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SURVEILLANCE AND DETERMINANTS OF THE GLOBAL, AFRICAN, SADC AND SOUTH AFRICAN HIV/AIDS/ STI EPIDEMICS

Ohangwena region lies in the north western part of Namibia. It is situated along the border with Angola. The region is a busy border point with a major transport route across into Angola and there is a significant movement of people especially due to the civil war in Angola. Ohangwena region has three district hospitals namely: Engela, Eenhana and Okongo Hospitals for which some of the data and information was collected for this assignment.

The region has a population of 228,384 people of which 99% live in rural areas. It has the highest population density in the country at 21.3 persons per square kilometer. Sixty percent of the households are headed by women and a full forty-four percent of the population is under fifteen years of age. Fifty two percent of the population state that farming is their main source of income and a full twenty percent indicate that pensions are their main source of income. The HIV/AIDS prevalence rate in Ohangwena is 19%, and 18% of the children under fifteen have lost either one or both parents. (Third Medium Term Plan, 2004-2009)

In this assignment, the trends in epidemiology will mainly focus on Eenhana Town which is the capital of Ohangwena region. Eenhana has a population of about 24, 000 people living in it and it is classified as a developing town though it still remains largely rural. The HIV trends in Eenhana do not vary within the region as the people are faced with similar problems. 1. TRENDS IN THE EPIDEMIOLOGY OF HIV/ AIDS

In Namibia, HIV is transmitted among adults primarily through heterosexual contact between an infected partner and a non-infected partner. Consequently, HIV prevention programmes focus their messages and efforts on promoting three specific behaviors: use of condoms, limiting the number of sexual partners or staying faithful to one uninfected sexual partner, and for persons delaying first sexual intercourse (sex debut) through abstinence. (Demographic and Health Survey, 2006-2007). The bi-annual Sentinel Survey carried out in Namibia gives a reflection of the HIV prevalence amongst pregnant women attending antenatal clinics. This data gives an estimate of what is going on at ground level. Table one gives an insight on the prevalence rate of women aged between 15-49 years of age. The data in the table was collected from the 2008 HIV Sentinel Surveillance. Reference is focusing on Ohangwena region mainly.

Site 	Tested for HIV	Tested negative	Tested positive

Eenhana	258	228	30 Engela	309	247	62 Okongo	169	134	35 Total 	736	609	127

Table 1: HIV prevalence rate by ANC Sentinel Site, 2008 HIV Sentinel Surveillance, Namibia.

From the table above, we can see that out of the 736 number of women who tested for HIV, only 17.3% tested positive, which is relatively low compared to the 82.7% who tested negative for the whole region. It should be noted however, that not all births take place in health facilities. A majority of live births take place in the homesteads and go unregistered. This also results in the low numbers of women attending ANC in comparison to the regions population.

Facility-based HIV Care/ ART at Eenhana Hospital- CDC Clinic (New and cumulative data as of 05/02/2009) 	Number of persons enrolled in HIV care	New patients enrolled in HIV care	Total number of persons ever enrolled in HIV

1. Males (14years+)	1039	20	1059 2. Females (14years+) 	2607	54	2661 3. Males (0-5 yrs) 	118	1	119 4. Females (0-5yrs)	161	2	163 5. Males (5-14 yrs)	135	0	135 6. Females (5-14yrs)	172	1	173 Total 	4232	78	4310

Table 2: HIV Care (non-Art and ART)1.1. Trends in terms of age distribution

The age group from 14 years and above for both sexes has a high HIV infection rate compared to the 0-5years and 5-14years age group. It can be presumed that those in the 14 - 49years age group are more sexually active than those under the age of 14 years. It must also be noted that there are a total of 590 HIV infected children in Eenhana between the ages of 0-14years. This can be attributed to the presumption that these children were born with the virus from their mothers. Infection levels are high for girls and women in the age group 14-49 years compared to men of the same age group. It can also be seen that the number of new infections are high in the same age group. Overall, there is high HIV infection rate over the board amongst females irregardless of their age groups. 1.2. Trends in terms of gender distribution From the data given in table above, it can be noted that overall females have a higher HIV prevalence compared to males. This can be attributed to the fact that some of these persons could have been referred by Ante Natal Clinic. Other reasons could be that, the region is highly populated by more females than males, which means that only half of the male population would seek medical help as some of them are not presently living in the region. Irregardless of the age and gender given in the table, females have a higher prevalence than their male counterparts. This could also owe to the fact that there are also a lot of Female headed households. This could be so especially to those women whose husbands are working in other towns and only come home for holidays. There is a possibility that their husbands have other sexual partners in their places of work.

1.3. Trends in terms of geographic distribution Much of Eenhana can be regarded as being rural with very little economic opportunity. The majority of the population has not attained high levels of education and a majority is unemployed. Although condom distribution in this part of the region may be available, very few people are willing or open enough to get some from centers where they may be available. The area is also characterized with bars and shebeens where all sorts of liquor are available ranging from traditional illicit brews to hard liquor. Many of the people are seen spending most of their time at these spots irregardless of their age. Alcohol abuse is seemingly a problem in the area. As a result a lot of the youth and some adults may engage in unprotected sexual encounters after consuming a lot of alcohol.

