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Status and Projected Course of the HIV Epidemic in Uganda
Results of 2016/17 UPHIA and Other Surveillance Sources
Dr Wilford L Kirungi
Medical Epidemiologist
AIDS Control Programme / Ministry of Health
Introduction / Background
• We track the magnitude and dynamics of HIV to inform target setting, resource mobilisation / allocation, strategic planning and evaluation of programmes
• Involves triangulation of data from various sources:
• We mainly use spectrum to triangulate demographic / population surveillance data, routine service, etc
• We also project the future course of the HIV epidemic
• We present highlights of estimates for 2018/19 and UPHIA, to keep it simple, present only national estimates
• UPHIA 2016/17• Cross-sectional household-based survey (approx 13,000 HH)
• Nationally and regionally representative
• Focused on measuring impact through HIV Incidence and VL
UPHIA Findings: HIV Prevalence Among Adults 15 – 64 yrs) was 6.2%, but highly heterogenous by covariates
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
Males Females Total
HIV Burden: Estimates No PLHIV still expanding albeit at a reduced rate
562,790 511,109402,367
108,743 65,795 35,291 51,681
825,337
774,911
654,699
120,21394,681
54,373 50,425
100
93
76
17
12
6 7
0
10
20
30
40
50
60
70
80
90
100
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
All Agegroups
Adults 15yrs+
Adults ReprAge 15 - 49
Adults50yrs+
Youngpeople 15 -
24 yrs
Adolescent10-19
Children 0 -14
Subgroups of PLHIV in 2018
Male Females Percent
1,139,2411,168,038
1,192,3951,221,851
1,253,2971,287,640
1,325,7061,360,912
1,390,6591,417,686
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
No PLHIV
88% of HIV infections Appear to have been diagnosed, on treatment; but 5% long standing infections not diagnosed and 5% long standing, diagnosed, previously on treatment
• Among adults, we estimate that• Approx 90,000 HIV infections not
yet diagnosed, one-third being incident infections
• Approx 67,000 long standing infections already diagnosed but disengaged from care
• Prevalence of undiagnosed HIV infections may be <1%, so Uganda took a correct decision to go for highly targeted testing
6,023 12,800 -66,540
1,144,510
28,235 61,049
-
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
Long-standing infection(1+ years), not diagnosed
Incident infection (<1year), not diagnosed
Long-standing infection(1+ years), diagnosed, ontreatment
Long-standing infection(1+ years), diagnosed,previously on treatment
Long-standing infection(1+ years), diagnosed,never treated
Incident infection (<1year), diagnosed, ontreatment
Incident infection (<1year), diagnosed, nevertreated
UPHIA HIV Incidence Test Algorithm took into account the circulating sub-types, OD, VLS and plasma ARVs
• HIV Incidence estimates were based on LAg Assay where the MDRI was dependent on the sub-type of HIV in circulation
• Samples with plasma ARVs were excluded from recent infections
A75.1%
AD1.0%
AG0.5%
C2.6%
D19.7%
G1.0%
UPHIAHIV-1SUBTYPEDISTRIBUTION
A
AD
AG
C
D
G
UPHIA HIV Incidence Estimate was 0.4% or approximately 73,000 New HIV infections, close to Spectrum estimate
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Total MaleFemale Urban Rural 15-24 25-34 35-49 50-64
15-64 yrs Sex Residence Age groups
73,000
60,000
50,000
0.4
0.3
0.26
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
PHIA Spectrum 2016 Spectrum 2018
New HIV Infections Incidence estimates
New HIV Infections declined during past decade but not sufficiently to meet Fast Track Targets
23,31019,485 18,344
1,1424,637
9183,825
29,695
25,97624,862
1,114
13911
6,8353,719
100%
86%82%
4%
35%
15% 14%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
10,000
20,000
30,000
40,000
50,000
60,000
AllAgegroups
15 yrs+ 15 - 49 yrs 50 yrs+ 15-24 yrs 10-19 yrs 0-14 yrs
New HIV Infections by Pop Sub Groups
Males Females Percent
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Trends New HIV Infections
Correct to focus on AFYW
UPHIA - Viral Load Suppression Among Adults –Heterogenous Across Regions and by Age groups
-
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 0-14 15-24 15-49 50-64 15-64
Males Females Total
Achievement of 90-90-90 goals among HIV-positive adults by sex, UPHIA 2016-17
Diagnosed: awareness was defined as self-reporting HIV positive and/ or having a detectable antiretroviral (ARV) in the blood.On Treatment: being on ART was defined as self-reporting current use of ART and/or having a detectable ARV in the blood.
*Inset numbers are conditional proportions.Error bars represent 95% confidence intervals.
