HIV Prevalence In sub-Saharan Africa Research Articles

Integration of Telehealth Systems into HIV Care Services in Sub-Saharan Africa: A Scoping Review

Telehealth programs have been documented to help conserve scarce resources and enable the provision of quality and convenient patient care. Given the high HIV prevalence in sub-Saharan Africa, it is crucial for telehealth programs to be implemented. The purpose of this scoping review is to map the literature on telehealth in HIV care in sub-Saharan Africa, determine gaps in the utilisation of telehealth, and identify the barriers to implementation. A keyword search for studies reporting on telehealth in HIV care from PubMed, Research gate and gray literature was conducted, and studies published from 2015 to 2022, meeting the research criteria were included in the scoping review. Thematic content analysis was used to analyze findings from the included articles. Extraction of themes was performed using NVIVO version 12. Quality appraisal of the included studies was conducted using the mixed methods appraisal tool 2018 version. Database search retrieved 395 potentially eligible articles. Of these, 13 studies reported evidence of telehealth in HIV care. Included studies were conducted in South Africa, Kenya, Zambia, Zimbabwe, Togo, Mozambique, Tanzania, and Uganda. Three main themes emerged from the thematic content analysis: telehealth systems in sub-Saharan Africa are still at pilot stages or not widely implemented; users accept telehealth but raise concerns about privacy; and that low mobile phones ownership hampers telehealth implementation. The review revealed evidence for the effectiveness of telehealth in HIV care despite the presence of barriers. In this sense, it is recommended to adopt telehealth, which is cost effective, and improves access to healthcare. Keywords: HIV; Sub-Saharan Africa; Telehealth; Utilisation.

Household wealth and HIV incidence over time, rural Uganda, 1994-2018.

Objective:To examine the relationship between household wealth and HIV incidence in rural Uganda over time from 1994 to 2018. In research conducted early in the epidemic, greater wealth (i.e. higher socioeconomic status, SES) was associated with higher HIV prevalence in sub-Saharan Africa (SSA); this relationship reversed in some settings in later years.Design:Analysis of associations over time in a population-based open cohort of persons 15–49 years from 17 survey-rounds in 28 continuously followed communities of the Rakai Community Cohort Study (RCCS).Methods:The RCCS sample averaged 8622 individuals and 5387 households per round. Principal components analysis was used to create a nine-item asset-based measure of household wealth. Poisson regression with generalized estimating equation (GEE) and exchangeable correlation structure was used to estimate HIV incidence rate ratios (IRRs) by SES quartile, survey-round, sex, and age group.Results:From 1994 to 2018, SES rose considerably, and HIV incidence declined from 1.45 to 0.40 per 100 person-years (IRR = 0.39, 95% CI = 0.32--0.47, P < 0.001). HIV incidence was similar by SES category in the initial survey intervals (1994–1997); however, higher SES groups showed greater declines in HIV incidence over time. Multivariable analyses showed significant associations between HIV incidence and SES (IRR = 0.55 for highest compared with lowest quartile, 95% CI = 0.45--0.66, P < 0.001) controlling for time, sex, and age group.Conclusion:Beyond the early years of the RCCS, higher SES was associated with lower HIV incidence and SES gradients widened over time. The poor, like other key populations, should be targeted for HIV prevention, including treatment as prevention.

Colonial and Socio-economic History and HIV Prevalence in Sub-Saharan Africa: A Multi-Level Model Analysis

The present study shows that in sub-Saharan Africa, besides some individual characteristics (including gender, age, education, marital status, place of residence and the wealth index), the colonial and socio-economic history of an individual’s living country significantly determines his/her current-day probability of being HIV positive. As a matter of fact, by using, essentially, the Demographic and Health Surveys (DHS) data of 16 African countries, we noticed that the risk of infection is higher among people living in Southern or Eastern Africa and lower in Western African countries. Those relatively high risk countries are generally land-locked and got their independence very early. They had relatively high fertility and HIV prevalence rate in the 80’s and their legal system is derived from Common Law and Custom regulations. Compared to people in France former colonial countries, inhabitants of Belgium or both France and the United Kingdom former colonial countries have higher prevalence.

