.72% (95% CI 1.38 – 2.06), compared with the mathematical models, 1.47% (95% CI 1.23 – 1.72) in Thembisa and 1.52% (95% CI 1.43 – 1.62) in EPP/Spectrum, and slightly lower estimates of incidence compared to the synthetic cohort, 1.9% (95% CI 0.8 – 3.1) over the period from 2008 to 2012. Among youth aged 15-24 years, a declining trend in HIV incidence was estimated by all three mathematical estimation methods. Conclusions The multi-method comparison showed similar levels and trends in HIV incidence and validated the estimates provided by the assay-based incidence testing algorithm. Our results confirm that South Africa is the country with the largest number of new HIV infections in the world, with about 1 000 new infections occurring each day among adults aged 15-49 years in 2012.

Age-disparate sex and HIV risk for young women from 2002 to 2012 in South Africa

Introduction: Age‐disparate sex has long been considered a factor that increases HIV risk for young women in South Africa. However, recent studies from specific regions in South Africa have found conflicting evidence. Few studies have assessed the association between age‐disparate partnerships (those involving an age gap of 5 years or more) and HIV risk at the national level. This study investigates the relationship between age‐disparate sex and HIV status among young women aged 15–24 in South Africa.

Contraception coverage and methods used among women in South Africa: A national household survey

BACKGROUNDnGlobally, family planning services are being strengthened and the range of contraceptive choices expanded. Data on contraceptive coverage and service gaps could help to shape these initiatives.nnnOBJECTIVEnTo assess contraception coverage in South Africa (SA) and identify underserved populations and aspects of programming that require strengthening.nnnMETHODSnData from a 2012 SA household survey assessed contraception coverage among 6 296 women aged 15 - 49 years and identified underserved populations.nnnRESULTSnTwo-thirds had an unintended pregnancy in the past 5 years, a quarter of which were contraceptive failures. Most knew of injectable (92.0%) and oral contraception (89.9%), but fewer of intrauterine devices (56.1%) and emergency contraception (47.3%). Contraceptive prevalence was 49.1%, and 41.8% women used modern non-barrier methods. About half had ever used injectable contraception. Contraception was lower in black Africans and younger women, who used a limited range of methods.nnnCONCLUSIONnContraception coverage is higher than many previous estimates. Rates of unintended pregnancy, contraceptive failure and knowledge gaps, however, demonstrate high levels of unmet need, especially among black Africans and young women.

Determinants of multiple sexual partnerships in South Africa

BACKGROUNDnThis paper aims to examine determinants of multiple sexual partnerships (MSPs) among South African men and women using a nationally representative sample.nnnMETHODSnQuantitative and qualitative data from a 2008 population-based cross-sectional survey were used. The analysis focused on the 6990 (33.6% of total sample) who were 15 years and older and reported sexual activity in the prior 12 months. The qualitative component consisted of 15 focus group interviews investigating values underlying MSP behaviors.nnnRESULTSnPredictors of MSP common across gender were race, having a history of STI, being in a short relationships (<1 year) and suspecting the current partner of infidelity. MSP among men enjoyed greater community acceptance and was mainly done for social status. Furthermore, men reporting MSP were mostly younger (15-24 years old) and use condom at last sex. Among women, determinants of MSP included economic vulnerability, younger age at sexual debut and living in formal urban rather than formal rural areas.nnnCONCLUSIONSnThe data presented in this paper reinforces the importance of MSP as a risk factor for HIV and outline factors that should strongly be considered in strengthening condom use promotion and of partner reduction programs messaging in South Africa.

