Abstract
Recent data from the Manicaland HIV/STD Prevention Project, a general-population open HIV cohort study, suggested that between 2004 and 2007 HIV prevalence amongst males aged 15–17 years in eastern Zimbabwe increased from 1.20% to 2.23%, and in females remained unchanged at 2.23% to 2.39%, while prevalence continued to decline in the rest of the adult population. We assess whether the more likely source of the increase in adolescent HIV prevalence is recent sexual HIV acquisition, or the aging of long-term survivors of perinatal HIV acquisition that occurred during the early growth of the epidemic. Using data collected between August 2006 and November 2008, we investigated associations between adolescent HIV and (1) maternal orphanhood and maternal HIV status, (2) reported sexual behaviour, and (3) reporting recurring sickness or chronic illness, suggesting infected adolescents might be in a late stage of HIV infection. HIV-infected adolescent males were more likely to be maternal orphans (RR = 2.97, p<0.001) and both HIV-infected adolescent males and females were more likely to be maternal orphans or have an HIV-infected mother (male RR = 1.83, p<0.001; female RR = 16.6, p<0.001). None of 22 HIV-infected adolescent males and only three of 23 HIV-infected females reported ever having had sex. HIV-infected adolescents were 60% more likely to report illness than HIV-infected young adults. Taken together, all three hypotheses suggest that recent increases in adolescent HIV prevalence in eastern Zimbabwe are more likely attributable to long-term survival of mother-to-child transmission rather than increases in risky sexual behaviour. HIV prevalence in adolescents and young adults cannot be used as a surrogate for recent HIV incidence, and health systems should prepare for increasing numbers of long-term infected adolescents.
Highlights
Recent evidence suggests progress in reducing HIV prevalence amongst 15–24 year-olds in several of the most severely affected countries in sub-Saharan Africa [1]
All three correlates of perinatal and sexual HIV transmission that we tested were consistent with the hypothesis that newly detected HIV infections in adolescents are primarily attributable to mother-to-child HIV transmission: mothers of HIV-infected adolescents were much more likely to be deceased or HIV-infected themselves, HIV infection was not associated with sexual risk behaviours in adolescent males or females, and HIV-infected adolescents were more likely to report illness, indicative of being in late-stage HIV infection, than were HIV-infected young adults
This is the first population-based cohort data to demonstrate that, as generalized HIV epidemics in southern Africa mature, a substantial proportion of HIV infections in older adolescents and young adults may be attributable to long-term survivors of perinatal infections
Summary
Recent evidence suggests progress in reducing HIV prevalence amongst 15–24 year-olds in several of the most severely affected countries in sub-Saharan Africa [1]. The Manicaland HIV/STD Prevention Project in rural eastern Zimbabwe was one of the earliest studies to document declining HIV prevalence in southern Africa, and has demonstrated the role of reductions in casual sexual partnerships and delaying sexual debut for reducing the incidence of HIV [3,4,5]. Given this previous evidence of young people’s leading role in reducing HIV incidence in Zimbabwe, and the continuing decline in HIV prevalence in the general adult population, we were surprised by a trend towards increasing HIV prevalence amongst adolescents (aged 15–17 years) in the most recent available data (Figure 1). HIV prevalence declined in male and female young adults (aged 18–29 years)
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