Adult HIV Prevalence Research Articles

Causes of death in people living with HIV: Lessons from five health facilities in Eswatini.

Eswatini has a high HIV prevalence in adults and, despite being one of the first countries to achieve the UNAIDS 95-95-95 targets, AIDS-related deaths are still high. This study describes the causes of death among people living with HIV (PLHIV) receiving care at five clinics in Eswatini. A cross-sectional review of sociodemographic, clinical and mortality data of deceased clients who received care from 01 January 2021 to 30 June 2022, was conducted. Data were extracted from the deceased clients' clinical records, and descriptive and comparative analysis was performed. Of 257 clients, 52.5% (n = 135) were male, and the median age was 47 years (interquartile range [IQR]: 38, 59). The leading causes of death were non-communicable diseases (NCDs) (n = 59, 23.0%), malignancies (n = 37, 14.4%), COVID-19 (n = 36, 14.0%), and advanced HIV disease (AHD) (n = 24, 9.3%). Clients who had been on antiretroviral therapy (ART) for 12-60 months (OR: 0.01; 95% confidence interval [CI]: 0.0006, 0.06) and > 60 months (OR: 0.006; 95% CI: 0.0003, 0.029) had lower odds of death from AHD compared to those on ART for < 12 months. Clients aged ≥ 40 years had higher odds of dying from COVID-19, while female clients (OR: 2.64; 95% CI: 1.29, 5.70) had higher odds of death from malignancy. Most clients who died were aged 40 years and above and died from NCD-related causes, indicating a need to integrate prevention, screening, and treatment of NCDs into HIV services. Specific interventions targeting younger PLHIV will limit their risk for AHD.

Characterising HIV acquisition risk, treatment gaps and populations reached through venue-based outreach and clinical services in Blantyre, Malawi: findings from a district-wide CLOVE Study.

In 2017, Blantyre district had the highest adult HIV prevalence in Malawi (17.7%) and lowest viral suppression (60%). In response, the Ministry of Health expanded prevention and treatment services. We assessed whether outreach to social venues could identify individuals with increased HIV acquisition risk or with unsuppressed HIV not currently reached by clinic-based services. We conducted a cross-sectional bio-behavioral survey in Blantyre, Malawi, from January to March 2022. We visited social venues where people meet new sexual partners and government clinics providing HIV testing or STI screening. Participants aged > 15 years were interviewed, and tested for HIV infection if not on ART. HIV recency tests were performed on those testing positive, and dried blood spots (DBS) was collected to quantify viral load and also to identify acute infection in those with HIV- results. HIV prevalence (18.5% vs 8.3%) and unsuppressed HIV infection (3.9% vs 1.7%) were higher among venue-recruited (n=1802) compared with clinic-recruited participants(n=2313). Among PLHIV at both clinics (n=199) and venues (n=289), 79% were virally suppressed. Few had acute(n=1) or recent infection(n=8). Among women, HIV prevalence was four times higher (38.9% venue vs 8.9% clinic). At clinics, PLHIV reporting visiting venues were less likely to be suppressed (54.6 vs 82.6%). More men at venues than at clinics reported paying for sex (49% vs 30%) or having multiple sex partners in the past 4 weeks (32% vs 16%). Enhanced venue-based prevention and testing for men and women could reduce treatment lapses, HIV treatment outcomes and reduce onward transmission.

The impact of emergency guidance to the COVID-19 pandemic on treatment entry, retention and mortality among patients on methadone in Ukraine.

