The network has contributed to a strengthened evidence-base in HIV epidemiology to inform policy in Africa and has built capacity in epidemiological analysis in its partner institutions.

ALPHA Network partners are independently managed institutions, each with their own wider scientific agendas and have developed research methods tailored to their own needs. All network members share a common interest in understanding the spread and impact of the HIV epidemic in the communities they study, and its interactions with the socio-demographic characteristics of their populations.

The network regularly contributes detailed statistical estimates of HIV incidence, mortality patterns and fertility impacts to the UNAIDS Reference Group on Estimates and Projections, which oversees the data and methods used for producing HIV epidemic updates and projections in African countries. It also supplies anonymised individual level data to the modelling community through an agreement with the HIV Modelling Consortium.

An effective response to HIV is a global priority, and sub-Saharan Africa faces the greatest challenge as the region with the largest share of the global HIV burden and the most severe resource constraints.

The ALPHA network brings together ten collaborating African research institutions which conduct population-based HIV surveillance in eastern and southern Africa, and is coordinated by the London School of Hygiene & Tropical Medicine (LSHTM).

http://alpha.lshtm.ac.uk

Location of ALPHA network partners

• Rakai study: Managed by Makerere University and the Uganda Virus Research Institute (UVRI) in collaboration with Johns Hopkins School of Public Health, USA

• Masaka district, Uganda (Kyamulibwa general population cohort): managed by UVRI in collaboration with the UK Medical Research Council (MRC)

• Kisumu study in Siaya and Rarieda districts of Kenya managed by Kenya Medical Research Institute (KEMRI) in collaboration with the US Centre for Disease Control (CDC)

• Nairobi urban cohort study managed by the Africa Population Health Research Centre (APHRC), Kenya

• Kisesa open cohort study in Magu district, managed by the TAZAMA program at the National Institute for Medical Research (NIMR) Mwanza campus, Tanzania

• Ifakara rural and urban cohort in Kilombero district, managed by the Ifakara Health Institute, Tanzania

• Karonga Prevention Study in Northern Malawi managed by the Malawi Epidemiology and Intervention Research Unit (MEIRU) and LSHTM

• Manicaland study in Eastern Zimbabwe managed by the Bio-Medical Research Training Institute, Harare and Imperial College, London

• Agincourt study in Mpumalanga Province of South Africa, managed by the University of the Witwatersrand and the South African MRC

• uMkhanyakude district cohort in KwaZulu Natal province of South Africa managed by the Africa Centre for Population Health in collaboration with the University of KwaZulu Natal, the South African MRC and University College, London.

The network gradually coalesced between 1997 and 2003, as some of the original collaborating institutions were asked to present evidence on HIV epidemiology by UNAIDS, the World Bank, WHO, UNICEF and the International Union for Scientific Study of Population. They collaborated in a series of workshops, scientific meetings and conferences, which aimed to understand the spread and the demographic impact of HIV in African populations.

It became clear that population-based, longitudinal observational studies had a critical role to play in furnishing the evidence required to interpret survey data collected in the simpler but more wide-ranging and representative cross-sectional studies and anonymous surveillance data from ante-natal clinics. Data from the ALPHA studies provide the only direct measures of HIV incidence and mortality outside of clinic and trial settings.

The network was formally established in 2005 with funding from the Wellcome Trust, bringing together six research institutes from Uganda, Tanzania, Malawi, Zimbabwe and South Africa. In 2010, it expanded with continued Wellcome Trust support, to include another four partners from Kenya, Tanzania and South Africa.

The estimates are based on pooled data from studies with HIV surveillance rounds pre- and post-ART roll-out (Rakai, Masaka, Kisesa, Manicaland). Women have younger incidence patterns than men, but whereas incidence fell for men at all ages after ART roll-out, incidence rose for women over 30. As a result, the gender disparity in incidence in young people has become even wider, but in older men and women incidence levels have converged.

HIV incidence trends by sex, age and ART availability

Recent example of key findings

The history of the ALPHA network

Trends in adult mortality by sex and HIV treatment status

Recent example of key findings

The pooled data are from studies that started to monitor mortality by HIV status before 1999 (Rakai, Masaka, Kisesa, Manicaland). Immediately after introduction of ART, mortality of patients on ART was very high as many were too ill to benefit from treatment. Mortality of the ever treated fell rapidly as programs stabilised and recruited patients in better health. Female mortality is more favourable throughout because of their younger age at infection and quicker uptake of treatment.

Mortality among those who have never received treatment has also improved due to selection effects: those with longer duration or faster progressing infection are recruited earlier into treatment programs, leaving progressively healthier individuals in the never treated group.

