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Abstract
Background: It is unclear why HIV prevalence varies by nearly two orders of magnitude between regions within countries in sub-Saharan Africa. In this ecological study, we assess if HIV prevalence by region is associated with any of four markers of higher risk sexual behavior: lifetime number of partners, multiple partners in past year, higher risk sex (defined as sex with non-cohabiting, non-marital partners) and age at debut. Methods: We performed Pearson's correlation between the 4 behavioral risk factors and HIV prevalence by region in 47 nationally representative surveys from 27 sub-Saharan African countries, separately by gender. In addition, principal components analysis was used to reduce the eight risk factors (four for each gender) to two principal components (PCs). Mixed effects linear regression was used to assess the relationship between the resulting two PCs and HIV prevalence after controlling for the prevalence of male circumcision. Results: HIV prevalence varied by a median 3.7 fold (IQR 2.9-7.9) between regions within countries. HIV prevalence was strongly associated with higher risk sex and, to a lesser extent, the other risk factors evaluated. Both PCs were strongly associated with HIV prevalence when assessed via linear regression. Conclusions: Differences in sexual behavior may underpin the large differences in HIV-prevalence between subpopulation within sub-Saharan African countries.
Highlights
It is unclear why HIV prevalence varies by nearly two orders of magnitude between regions within countries in sub-Saharan Africa
Whilst a few ecological studies have found a difference in sexual behavior could explain differences in HIV prevalence (De Walque, 2006; Kenyon et al, 2013; Kenyon & Colebunders, 2012; Morris et al, 2010; Morris et al, 2009), many have not (Auvert et al, 2001; Cleland & Ferry, 1995; Drain et al, 2004; Sawers & Stillwaggon, 2010; Wellings et al, 2006), and the meted cross-country comparisons; these are suboptimal because national populations may be constituted by several relatively separate sexual networks (Kenyon & Colebunders, 2013; Laumann & Youm, 1999)
There was a high difference in HIV prevalence between regions and this correlated closely at an ecological level with a number of behavioral variables such as lifetime number of partners, reporting sex with a non-marital, non-cohabiting partner, and age at first sex (Kenyon et al, 2015b). We extend these earlier analyses to assess systematically if differences in HIV prevalence by region within countries in sub-Saharan Africa are associated with markers of sexual risk behavior
Summary
Aral and others have argued persuasively that population-level parameters such as the structure of sexual networks determine the prevalence of sexually transmitted infections (STIs) (Aral et al, 2007; Morris et al, 2010; Morris et al, 2009) If this is true, it follows that ecological studies are necessary to assess which markers of network structure are associated with higher HIV prevalence (Kenyon & Colebunders, 2012; Morris et al, 2010). This type of study from the USA, UK, Kenya, Uganda and South Africa has revealed positive ecological associations between various markers of sexual behavior (number of partners in past year and lifetime, partner concurrency and age of sexual debut), by ethnic group and HIV prevalence (Kenyon et al, 2014a; Kenyon et al, 2013; Kenyon et al, 2014b; Kenyon et al, 2014c; Kenyon et al, 2016b; Morris et al, 2009)
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