Ukraine's Ministry of Health released urgent COVID-19 guidelines, allowing for early implementation of take-home dosing (THD) for opioid agonist therapies (OAT) such as methadone. Enrollment in OAT and retention in the program are the most effective HIV prevention strategies for people who inject drugs (PWID). This study aimed to evaluate the impact of Ukraine's COVID-19 emergency guidance on OAT treatment enrollment, retention on treatment and mortality. Using Ukraine's national OAT registry for 252 governmental clinics across 25 regions, we conducted a 12-month comparative prospective cohort survival analysis. This study compared newly enrolled methadone patients within the initial 6 months following the COVID-19 guidance (COVID) with patients from the preceding year (pre-COVID) in a country with high adult HIV prevalence (1.2%) that is concentrated in PWID. In the nation-wide sample of newly enrolled PWID in Ukraine, comprising 2798 individuals, 1423 were in the COVID cohort and 1375 were in the pre-COVID cohort. The majority were male (86.7%), with an average age of 39.3years. Primary outcomes were average monthly enrollment per cohort, treatment retention and mortality, with internal time-dependent predictors, including THD and optimal (> 85 mg) methadone dosing. Relative to the pre-COVID period, the monthly average patient enrollment was statistically significantly higher during the COVID period (283.7 versus 236.0; P < 0.0001), where patients were more likely to transition to THD and achieve optimal dosing earlier. Significant differences were observed in the proportions of person-months on THD (41 versus 13%, P < 0.0001) and optimal dosing (38 versus 31%, P < 0.0001) between the COVID and pre-COVID cohorts. Predictors of treatment retention, expressed as adjusted hazard ratios (aHR), included early THD [aHR = 1.90, 95% confidence interval (CI) = 1.47-2.45], early optimal dosing (aHR = 1.71, 95% CI = 1.37-2.13) and prior methadone treatment (aHR = 1.39, 95% CI = 1.15-1.68). These factors persisted, respectively, in the pre-COVID (aHR = 2.28, 95% CI = 1.41-3.70; aHR = 1.84, 95% CI = 1.32-2.56; and aHR = 1.36, 95% CI = 1.06-1.74) and COVID (aHR = 1.91, 95% CI = 1.40-2.59; aHR = 1.61, 95% CI = 1.20-2.16; and aHR = 1.49, 95% CI = 1.08-1.94) cohorts. Survival did not differ significantly between the two prospective cohorts. Ukraine's prompt adoption of early take-home dosing for opioid agonist therapies, such as methadone, following the emergency COVID-19 guidance appears to have increased enrollment into methadone and improved treatment retention for people who inject drugs without adverse effects on patient survival.

Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial.

Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique. This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective. SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning. ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Prevalence and association of HIV and tuberculosis status in older adults in South Africa: an urgent need to escalate the scientific and political attention to aging and health.

This study examined the prevalence and sociodemographic factors among older adults with HIV and TB status in South Africa. This data was cross-sectional and obtained from the 2019 General Household Surveys in South Africa. Adults 50 years and over with reported HIV and TB status were included (N = 9,180,047). We reported statistical analyses of the descriptive, Chi-square and Fisher's exact tests, and binary logistic regression. The study has found a prevalence rate of HIV to be 5.3% and TB to be 2.9% among older adults aged 50 years and above in South Africa. However, the study found HIV and TB to be highest among older adults residing in Gauteng, KwaZulu-Natal and Eastern Cape provinces. For HIV status, the female gender [AOR = 0.80*, CI 95% = 0.80-0.80] and secondary education [AOR = 0.57, CI 95% = 0.56-0.58] have lower odds of association among older adults with HIV. Regarding TB status, primary education [AOR = 1.08*, CI 95% = 1.06-1.10] and diabetes [AOR = 1.87*, CI 95% = 1.82-1.91] have lower likelihoods of associations among older adults with TB. There is an urgent need to escalate scientific and political attention to address the HIV/TB burden in older adults and, public health policymakers need to take cognizance of the interdependence of inequality, mobility, and behavioural modification among this high-risk population.

An Integrated Sample Referral System for HIV Viral Load and Early Infant Diagnosis in North-Western Province, Zambia-A Retrospective Cross-Sectional Study.

Zambia's adult HIV prevalence is high at 11% and faces challenges in achieving UNAIDS 95-95-95 targets for HIV, with a national viral load suppression of 86.2% falling short of the required 95%. North-Western Province has the lowest viral load suppression at 77.5%. Our study investigated the role of an integrated sample referral system in optimizing HIV viral load coverage and Early Infant Diagnosis turnaround time in the province. Using electronic data from the DISA Laboratory Information System and Smartcare, a retrospective cross-sectional analysis was conducted, involving 160,922 viral load and Early Infant Diagnosis results. The chi-square test and multiple linear regression were used for analysis. Following the implementation of the integrated sample referral system, viral load coverage consistently increased monthly (p < 0.001), Early Infant Diagnosis turnaround time improved by 47.7%, and sample volume increased by 25%. The study identifies associations between various factors and testing outcomes. These findings demonstrate improvements in viral load coverage and the Early Infant Diagnosis turnaround time and suggest targeting modifiable factors to further optimize the referral system. We recommend continued strengthening of the referral system and more deliberate demand-creation implementation strategies.