Sexually Transmitted Diseases at Monkey Bay Community Hospital in Mangochi, Malawi; an Analysis of Characteristics of Common Sexually Transmitted Diseases

We present the characteristics of the commonly diagnosed sexually transmitted infections (STI) at a clinic of Monkey Bay community hospital by a retrospective study. We conducted an audit of patients’ hospital records from a STIs clinic at Monkey Bay community hospital in Mangochi District (Malawi) covering a period from January 2019 to June 2019 (18 months). Data was tabulated in excel and analyses were made based on sex, age, male circumcision status, pregnancy and the pattern of STIs diagnosed within the chosen study period. A total number of 659 clients presented at STI clinic of Monkey Bay community hospital between January 2018 and June 2019. Out these clients, 409 (62%) were females and 250 (38%) were males. Most of the patients were in the age range of 25 years or above (447, 68%). Majority of the patients were HIV negative (523, 79%). Out of the 250 males, 113 (45%) were circumcised. Among female patients 56 of the 409 (14%) were pregnant. The most common presentations for all cases put together were lower abdominal pain (253, 38%), then urethral discharge (189, 29%), abnormal vaginal discharge (141, 21%), genital ulcer disease (64, 10%), in that order. Syphilis, genital warts, inguinal bubo and scrotal swelling were less common. The most common presentation in males was urethral discharge (178, 71%), while in females it was lower abdominal pain (214, 52%). Our audit showed that in Mangochi (Malawi) sexually transmitted diseases of various types are more common among young adults, females and uncircumcised men. There was no much difference in the percentage of STI’s between HIV positive and HIV negative people. These results point to an alarmingly high level of risky sexual behaviors among sexually active age groups in this part of Malawi, a country which still has one of the highest HIV prevalence in sub-Saharan Africa. This calls for continued and better research and control for transmission of STIs in the district.

The long-term determinants of female HIV infection in Africa: The slave trade, polygyny, and sexual behavior

We study the long-term determinants of the high rates of female HIV prevalence in sub-Saharan Africa, with a focus on the transatlantic slave trade. Our hypothesis is that the latter contributed to the contemporaneous diffusion of polygyny and associated forms of social and sexual behavior that are conducive to HIV infection. We uncover that an increase in the rate of historical slave density causes a sizeable and robust increase in the rate of HIV prevalence, with a more marked effect among married women, and particularly those that do not live with their husbands. A higher slave density also induces more widespread female infidelity. These patterns are consistent with the hypothesis that higher-rank, non-cohabiting, younger co-wives are driven to infidelity by marital dissatisfaction. The resulting risky sexual behavior increases their likelihood to contract and transmit the virus, through the husbands, to their faithful co-wives, with a multiplicative effect among women.

Mapping HIV prevalence in sub-Saharan Africa between 2000 and 2017

HIV/AIDS is a leading cause of disease burden in sub-Saharan Africa. Existing evidence has demonstrated that there is substantial local variation in the prevalence of HIV; however, subnational variation has not been investigated at a high spatial resolution across the continent. Here we explore within-country variation at a 5 × 5-km resolution in sub-Saharan Africa by estimating the prevalence of HIV among adults (aged 15–49 years) and the corresponding number of people living with HIV from 2000 to 2017. Our analysis reveals substantial within-country variation in the prevalence of HIV throughout sub-Saharan Africa and local differences in both the direction and rate of change in HIV prevalence between 2000 and 2017, highlighting the degree to which important local differences are masked when examining trends at the country level. These fine-scale estimates of HIV prevalence across space and time provide an important tool for precisely targeting the interventions that are necessary to bringing HIV infections under control in sub-Saharan Africa.

Patient Preferences and Willingness to Pay for Cervical Cancer Prevention in Zambia: Protocol for a Multi-Cohort Discrete Choice Experiment.