Even in studies served by clinics that have achieved the most favourable mortality outcomes for the ever and never treated groups, mortality in HIV infected adults continues to be nearly three times higher than in uninfected adults, but in the pre-treatment era it was over ten times higher.

ALPHA network’s investigation of recent HIV mortality change, policy analysis, facility surveys and qualitative studies that provided context to the cohort analyses, was funded by the Bill & Melinda Gates Foundation.

Where to find ALPHA at AIDS 2016

Monday 18 July 17:00 – 19:00 (session room 13) ALPHA network symposium HIV Mortality Trends in Africa in the Treatment Era: New Evidence from the ALPHA Network of Community-based HIV Surveillance Studies

Tuesday 19 July 12.00-14.30: Poster exhibition• Population-wide adult mortality following expansion of ART in the Rakai district (Uganda) (TUPEE526) Doreen Nabukalu, Rakai, Uganda• The rapidly shrinking burden of HIV on adult mortality in KwaZulu-Natal, South Africa (TUPEC132). Georges Reniers, LSHTM• Eddies, backflows and stagnancy: qualitative research findings on the HIV treatment cascade (TUPED273). Morten Skovdal, Manicaland• Factors associated with acquisition of HIV during 2005-2014 in 7 ALPHA network cohorts (TUPEC141). Emma Slaymaker, LSHTM

17:30: Oral Abstract Session Track D (Session Room 2) – Shame-Less: Stigma Interventions That Work Presentation: Changing forms of HIV stigma along the HIV care and treatment cascade: findings from a multisite qualitative study in eastern and southern Africa (TUAD0405). Joyce Wamoyi, Kisesa, Tanzania

Wednesday 20 July

12:00-14:30: Poster exhibition• HIV policy implementation in S.Africa: evidence from policy reviews and facility surveys (WEPED453). Natsayi Chimbindi, Africa Centre, S.Africa• Healthcare providers go beyond their call of duty in an ART programme in rural KwaZulu-Natal (WEPEE490). Natsayi Chimbindi, Africa Centre• Opportunities and challenges for 'test-and-treat' in E. and S. Africa: (WEPED431). Constance Nyamukapa, Manicaland. Zimbabwe• HIV testing models and their implications for patient engagement with HIV care (WEPED375). Alison Wringe, LSHTM• How ambivalences in the provider-patient relationship mediate access to care (WEPED430). Fredrick Odongo, Kisumu KEMRI, Kenya• What is the truth? A comparison of HIV results from VCT rapid test and standard ELISA (WEPEC144). Emanuel Mwendo, Kisesa, Tanzania• When 'bad' patients transform into 'good' patients. (WEPED333). Mosa Moshabela, University of KwaZulu-Natal, S.Africa • Understanding couple dynamics and engagement with HIV care services: (WEPED314). Joyce Wamoyi, Kisesa, NIMR, Tanzania

13.00: Oral Poster Discussion Session (Session Room 9) – Translating Tradition in the AIDS Response Presentation: Promise or Peril? The nature of medical pluralism along the cascade of care for HIV/AIDS in eastern and southern Africa (WEPDD0101). Mosa Moshabela, University of KwaZulu-Natal, South Africa

13:05: Oral Poster discussion (Session Room 3) – Filling the Gaps in PMTCT/B+ Programmes Presentation: Counselled to compliance: experiences of Option B+ for the prevention of mother to child transmission in four health and demographic surveillance sites in sub-Saharan Africa (WEPDE0102). Estelle McLean, LSHTM

15:15: Oral Abstract Session Track D (Session room 4) – It’s All in the FamilyPresentation: Partner communication and support around HIV and how this relates to health-seeking behaviour: a qualitative study amongst HIV-positive individuals and couples in Karonga, Malawi (WEAD0104). Jenny Renju, LSHTM

Thursday 21 July

12.00-14.30: Poster exhibition• A qualitative exploration of barriers to “test and treat” for HIV, in Rakai fishing communities (THPEE593). Robert Ssekubugu, Rakai, Uganda• What influences patients' presentation stage for HIV services in Uganda? (THPEE481). Dominic Bukenya Yiga, MRC/UVRI, Uganda

17:15: Oral Abstract Session Track D (Session Room 5) – Barriers Must Fall: Community-Led Delivery Presentation: A comparative study of policy and practice influencing progression through HIV care (THAD0104). Fredrick Otieno, Kisumu, Kenya

Tuesday-Friday: Exhibition stand 327 London School of Hygiene & Tropical Medicine