Qualitative Evaluation of Treatment Partners for People With HIV in Botswana: Current Healthcare Provider Practices and Recommendations for Improvement.

Botswana has an adult HIV prevalence of 20.8% and annual incidence of 0.2%. We aimed to evaluate current practices and advance recommendations for treatment partners (informal adherence supporters) for people with HIV in Botswana. In January-February 2020, we conducted seven focus groups with 36 healthcare providers at seven HIV clinics in Gaborone, Botswana. Providers perceived treatment partners to be critical for quality patient care. They shared that in the new era of universal antiretroviral therapy (ART) initiation immediately after diagnosis ("test-and-treat"), providers no longer require patients to select treatment partners at ART initiation. Providers suggested a renewed emphasis on treatment partners. They believed that standard guidance for providers around treatment partner selection would ensure that providers cover similar topics across patients and endorsed implementation of workshops to educate treatment partners on how to support patients. However, streamlined ART initiation policies require innovative strategies, including eHealth interventions, to engage treatment partners.

Exploring Interconnection Among Status of Literacy, Awareness and Comprehensive Knowledge about HIV/AIDS in India

It has long been believed that improved health outcomes are positively associated with enhanced literacy and better awareness. The study investigates the relationship between literacy rates, knowledge, awareness of HIV/AIDS, and adult HIV prevalence in Indian states over the last years. In India the adult HIV prevalence rate always remains a significant concern because access to primary health care is still a distant goal for the development practitioners. The study in India highlights the need for a comprehensive, multisectoral strategy to combat the adult HIV prevalence rate, highlighting disparities in literacy status, HIV awareness, and prevalences, and the need for a multisectoral approach to access primary health care. The study emphasizes the importance of interventions promoting gender equality, reducing stigma, improving HIV education, and increasing healthcare access, particularly personalized therapies for high-risk populations like drug injectors and sex workers. The study uses secondary data sources to examine the relationship between adult HIV prevalence rates and literacy rates, highlighting that awareness and literacy alone are not sufficient to combat the HIV epidemic.

Trends of HIV Infection and Progress Towards the 95-95-95 Targets in Gambella Regional State from 2019 to 2023, Southwest ETHIOPIA.

In 2022, there were 1.3 million new HIV infections, 630,000 AIDS-related deaths, and 39.0 million HIV-positive individuals worldwide. To put the world on track to eradicate AIDS by 2030, there are ambitious goals and commitments for 2025. However, the likelihood of these goals being met or even close to being met is highly dependent on the trend of new HIV infection, the prevalence of the disease, the commitment and capability of leaders, and the application of the planned strategies to achieve the goal. To look trend of HIV infection is changing and how far we have come toward the three 95-95-95 goals in Gambella Regional State, Southwest Ethiopia, 2023. From August 1 to August 20, 2023, a descriptive cross-sectional study was carried out. This study included all HIV testing service clients who were enrolled in HIV care and treatment and had viral load records or tests. The data were gathered from the electronic form of the territorial reports of District Health Information Software 2 (DHIS-2). Reviewing regional DHIS-2, a standardized checklist was used. Epi-Data version 3.1 software was used to enter the data. SPSS version 25 was used for the analysis. The proposed objectives' trend was described using a descriptive statistic. The number of people living with HIV decreased by 4.5%, new HIV infections decreased by 42.28% and adult HIV prevalence decreased from 4.37% to 3.69% between 2019 and 2023. The finding showed that the region progress toward the 95-95-95 goals was 73%, 75% and 95% in 2023. In the Gambella region, HIV testing services and linking HIV-positive cases to HIV treatment have increased. Despite the good progress toward achieving the three 95 targets; first 95 targets for HIV diagnosis are impractical. As a result, adequate attention is required.