BackgroundAlthough most countries in southern Africa have cervical cancer screening programs, these programs generally fail to reach a significant majority of women because they are often implemented as pilot or research projects, and this limits their scope and ability to scale up screening. Some countries have planned larger-scale programs, but these have either never been implemented or have not been successfully scaled up. Most of the global burden of cervical cancer is experienced in countries with limited resources, and mortality from cervical cancer is the most common cause of cancer-related deaths among women in Sub-Saharan Africa.ObjectiveThe purpose of this study is to learn about preferences for cervical cancer screening in Zambia, to identify barriers and facilitators for screening uptake, and to evaluate willingness to pay for screening services to support the scaling up of cervical cancer screening programs.MethodsWe will conduct a discrete choice experiment by interviewing women and men and asking them to choose among constructed scenarios with varying combinations of attributes relevant to cervical cancer screening. To inform the discrete choice experiment, we will conduct focus groups and interviews about general knowledge and attitudes about cervical screening, perception about the availability of screening, stigma associated with cancer and HIV, and payment for health care services. For the discrete choice experiment, we will have a maximum design of 120 choice sets divided into 15 sets of 8 tasks each with a sample size of 320-400 respondents. We will use a hierarchical Bayesian estimation procedure to assess attributes at the following two levels: group and individual levels.ResultsThe model will generate preferences for attributes to assess the most important features and allow for the assessment of differences among cohorts. We will conduct policy simulations reflecting potential changes in the attributes of the screening facilities and calculate the projected changes in preference for choosing to undergo cervical cancer screening. The findings from the discrete choice experiment will be supplemented with interviews, focus groups, and patient surveys to ensure a comprehensive and context-based interpretation of the results.ConclusionsBecause willingness to pay for cervical cancer screening has not been previously assessed, this will be a unique and important contribution to the literature. This study will take into account the high HIV prevalence in Sub-Saharan Africa and prevailing gender attitudes to identify an optimal package of interventions to reduce cervical cancer incidence. This simulation of women’s decisions (and men’s support) to undergo screening will lay the foundation for understanding the stated preferences and willingness to pay to help design future screening programs.Registered Report IdentifierRR1-10.2196/10429

Partnership duration, concurrency, and HIV in sub-Saharan Africa

A widely accepted explanation for the exceptionally high HIV prevalence in sub-Saharan Africa is the practice of long-term overlapping heterosexual partnering. This article shows that long-duration concurrent partnering can be protective against HIV transmission rather than promoting it. Monogamous partnering prevents sexual transmission to anyone outside the partnership and, in an initially concordant-seronegative partnership, prevents sexual acquisition of HIV by either partner. Those protections against transmission and acquisition last as long as the partnership persists without new outside partnerships. Correspondingly, these two protective effects characterise polygynous partnerships, whether or not the polygyny is formal or informal, until a partner initiates a new partnership. Stable and exclusive unions of any size protect against HIV transmission, and more durable unions provide a longer protective effect. Survey research provides little information on partnership duration in sub-Saharan Africa and sheds no light on the interaction of duration, concurrency, and HIV. This article shows how assumptions about partnership duration in individual-based sexual-network models affect the contours of simulated HIV epidemics. Longer mean partnership duration slows the pace at which simulated epidemics grow. With plausible assumptions about partnership duration and at levels of concurrency found in the region, simulated HIV epidemics grow slowly or not at all. Those results are consistent with the hypothesis that long-duration partnering is protective against HIV and inconsistent with the hypothesis that long-term concurrency drives the HIV epidemics in sub-Saharan Africa.

Covariates of Multiple Sexual Partnerships among Sexually Active Men in Lesotho.