AIDS 2016: From aspiration to implementation

2484 www.thelancet.com Vol 387 June 18, 2016 Since AIDS was fi rst recognised in 1981, more than 75 million HIV infections and more than 36 million deaths have occurred. HIV infection is no longer an inexorable death sentence but a chronic manageable infection. Key factors responsible for this transformation have been an understanding of the modes of HIV transmission, the development of eff ective combination antiretroviral therapy, and the validation of surrogate markers to monitor the response to treatment. But currently less than half of all people living with HIV worldwide have access to life-saving antiretroviral therapy, at a time when donor interest is uncertain and global funding fl attening. The upcoming 21st International AIDS Conference (AIDS 2016) in Durban, South Africa, on July 18–22, 2016, must take on the challenge of expanding access to HIV treatment. HIV incidence is not declining fast enough to reduce the global burden of the epidemic. In some populations, including young women in sub-Saharan Africa, young gay men and transgender women worldwide, and people who inject drugs in eastern Europe and central Asia, HIV infection rates are rising in 2016. The basics of HIV prevention have not been delivered for these populations (ie, condoms, clean needles, opiate substitution therapy), let alone provision of newer prevention methods such as antiretroviral preexposure prophylaxis (PrEP). Human rights and social justice protections required for safe implementation of evidence-based HIV prevention have not been established in many countries. Some nations have enacted harmful laws and policies that undermine eff ective HIV responses, including laws further marginalising lesbian, gay, bisexual, and transgender people. A highly eff ective HIV vaccine, or a cure, remains elusive. As the HIV world gathers in Durban this July, we face enormous challenges. The last International AIDS Society (IAS) meeting in Durban in 2000 was a transformative event. It was AIDS 2016: from aspiration to implementation amounts of assistance have been funnelled through programmes established for quick results outside of country systems, often prompting governments to reduce their spending on health. This approach is no longer tenable. Development assistance for health has to be better coordinated among partners than at present, fl ow increasingly through country systems, and be linked to increases in government spending on health. The recent slowdown in development assistance for health growth also highlights the need to prioritise institutional capacity building and to develop plans that help countries ease the transition from grant to concessional and eventually self-fi nancing. The Global Financing Facility in Support of Every Woman Every Child will spearhead these changes with its focus on national leadership, alignment of fi nancing behind strategic investments, and improvements in local health fi nancing systems. While the challenge is daunting, attaining UHC and its sustainable fi nancing by 2030 is feasible for most countries. Success will depend on governments and partners aligning their objectives into a coordinated strategic eff ort. Together, we can rise to this challenge and shape a new era of global health fi nancing. *Tim Evans, Ariel Pablos-Méndez World Bank Group, Washington, DC 20433, USA (TE); and US Agency for International Development, Washington, DC, USA (AP-M) tgevans@worldbank.org

Growing inequities in maternal health in South Africa: a comparison of serial national household surveys

BackgroundRates of maternal mortality and morbidity vary markedly, both between and within countries. Documenting these variations, in a very unequal society like South Africa, provides useful information to direct initiatives to improve services. The study describes inequalities over time in access to maternal health services in South Africa, and identifies differences in maternal health outcomes between population groups and across geographical areas.MethodsData were analysed from serial population-level household surveys that applied multistage-stratified sampling. Access to maternal health services and health outcomes in 2008 (nu2009=u20091121) were compared with those in 2012 (nu2009=u20091648). Differences between socio-economic quartiles were quantified using the relative (RII) and slope (SII) index of inequality, based on survey weights.ResultsHigh levels of inequalities were noted in most measures of service access in both 2008 and 2012. Inequalities between socio-economic quartiles worsened over time in antenatal clinic attendance, with overall coverage falling from 97.0 to 90.2xa0%. Nationally, skilled birth attendance remained about 95xa0%, with persistent high inequalities (SIIu2009=u20090.11, RIIu2009=u20091.12 in 2012). In 2012, having a doctor present at childbirth was higher than in 2008 (34.4xa0% versus 27.8xa0%), but inequalities worsened. Countrywide, levels of planned pregnancy declined from 44.6xa0% in 2008 to 34.7xa0% in 2012. The RII and SII rose over this period and in 2012, only 22.4xa0% of the poorest quartile had a planned pregnancy. HIV testing increased substantially by 2012, though remains low in groups with a high HIV prevalence, such as women in rural formal areas, and from Gauteng and Mpumalanga provinces. Marked deficiencies in service access were noted in the Eastern Cape ad North West provinces.ConclusionsThough some population-level improvements occurred in access to services, inequalities generally worsened. Low levels of planned pregnancy, antenatal clinic access and having a doctor present at childbirth among poor women are of most concern. Policy makers should carefully balance efforts to increase service access nationally, against the need for programs targeting underserved populations.

Antiretroviral Treatment and Sexual Risk Behavior in South Africa

The sexual behavior of individuals living with HIV determines the onward transmission of HIV. With the understanding that antiretroviral therapy (ART) prevents transmission of HIV, the sexual behaviors of the individuals not on ART with unsuppressed viral loads becomes of the greatest importance in elucidating transmission. We assessed the association between being on ART and sexual risk behavior among those living with HIV in a nationally representative population-based cross-sectional survey of households in South Africa that was conducted in 2012. Of 2237 adults (aged 15–49) who tested HIV-seropositive, 667 (29.8xa0%) had detectable antiretroviral drugs in their blood specimens. Among males, 77.7xa0% of those on ART reported having had sex in the past year contrasted with 88.4xa0% of those not on ART (pxa0=xa00.001); among females, 72.2xa0% of those on ART reported having had sex in the past year while 80.3xa0% of those not on ART did (pxa0<xa00.001). For males and females, the odds of reporting consistent condom use and condom use at last sex were statistically significantly higher for individuals on ART compared to those not on ART (males: consistent condom use aOR 2.8, 95xa0% CI 1.6–4.9, condom use at last sex aOR 2.6, 95xa0% CI 1.5–4.6; females: consistent condom use aOR 2.3, 95xa0% CI 1.7–3.1, condom use at last sex aOR 2.3, 95xa0% CI 1.7–3.1), while there were no statistically significant differences in odds of reporting multiple sexual partners in the past year. In this nationally representative population-based survey of South African adults, we found evidence of less risky sexual risk behavior among people living with HIV on ART compared to those not on ART.