Assessing the Impact of Universal Test and Treat Implementation Strategy on Retention to Antiretroviral Therapy in HIV Care: A Retrospective Cohort Review

Namibia has an adult HIV prevalence of 12.6% according to the Namibia population-based HIV impact assessment survey of 2017 making it one of the highest in the world. Early initiation of antiretroviral therapy (ART) has excellent outcomes for both morbidity and mortality. The National Strategic Framework for HIV and the Namibia Ministry of Health and Social Services (MoHSS) rolled out the WHO 2015 UTTS guidelines making Namibia one of the first African countries to implement UTTS. With UTTS guidelines, rolled out in October 2016, clients who test HIV positive are initiated on ART immediately preferably the same day or within seven days regardless of their HIV clinical stage or CD4 count. Retention in care is required for optimal clinical outcomes in patients with HIV infection. However, after two years of adopting the strategy, it is not well understood whether UTTS affects the retention to care. We therefore sought to establish any emerging differences in retention of ART care after the implementation of UTTS. We used a retrospective cohort review study design that employed both quantitative and qualitative methods. 879 client records were reviewed, 678 clients were initiated on treatment two years prior to the UTTS and 201 were initiated after January 2017 when the UTTS was fully rolled out and had been on treatment for at least 12 months. Data analysis was done using Excel and Statistical Package for Social Sciences (SPSS) version 23.0 software. The overall retention after 12 months of follow-up was (822/879) 93.5% (95% CI: 91.3% to 95.7%). The retention rate at 12 months among clients in the UTTS cohort was 95.5% (95% CI: 93.5% to 97.5%) and somewhat higher than that in the pre-UTTS cohort 92.9% (95% CI: 90.6% to 95.2%). At the end of the review period, attrition was higher in the pre-UTTS cohort 251/678 (37.0%; 95% CI 34.8 to 39.2) versus 42/201 (21.0%; 95% CI 19.0 to 23) during UTTS. Retention on ART was nearly 5% higher after UTTS implementation but young adults and men between 31 and 40 years of age had higher chances of attrition at the time of ART initiation. We recommend that all facilities in Namibia and other parts of sub-Saharan Africa should embrace the UTTS strategy to benefit their clients. Keywords: Antiretroviral therapy, Retention, Retrospective cohort review, Universal test &amp; treat.

Socio-demographic and behavioural determinants of HIV prevalence among homosexual and bisexual men having sex with men (MSM) in India: Integrated bio-behavioural surveillance.

HIV prevalence among men who have sex with men (MSM) is 16.5 times higher than adult HIV prevalence. With a socio-cultural context that demands marriage, a considerable proportion of MSM in India have female sexual partners and act as a bridge population. Stratified analysis of HIV risk factors among homosexual and bisexual MSM will be instrumental in identifying the high-risk MSM. We aim to identify the socio-demographic and behavioural factors associated with HIV risk among homosexual and bisexual MSM. Overall, 23081 MSM were enrolled in the IBBS conducted across India between October 2014 and November 2015. Data and blood samples were collected. Chi-square test, univariate and multivariable logistic regression methods were used in data analysis. HIV prevalence was significantly higher among homosexual MSM than bisexual MSM. Older age, lesser education, being a sex worker, being married, living with a male or hijra partner, younger age at initiation of MSM behaviour, duration, injecting drugs, and having STI symptoms were associated with higher prevalence. The prevalence of new homosexual MSM was 11.4%. Nearly 75% of the bisexual MSM reported inconsistent condom usage with female partners. Interventions for early identification of new MSM and advocacy for safe sex with alternative preventive techniques are recommended.

CARDIOVASCULAR AUTONOMIC DYSFUNCTION IN HIV-POSITIVE PATIENTS AND ITS CORRELATION WITH CD4 CELL COUNT

According to Global human immunodeciency virus and acquired immunodeciency disease syndrome statistics, 38.4 million(33.9 million-43.8 million) people live globally with HIV in 2021, and 1.5 million people became newly infected with HIV in 2021(1). As per India HIV estimation report 2020, national adult (15–49 years) HIV prevalence was estimated at 0.22% (0.17%–0.29%) in 2020, 0.23% (0.18%–0.31%) among males and 0.20% (0.15%– 0.26%) among females(2). HIV is a condition which can progressively affect almost all body organs and systems due to immune system failure. Infection with HIV is well known to cause peripheral neuropathy and other neurological complication thus affecting the quality of life(3). Autonomic nervous system involvement can affect heart rate, vasomotor tone, sexual function, gastrointestinal motility, urination, thermoregulation and production of tears and saliva. This can lead to diverse symptoms like postural syncope, impotence, sweating, diarrhea/constipation, dry eyes and mouth, urinary incontinence and changes in skin temperature. Abnormalities in cardiac autonomic function occur at all CD4 levels(4,5). The aim of our study is to assess autonomic dysfunction in HIV-positive patients and to show the correlation between decreasing CD4 + T cell counts with increasing severity of disease in the form of autonomic dysfunction.