1.4. Trends in terms of regional distribution

The town is close to the border of Namibia and Angola, and there is a lot movement of people. The region also serves as a transport route for traders to and from Angola. Due to the high poverty levels in the northern part of Namibia, there is an increase in prostitution amongst young girls and women. Traditional customs also still play a role in the status of women. Women are traditionally accorded low status and have no say in family planning and the use of condoms in risky sexual relationships.

2. COLLECTION OF HIV/AIDS SURVEILLANCE DATA

Most of the data collected by the hospitals is mainly from the CDC registers, HIV/ AIDS programmes such as PMTCT, syphilis surveillance and VCT are also used to enhance surveillance findings. The data collected is mainly done through blood tests in all the above mentioned programmes. The data collected from these sources are an estimate of the total figures required.

2.1. Advantages of data collection

•	Data collected from ante natal clinics is easier to collect as data is readily. available since all attendants are registered. Pregnant women have to visit the clinic at some point. •	Prevention and care can be planned out to reach the most affected areas in the country. •	Estimate HIV trends and impact in various age groups and regions, which can also be monitored over time. •	Data from ANC provides surety that the subjects are sexually active owing to the fact that the women are pregnant. •	PMTCT data has potential for future use in monitoring HIV prevalence trends as it collaborates with HIV rates from the HIV sentinel surveillance collected during the same survey. •	Other infections such as STI’s can be detected through ANC sentinel surveys. •	ANC surveillance provides an estimate of pregnant women living with HIV, which is essential in planning and evaluation of PMTCT. •	It also helps in attaining the number unborn children could be born with the virus and or how many will receive treatment. •	All data collected gives an estimation of HIV and syphilis prevalence in all geographical and health districts of the country using sites.

2.2. Limitations of data collection

•	Only women aged 15-49 who are pregnant are included in the Sentinel Surveys. •	All men are excluded and women younger than 15 years or older than 49 years are not included in Sentinel Surveys. •	Sentinel surveys do not include information on new HIV infections. •	Behavioral surveillance data to compliment the sero-surveillance data presented is not available on a national scale. •	Some sites do not reach their targeted sample sizes as required. •	Information on specific high risk groups cannot be provided by the sentinel surveillance. •	The Namibia HIV Sentinel Survey is carried out every 2 years due to resource limitations and not annually as recommended by the World Health Organisation. •	Some satellite sites are not accessible, such the sites in northern Namibia that were affected by floods.

3. FACTORS CAUSING THE SPREAD OF HIV/AIDS IN EENHANA

AIDS is the primary cause of death in the 20-49 year age group according to Hospital records. Currently, 10% of hospital occupants in the region are Angolans with a high incidence of both STI’s and HIV related illnesses.

•	Migrant workers There is limited economic opportunity in the region and many men leave the region to work elsewhere. Sometimes they initiate sexual relationships in their work locations and returning to wife and family in Ohangwena for holidays. Thus there is a high level of female headed households in the region. Amongst other high risk groups are military, police, traders and mine workers, who can also be classified as rotational and transient workers.

•	Traditional practices As elsewhere, women are traditionally accorded a low status within society and customs such as wife inheritance, while decreasing in frequency are still practiced. Women still do not have a say in initiation and family planning. Usually the men are not willing to use condoms, even when they are unsure of their HIV status.

•	Alcohol abuse Alcohol abuse is high and is coupled with the discouraging socio-economic environment. This is especially true amongst young people, resulting in them having unprotected sex after drinking sprees.

•	Sexual behaviour Having multiple sexual partners is quite common in this community. This is also worsened with the fact that, there is a high incidence of transactional sex involving women and young girls and commercial sex is on the increase. This is common in the border town of Oshikango which is the busy border crossing for Angolans seeking refuge from the conflict prone areas and it is also a commercial transport route.

According to studies conducted by Nawa Life Trust and NASOMA, knowledge of HIV/AIDS in Namibia is high. However, the results of the Sero- surveillance survey in 2006 and the KAP surveys indicate that there has been no significant change in sexual behaviour. New HIV prevention strategies are needed to effectively address the factors during the epidemic. (Nawa Life Trust, 2007) CONCLUSION HIV remains a major public health in the northern regions. The prevalence rate in Eenhana is uniform across Ohangwena region. There exist a lot of common factors such female headed households, rotational and transient workers, low status of women, high infection of women and girls especially amongst 14- 49 year olds. The infection rates are on the rise as very few people have changed their sexual behaviors, even though they may have comprehensive knowledge about HIV/ AIDS.

The remedy lies in the need to intensify HIV/ AIDS intervention programmes especially among the youth and women so as to continue to reduce HIV prevalence. The need to empower female headed households with skills to improve their livelihoods as well is vital. This is owing to the fact that the numbers of prostitution is also on the rise. The youth should live up to the motto of abstaining, be faithful and condomise in their daily lives.

REFERENCES

1.	Demographic and Health Survey, Namibia: 2006-2007

2.	Eenhana Hospital- CDC Clinic data base, Monthly Facility Based HIV Care.

3.	Ministry of Health and Social Services, 2006: Report of the 2006 National HIV Sentinel Survey.

4.	Ministry of Health and Social Services, 2008: Report of the 2008 National HIV Sentinel Survey.

5.	Nawa Life Trust, 2007.

6.	National Strategic Plan on HIV/ AIDS (MTP III),2004-2009. 7.	National Planning Commission, 2006: Population projections, 2001-2031, National and Regional figures, Central Bureau of Statistics.