Spectrum Estimates of the Trends in HIV Testing –Treatment Cascade
In formulating this cascade, ART numbers for the period 2015 – 18 were discounted by 15% on account of data quality
-
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
2015 2016 2017 2018 2019
HIV Testing - Treatment Cascade 2015 - 19
PLHIV Know status On ART Virally suppressed
0
20
40
60
80
100
120
2015 2016 2017 2018 2019
HIV Testing-Treatment Cascade 2015-19: 90-90-90
PLHIV Know status On ART Virally suppressed
0
20
40
60
80
100
120
2015 2016 2017 2018 2019
HIV Testing-Treatment Cascade 2015-19: 90-81-73
PLHIV Know status On ART Virally suppressed
Age and Gender Specific HIV-Testing and Treatment Cascade 2019
130000 80000 30000 20000 70000 120000
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-80
80+
Number of People
Age
Clinical Cascade
AIDS-Related MortalityDeclined significantly during the past decade, possibly meet Tast Track targets
-10,000
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
2010 2011 2012 2013 2014 2015 2016 2017 2018
TRENDS IN AIDS RELATED MORTALITY 2010-18
AIDS Mortality Averted
9,717
7,001
5,833
1,168
1051 994
2,716
100%
76%
60%
16%
9% 9%
24%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
5,000
10,000
15,000
20,000
25,000
AllAgegroups
15 yrs+ 15 - 49 yrs 50 yrs+ 15-24 yrs 10-19 yrs 0-14 yrs
AIDS Related Mortality By Popn Sub Groups
Males Females Percent
Vertical Infections – Persisting problem, but what are the causes
163297
1394
172
1176
676
134213
1207
35
503
1573
0
1000
2000
3000
4000
5000
6000
7000
8000
1
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
2010 2011 2012 2013 2014 2015 2016 2017 2018
TRENDS IN MTCT AND MTCT AVERTED
No MTCT MTCT Averted
Heterogenous Pattern of Vertical Infections Among Geographical Regions
• Estimates for three regions shown
• Different pattern of vertical infections in the various regions apparent• Defaulting on ART
significant across all regions but more marked in Central 1&2
• NE Region predominantly – not starting ART at all
• Mid East having a higher proportion of incident infections in Pregnancy and during BF period
UPHIA 2016/17: Still High Proportion of PLHIVs with low CD-4
2.7
4.5
4.0
7.1
8.3
4.0
18.3
15.4
17.5
23.0
22.5
23.6
48.9
49.3
50.9
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not previously diagnosed
Previously diagnosed, not on ART
Previously diagnosed, on ART
< 100 100 - 199 200-349 350 - 499 ≥500
5.0
2.9
4.3
3.3
6.1
4.9
5.4
5.3
25.5
13.2
16.2
18.3
25.1
22.3
23.1
23.4
38.2
56.8
51.1
49.7
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Male
Female
Urban
Rural
Sex
Res
iden
ce
< 100 100 - 199 200-349 350 - 499 ≥500
Prevalence of Syphilis and Co-infection with HIV
West
Nile
1.6% Mid
North
2.3%North
East
1.8%
Central 2
3.2%
Mid
West
2.3%
Central 1
2.0%
Kampala
1.2%
East
Central
2.8%
Souh
West
1.8%
Mid
East
1.0%
Uganda
2.1%
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Residence Urban Rural HIV +ve HIV -ve Never married
Married / Living
together
Divorced / separated
Widowed
% ever infected %active infection
Prevalence of Hepatitis B Infection and Co-infection with HIV
West
Nile
3.8% Mid
North
4.6%North
East
4.4%
Central 2
2.0%
Mid
West
1.8%
Central 1
1.6%
Kampala
1.9%
East
Central
2.7%
South
West
0.8%
Mid
East
2.1%
Uganda
4.1%
HIV positive HIV negative Urban Rural
HIV Status Residence
Males 6.3 3.0 2.8 3.1
Females 3.8 1.8 1.9 1.9
Total 4.7 2.4 2.3 2.5
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Males Females Total
Is Uganda on Course to Meet Fast Track Targets for HIV Epidemic Control?