The declining trend in HIV prevalence from population-based surveys in Cameroon between 2004 and 2018: myth or reality in the universal test and treat era?

BackgroundHIV remains an epidemic of major public health importance in Cameroon but a decline in HIV prevalence has been observed according to population-based surveys conducted in 2004, 2011 and 2018. We sought to review current evidence for declining HIV prevalence despite increasing survival owing to ‘universal test and treat’ and to explore the reason for the decrease, particularly the role of behavioural change.MethodsWe conducted a secondary analysis using HIV prevalence, behavioural and social determinants data of the Demographic and Health Survey Program databases. Trend lines were fitted to data that were available for a minimum of three points in time during the 1991–2018 period. Regression coefficients associated p-values and 95% confidence intervals were obtained using Microsoft Excel software.ResultsOverall adult HIV prevalence decreased significantly from 5.4% (95%CI: 4.8-6.0) in 2004 to 4.3% (95%CI: 3.8–4.8) in 2011 and further down to 2.7% (95%CI: 2.3–3.1) in 2018 at a rate of about 1.4% every septennium (β = -1.4, R² = 0.98, p = 0.03). Yet, the number of persons surviving with HIV increased from about 0.05 million in 1991 to 0.5 million in 2018 corresponding to an increase in access to antiretroviral therapy from less than 10% to universal coverage of 80% respectively. Concurrent reductions in risky sexual behaviours were observed: a delayed sexual debut by one year, decreased sexual violence by 7%, decreased polygamous unions by 16%, decreased multiple sexual partners by 15.3% and increased condom use by 26.3%.ConclusionThe observed decline in HIV prevalence is statistically valid and reflects the observed decline in risky sexual behaviour that need to be sustained by the National HIV programme. Though universal access to ART has increased the number of persons surviving with HIV, this has not led to an increased prevalence of HIV in a setting with a rising population.

High PrEP uptake and objective longitudinal adherence among HIV-exposed women with personal or partner plans for pregnancy in rural Uganda: A cohort study.

In Uganda, fertility rates and adult HIV prevalence are high, and many women conceive with partners living with HIV. Pre-exposure prophylaxis (PrEP) reduces HIV acquisition for women and, therefore, infants. We developed the Healthy Families-PrEP intervention to support PrEP use as part of HIV prevention during periconception and pregnancy periods. We conducted a longitudinal cohort study to evaluate oral PrEP use among women participating in the intervention. We enrolled HIV-negative women with plans for pregnancy with a partner living, or thought to be living, with HIV (2017 to 2020) to evaluate PrEP use among women participating in the Healthy Families-PrEP intervention. Quarterly study visits through 9 months included HIV and pregnancy testing and HIV prevention counseling. PrEP was provided in electronic pillboxes, providing the primary adherence measure ("high" adherence when pillbox was opened ≥80% of days). Enrollment questionnaires assessed factors associated with PrEP use. Plasma tenofovir (TFV) and intraerythrocytic TFV-diphosphate (TFV-DP) concentrations were determined quarterly for women who acquired HIV and a randomly selected subset of those who did not; concentrations TFV ≥40 ng/mL and TFV-DP ≥600 fmol/punch were categorized as "high." Women who became pregnant were initially exited from the cohort by design; from March 2019, women with incident pregnancy remained in the study with quarterly follow-up until pregnancy outcome. Primary outcomes included (1) PrEP uptake (proportion who initiated PrEP); and (2) PrEP adherence (proportion of days with pillbox openings during the first 3 months following PrEP initiation). We used univariable and multivariable-adjusted linear regression to evaluate baseline predictors selected based on our conceptual framework of mean adherence over 3 months. We also assessed mean monthly adherence over 9 months of follow-up and during pregnancy. We enrolled 131 women with mean age 28.7 years (95% CI: 27.8 to 29.5). Ninety-seven (74%) reported a partner with HIV and 79 (60%) reported condomless sex. Most women (N = 118; 90%) initiated PrEP. Mean electronic adherence during the 3 months following initiation was 87% (95% CI: 83%, 90%). No covariates were associated with 3-month pill-taking behavior. Concentrations of plasma TFV and TFV-DP were high among 66% and 47%, 56% and 41%, and 45% and 45% at months 3, 6, and 9, respectively. We observed 53 pregnancies among 131 women (1-year cumulative incidence 53% [95% CI: 43%, 62%]) and 1 HIV-seroconversion in a non-pregnant woman. Mean pillcap adherence for PrEP users with pregnancy follow-up (N = 17) was 98% (95% CI: 97%, 99%). Study design limitations include lack of a control group. Women in Uganda with PrEP indications and planning for pregnancy chose to use PrEP. By electronic pillcap, most were able to sustain high adherence to daily oral PrEP prior to and during pregnancy. Differences in adherence measures highlight challenges with adherence assessment; serial measures of TFV-DP in whole blood suggest 41% to 47% of women took sufficient periconception PrEP to prevent HIV. These data suggest that women planning for and with pregnancy should be prioritized for PrEP implementation, particularly in settings with high fertility rates and generalized HIV epidemics. Future iterations of this work should compare the outcomes to current standard of care. ClinicalTrials.gov Identifier: NCT03832530 https://clinicaltrials.gov/ct2/show/NCT03832530?term=lynn+matthews&cond=hiv&cntry=UG&draw=2&rank=1.