Multiple sexual partnerships (MSP) have been identified as the main reason for the high rate of HIV prevalence in sub-Saharan Africa, including Lesotho. The aim of this paper is to identify the social and economic variables associated with MSP among men in Lesotho. The study used data from 2009 Lesotho Demographic and Health Survey. A sample of 2335 males in the age group 15-44 was used. Participants qualified if they were sexually active during the past year before the survey. Binary logistic regression was used to analyse the data. Results indicated that 29% of the respondents had engaged in sexual intercourse with multiple partners in the past year. Lower age at sexual debut, employment; having ever moved from home in the past year; believing that men have the right to have sex with other women; believing that beating a woman is justified if she argues with husband and having sex with casual partner were associated with an increased likelihood of MSP. On the other hand, coming from household led by a woman reduced the odds ratio. The study recommends that promotion of awareness programmes on MSP coupled with economic empowerment of women should be intensified in Lesotho.

Changing spatial patterns and increasing rurality of HIV prevalence in the Democratic Republic of the Congo between 2007 and 2013

The Democratic Republic of the Congo (DRC) has one of the lowest HIV prevalence in sub-Saharan Africa, estimated at 1.1% [0.9–1.3] of adults aged 15–49 in 2013 (UNAIDS). Within the 2 million km2 country, however, there exists spatial variation in HIV prevalence, with the highest HIV prevalence observed in the large cities of Kinshasa and Lubumbashi. Globally, HIV is an increasingly rural disease, diffusing outwards from urban centers of high HIV prevalence to places where HIV was previously absent or present at very low levels. Utilizing data collected during Demographic and Health Surveillance (DHS) in 2007 and 2013 in the DRC, we sought to update the map of HIV prevalence in the DRC as well as to explore whether HIV in the DRC is an increasingly rural disease or remains confined to urban areas. Bayesian kriging and regression indicate that HIV prevalence in rural areas of the DRC is higher in 2013 than in 2007 and that increased distance to an urban area is no longer protective against HIV as it was in 2007. These findings suggest that HIV education, testing and prevention efforts need to diffuse from urban to rural areas just as HIV is doing.

Population sexual behavior and HIV prevalence in Sub-Saharan Africa: missing links?

Patterns of sexual partnering should shape HIV transmission in human populations. The objective of this study was to assess empirical associations between population casual sex behavior and HIV prevalence, and between different measures of casual sex behavior. An ecological study design was applied to nationally representative data, those of the Demographic and Health Surveys, in 25 countries of Sub-Saharan Africa. Spearman rank correlation was used to assess different correlations for males and females and their statistical significance. Correlations between HIV prevalence and means and variances of the number of casual sex partners were positive, but small and statistically insignificant. The majority of correlations across means and variances of the number of casual sex partners were positive, large, and statistically significant. However, all correlations between the means, as well as variances, and the variance of unmarried females were weak and statistically insignificant. Population sexual behavior was not predictive of HIV prevalence across these countries. Nevertheless, the strong correlations across means and variances of sexual behavior suggest that self-reported sexual data are self-consistent and convey valid information content. Unmarried female behavior seemed puzzling, but could be playing an influential role in HIV transmission patterns.

P04.10 The link between population sexual behaviour and hiv prevalence in sub-saharan africa

Introduction The patterns of sexual partnering and structure of sexual networks should shape HIV transmission in human populations. We examined the empirical association between population casual-sex behaviour and HIV prevalence, and the empirical associations between different measures of casual-sex behaviour. Methods An ecologic study design was applied to the nationally-representative data of the Demographic and Health Surveys in 25 countries in sub-Saharan Africa. Spearman rank correlation was used to assess the association between HIV prevalence and means and variances of the number of casual-sex partners. Spearman rank correlation was also used to assess the associations between the different means, different variances, and means and variances of the number of casual-sex partners. Results Correlations between HIV prevalence and means and variances of the number of casual-sex partners were positive, but small and statistically insignificant. The majority of correlations across means and variances of the number of casual-sex partners were positive, large, and statistically significant. However, all correlations between the means, as well as variances, and the variance of unmarried females were weak and statistically insignificant. Population casual-sex behaviour was not predictive of HIV prevalence across these African countries. Nevertheless, the strong correlations across means and variances suggest that self-reported sexual data are self-consistent and may convey credible information. Conclusion Self-reported population sexual behaviour was not found predictive of HIV prevalence, but appears inherently self-consistent and with valid information content. Unmarried female behaviour seems puzzling, but could be playing an influential role in HIV transmission patterns. Disclosure of interest statement No pharmaceutical grants were received in the development of this study.