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
New HIV Infections AIDS Mortality
Targets - New Infection Target - AIDS Mortality
-
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
20
26
20
27
20
28
20
29
20
30
Incidence : Mortality Ration
Incidence: Mortality Ratio Target
What will it take for Uganda to Attain HIV Epidemic Control
Cost effective / High Impact interventions: We are alredy focussing on CE and Impactful interventions
• SMC – cost saving
• ART for Males and Females
• Condoms – cost saving
• HCT
• PMTCT
• PREP for HR and MR not LR
• Cash Transfers
• The other interventions appear to either have the potential for reduction of few infections, or do so at high cost
Achieving Fast Track target could potentially avert 670,000 new HIV infections during 2018-30 (70% 0f projected infections for this period)
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
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20
22
20
23
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25
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26
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20
28
20
29
20
30
Uganda - base FT ART - 90
ART-95 ART-95+Eff CondomsPMTCT SMC SWBCC PrEP Cash Transfers
2018-20 % Diff 2018-23 2018-30 % Diff2
Fast Track 78,103 41.6% 232,899 59.3% 665,334 70.6%
ART-90 17,574 9.4% 69,719 17.7% 259,499 27.6%
ART-95 19,599 10.4% 83,815 21.3% 291,340 30.9%
ART-95+Eff 51,617 27.5% 178,918 45.5% 541,204 57.5%
SMC 23,110 12.3% 66,515 16.9% 207,565 22.0%
Condoms 10,249 5.5% 29,108 7.4% 88,835 9.4%
PMTCT 3,690 2.0% 8,995 2.3% 20,509 2.2%
SW 1,801 1.0% 5,020 1.3% 14,821 1.6%
BCC 11,238 6.0% 32,071 8.2% 99,859 10.6%
PrEP 655 0.3% 1,891 0.5% 5,848 0.6%
Cash Transfers 983 0.5% 2,577 0.7% 7,676 0.8%
Meeting Fast Track targets could potentially avert 230,000 AIDS-related mortality during 2018-30 (60% of projected mortality)
2018-20 % Diff 2018-23 % Diff 2018-30 % Diff
Fast Track 26,441 37% 83,086 53% 228,147 60%
ART 95% +Eff 24,291 34% 78,307 50% 224,718 59%
ART 95% 12,651 18% 49,498 31% 156,296 41%
ART 90 12,358 17% 46,182 29% 147,854 39%
SMC -208 0% -3,138 -2% -6,866 -2%
Condoms 72 0% -309 0% 374 0%
BCC 63 0% -441 0% 82 0%
PMTCT 1,104 2% 2,935 2% 7,671 2%
PREP 14 0% 31 0% 128 0%
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
20
26
20
27
20
28
20
29
20
30
base FT ART 95+eff ART 95 ART 90
SMC Condoms BCC PMTCT Ret PREP
Fast Track to HIV Epidemic Control
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
20
26
20
27
20
28
20
29
20
30
New Infections - base New Infections FT
AIDS-deaths - base AIDS deaths FT
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
20
26
20
27
20
28
20
29
20
30
New HIV Infections - Fast Track New HIV Infections Averted
665,000 new HIV infections Averted
The super-fast track i.e. meeting triple 95 targets by 2020, and meeting 80% coverage targets for SMC, condoms among high risk groups, BCC, etc will potentially avert up to 665,000 new HIV infections during 2018-30
Plans for UPHIA2020
• Plans underway to conduct another Population-based Survey in 2020 –UPHIAlite – UPHIA2020, • aim to provide results by 1st Dec 2020 in order to assess achievement of 2020 targets
• Primary Objectives
• To estimate national and sub-national viral load suppression of people 15 years and older
• Secondary Objectives: To estimate the following in people 15+ years
• Prevalence (%) and number of HIV-infected people
• The number of new HIV infections (incidence)
• The behaviors of HIV infected people
• Other programme coverage and outcome indicators
Plans for UPHIA2020
• Only HIV biomarkers: HIV prevalence, CD-4 counts, VL, HIVDR, plasma ARVs
• Smaller sample size, approximately 25,000 adults
• No estimates for children
• Protocol already cleared by UVRI SEC, awaiting clearance by CDC and University of Columbia – IRBs and also to UNCST
• Training of field workers already commenced in November / December 2019
• Field work expected February – June 2019
• Preliminary results expected by 1st December 2020
Summary / Conclusions
• Uganda significantly reduced new HIV infections and AIDS-related mortality during the past decade
• Meeting Fast-track HIV epidemic control targets could potentially to avert 665,000 new HIV infections and 230,000 AIDS-related deaths during 2018 – 20
• HIV incidence decline during 2010-20 appears to fall short of the Fast Track targets; AIDS-related mortality appears to be on track.
• HIV Epidemic control will perhaps require increasing coverage and uptake of efficacious intervention with strategic balance between HIV prevention and efficient HIV treatment services
Summary / Conclusions
• Gender differences in HIV incidence and mortality - disproportionate HIV incidence among females especially AGYW and AIDS mortality among adult males and children
• Apparent shift of HIV burden to older individuals calls for focus on management of HIV in the elderly involving strengthening the integration of HIV treatment and other NCDs
• Vertical infections remain high, driven mainly by women LTFU, women not enrolled on ART, and incident infections during pregnancy and BF, but with significant regional heterogeneity in these patterns of transmission
Acknowledgement
•Uganda HIV estimates Interest Group• MoH, UAC, UBOS, UNAIDS, UNICEF, CDC, USAID, WHO,
USAID-SITES
• Technical Assistance Partners• Avenir Health (formally Futures Institute); UNAIDS; UNAIDS
Reference on Estimates and Projections, WHO, CDC, USAID-SITES
•UPHIA Partners• MoH/ACP, UVRI, UBOS, UAC, CDC-Uganda, CDC Atlanta,
USAID, USAID-SITES, ICAP,