Equity in HIV/AIDS management and prophylaxis: How free is the free ART program in India?

The concern for most public health policies and decision-makers is the equitable distribution of the nation’s healthcare resources. Also, in the public health care system, the primary aim is assuaging the burden of the disease. This study captures and evaluates some important health equity aspects with its relevance with the ART (Antiretroviral Therapy) program in India. The study is an exploratory and descriptive study based on secondary data. The sources of secondary data are published official reports from NACO (National AIDS Control Organization), United Nations AIDS Program (UNAIDS), World Health Organization (WHO) etc. The roll-out of the ART program in 2004 by the Govt. of India made a paradigm shift in the HIV/AIDS scenario in the country. “The adult HIV prevalence at the national level has continued its steady decline from an estimated level of 0.41% in 2001 through 0.35% in 2006 to 0.27% in 2011”. Equity in plain words means fairness. In the sense of health policy and HIV/AIDS studies, the reduction in prevalence rate equates to positive health equity. The enervation of HIV infection by taking ART drugs had helped in curbing the prevalence and the fact that it is provided free of cost has proven this program to be the epitome of distributive justice in public health.

Mapping age- and sex-specific HIV prevalence in adults in sub-Saharan Africa, 2000–2018

BackgroundHuman immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) is still among the leading causes of disease burden and mortality in sub-Saharan Africa (SSA), and the world is not on track to meet targets set for ending the epidemic by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Sustainable Development Goals (SDGs). Precise HIV burden information is critical for effective geographic and epidemiological targeting of prevention and treatment interventions. Age- and sex-specific HIV prevalence estimates are widely available at the national level, and region-wide local estimates were recently published for adults overall. We add further dimensionality to previous analyses by estimating HIV prevalence at local scales, stratified into sex-specific 5-year age groups for adults ages 15–59 years across SSA.MethodsWe analyzed data from 91 seroprevalence surveys and sentinel surveillance among antenatal care clinic (ANC) attendees using model-based geostatistical methods to produce estimates of HIV prevalence across 43 countries in SSA, from years 2000 to 2018, at a 5 × 5-km resolution and presented among second administrative level (typically districts or counties) units.ResultsWe found substantial variation in HIV prevalence across localities, ages, and sexes that have been masked in earlier analyses. Within-country variation in prevalence in 2018 was a median 3.5 times greater across ages and sexes, compared to for all adults combined. We note large within-district prevalence differences between age groups: for men, 50% of districts displayed at least a 14-fold difference between age groups with the highest and lowest prevalence, and at least a 9-fold difference for women. Prevalence trends also varied over time; between 2000 and 2018, 70% of all districts saw a reduction in prevalence greater than five percentage points in at least one sex and age group. Meanwhile, over 30% of all districts saw at least a five percentage point prevalence increase in one or more sex and age group.ConclusionsAs the HIV epidemic persists and evolves in SSA, geographic and demographic shifts in prevention and treatment efforts are necessary. These estimates offer epidemiologically informative detail to better guide more targeted interventions, vital for combating HIV in SSA.

Spatial distribution and determinants of HIV prevalence among adults in urban Ethiopia: Findings from the Ethiopia Population-based HIV Impact Assessment Survey (2017–2018)

The design and evaluation of national HIV programs often rely on aggregated national data, which may obscure localized HIV epidemics. In Ethiopia, even though the national adult HIV prevalence has decreased, little information is available about local areas and subpopulations. To inform HIV prevention efforts for specific populations, we identified geographic locations and drivers of HIV transmission. We used data from adults aged 15-64 years who participated in the Ethiopian Population-based HIV Impact Assessment survey (October 2017-April 2018). Location-related information for the survey clusters was obtained from the 2007 Ethiopia population census. Spatial autocorrelation of HIV prevalence data were analyzed via a Global Moran's I test. Geographically weighted regression analysis was used to show the relationship of covariates. The finding indicated that uncircumcised men in certain hotspot towns and divorced or widowed individuals in hotspot woredas/towns might have contributed to the average increase in HIV prevalence in the hotspot areas. Hotspot analysis findings indicated that, localized, context-specific intervention efforts tailored to at-risk populations, such as divorced or widowed women or uncircumcised men, could decrease HIV transmission and prevalence in urban Ethiopia.

HIV care cascade and associated factors among men who have sex with men, transgender women, and genderqueer individuals in Zimbabwe: findings from a biobehavioural survey using respondent-driven sampling.

Globally, men who have sex with men (MSM), transgender women, and genderqueer individuals are at greater risk for HIV than the general population although little data are available from these groups in Zimbabwe, a country with a national adult HIV prevalence of 12·9%. We aimed to examine progress towards the UNAIDS 90-90-90 treatment targets and factors associated with meeting the targets among a sample of MSM, transgender women, and genderqueer individuals in Zimbabwe. In this cross-sectional survey in 2019, we used respondent-driven sampling to identify MSM, transgender women, and genderqueer individuals aged at least 18 years to participate in a biobehavioural survey in Harare and Bulawayo, Zimbabwe. Participants were eligible to participate if they were assigned male at birth; had engaged in anal or oral sex with a man in the past 12 months; resided in Harare or Bulawayo for at least 1 month; spoke English, Shona, or Ndebele; provided written informed consent; and were in possession of a valid recruitment coupon if applicable. Enrolled participants completed a questionnaire and underwent HIV testing, and off-site viral load testing was done on all HIV-positive samples. Unweighted bivariate analyses and multivariable logistic regression models were used to evaluate the association of sociodemographic, behavioural, and other factors with HIV-positive status awareness among MSM, transgender women, and genderqueer individuals, and with viral load suppression among MSM. Analyses were done firstly using self-reported information and then by classifying those with a viral load of less than 200 copies per mL as being aware of their status and on treatment (viral load recategorisation). Among MSM, 248 (21%; 95% CI 19-24) of 1176 tested positive for HIV. Of those who tested positive, based on self-report, 119 (48%; 95% CI 42-54) reported knowing their HIV status, of whom 112 (94%; 88-98) reported using antiretroviral therapy (ART), of whom 89 (79%; 71-87) had viral load suppression. Based on viral load recategorisation, 180 (73%; 67-78) of 248 MSM testing HIV positive reported knowing their HIV status, of whom 174 (97%; 93-99) reported using ART, of whom 151 (87%; 81-91) had viral load suppression. 92 (28%; 23-33) of 335 transgender women and genderqueer individuals tested positive for HIV. Based on self-reports from these individuals 34 (37%; 27-48) of 92 participants reported knowing their HIV status, of whom 31 (91%; 76-98) reported using ART, of whom 27 (87%; 70-96%) had viral load suppression. Based on viral load recategorisation of data from transgender women and genderqueer participants, 53 (58%; 47-58) of 92 reported awareness of their HIV status, of whom 50 (94%; 84-99) reported using ART, of whom 46 (92%; 81-98) had viral load suppression. HIV-positive MSM aged 18-24 years had lower odds of being aware of their status than those aged at least 35 years (adjusted odds ratio [aOR] 0·34; 95% CI 0·13-0·92), as did HIV-positive MSM aged 25-34 years (aOR 0·26; 0·12-0·56). HIV-positive MSM aged 18-24 years also had a lower odds of having viral load suppression than those aged 35 years and older (aOR 0·35; 0·16-0·78), as did those aged 25-34 years (aOR 0·36; 0·19-0·67). No factors were significantly associated with awareness among transgender women and genderqueer individuals in multivariable models. Our survey showed that HIV prevalence was high and the largest difference between our results and the 90-90-90 treatment targets was in HIV status awareness, indicating the need for improvements in engaging MSM (especially young MSM), transgender women, and genderqueer individuals in HIV testing services. US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

Naomi: a new modelling tool for estimating HIV epidemic indicators at the district level in sub-Saharan Africa.

IntroductionHIV planning requires granular estimates for the number of people living with HIV (PLHIV), antiretroviral treatment (ART) coverage and unmet need, and new HIV infections by district, or equivalent subnational administrative level. We developed a Bayesian small‐area estimation model, called Naomi, to estimate these quantities stratified by subnational administrative units, sex, and five‐year age groups.MethodsSmall‐area regressions for HIV prevalence, ART coverage and HIV incidence were jointly calibrated using subnational household survey data on all three indicators, routine antenatal service delivery data on HIV prevalence and ART coverage among pregnant women, and service delivery data on the number of PLHIV receiving ART. Incidence was modelled by district‐level HIV prevalence and ART coverage. Model outputs of counts and rates for each indicator were aggregated to multiple geographic and demographic stratifications of interest. The model was estimated in an empirical Bayes framework, furnishing probabilistic uncertainty ranges for all output indicators. Example results were presented using data from Malawi during 2016–2018.ResultsAdult HIV prevalence in September 2018 ranged from 3.2% to 17.1% across Malawi's districts and was higher in southern districts and in metropolitan areas. ART coverage was more homogenous, ranging from 75% to 82%. The largest number of PLHIV was among ages 35 to 39 for both women and men, while the most untreated PLHIV were among ages 25 to 29 for women and 30 to 34 for men. Relative uncertainty was larger for the untreated PLHIV than the number on ART or total PLHIV. Among clients receiving ART at facilities in Lilongwe city, an estimated 71% (95% CI, 61% to 79%) resided in Lilongwe city, 20% (14% to 27%) in Lilongwe district outside the metropolis, and 9% (6% to 12%) in neighbouring Dowa district. Thirty‐eight percent (26% to 50%) of Lilongwe rural residents and 39% (27% to 50%) of Dowa residents received treatment at facilities in Lilongwe city.ConclusionsThe Naomi model synthesizes multiple subnational data sources to furnish estimates of key indicators for HIV programme planning, resource allocation, and target setting. Further model development to meet evolving HIV policy priorities and programme need should be accompanied by continued strengthening and understanding of routine health system data.

Improving Sampling Efficiency for Determining Pediatric HIV Prevalence in National Surveys: Evidence From 8 Sub-Saharan African Countries.

Measurement of mother-to-child HIV transmission through population-based surveys requires large sample sizes because of low HIV prevalence among children. We estimate potential improvements in sampling efficiency resulting from a targeted sample design. Eight countries in sub-Saharan Africa with completed Population-based HIV Impact Assessment (PHIA) surveys as of 2017. The PHIA surveys used a geographically stratified 2-stage sample design with households sampled from randomly selected census enumeration areas. Children (0-14 years of age) were eligible for HIV testing within a random subsample of households (usually 50%). Estimates of child HIV prevalence in each country were calculated using jackknife replicate weights. We compared sample sizes and precision achieved using this design with a 2-phase disproportionate sample design applied to strata defined by maternal HIV status and mortality. HIV prevalence among children ranged from 0.4% (95% confidence interval: 0.2 to 0.6) in Tanzania to 2.8% (95% confidence interval: 2.2 to 3.4) in Eswatini with achieved relative standard errors between 11% and 21%. The expected precision improved in the targeted design in all countries included in the analysis, with proportionate reductions in mean squared error ranging from 27% in Eswatini to 61% in Tanzania, assuming an equal sample size. Population-based surveys of adult HIV prevalence that also measure child HIV prevalence should consider targeted sampling of children to reduce required sample size, increase precision, and increase the number of positive children tested. The findings from the PHIA surveys can be used as baseline data for informing future sample designs.