O11.5 Incorporating spatial variability to generate sub-national estimates of hiv prevalence

Introduction The design and evaluation of national HIV programs often relies on aggregated national level data. However, there is often substantial geographical heterogeneity in the HIV epidemic within countries, which could be used to tailor programmatic responses to the specific local needs. Given this background, the study attempts to answer the question: Could environmental and socio-behavioural factors be used to generate sub-national estimates of HIV prevalence in sub-Saharan Africa? Methods Data were obtained from Demographic and Health Surveys (DHS) conducted in Tanzania, Malawi, and Kenya. Associations between covariates and HIV prevalence were assessed using non-spatial logistic regression models. Covariates included life time number of sexual partners, percentage of condom use, wealth index, percentage of male circumcision (MC), distance to urban settings, distance to roads, and normalised difference vegetation index (NDVI). The prediction formula generated from the covariate analysis along with kriging interpolation techniques were used to produce high resolution continuous surface maps of HIV prevalence. Results Condom use, MC, distance to main roads, NDVI, poverty and wealth index were associated with HIV prevalence in Tanzania and Malawi, and were included to generate HIV prevalence maps in these countries. Conversely, only NDVI, poverty life time number of sexual partners and MC were associated with HIV prevalence in Kenya. All three maps illustrated substantial geographical variation of HIV prevalence within the country, and localised areas where HIV prevalence is concentrated. Conclusion The HIV prevalence maps generated highlight the stark spatial disparities in the epidemic within a country, and localise areas where both the burden and drivers of the HIV epidemic are concentrated. These maps present an opportunity to apply differential local approaches to maximise impact by informing both planning and delivery of defined packages of services. Additional work is needed for routine incorporation of such strategies into existing national HIV estimation processes. Disclosure of interest statement Nothing to declare.

The political economy of concurrent partners: toward a history of sex–love–gift connections in the time of AIDS

Over the last decade, one of the most influential explanations for high HIV prevalence in sub-Saharan Africa is the existence of sexual networks characterised by concurrent partners. Recently, however, a growing number of scholars have challenged the evidential basis for the concurrency argument. While this dispute has led to a call for more sophisticated quantitative methods to measure concurrency, this article widens the discussion to emphasise the political economic roots and qualitative dimension of concurrent partnered relations. Specifically, the paper argues for the importance of situating concurrency within key historical processes and, to that end, gives special consideration to the growth of ‘transactional sex' – non-prostitute but material relations between men and women. Critics of the concurrency–HIV thesis have sometimes dismissed as anecdotal accounts of sex–gift exchanges in Africa. Yet by exploring through an ethnographic/historical lens the changing configuration of sex, love and gifts in South Africa, this article illuminates different manifestations of concurrency, including connections between concurrency and condom use.

AN ASSOCIATION BETWEEN NEIGHBOURHOOD WEALTH INEQUALITY AND HIV PREVALENCE IN SUB-SAHARAN AFRICA

AN ASSOCIATION BETWEEN NEIGHBOURHOOD WEALTH INEQUALITY AND HIV PREVALENCE IN SUB-SAHARAN AFRICA

Promoting reproductive options for HIV-affected couples in sub-Saharan Africa.

HIV-affected couples face unique challenges that require access to information and reproductive services to prevent HIV transmission to the uninfected partner and offspring while allowing couples to fulfil their reproductive goals. In regions of high HIV prevalence in sub-Saharan Africa, HIV-affected couples require multipurpose prevention technologies (MPTs) to enhance their reproductive healthcare options beyond contraception and prevention of HIV/sexually transmitted infections (STIs) to include assistance in childbearing. The unique characteristics of the condom and its accepted use in conjunction with safer conception interventions allow HIV-serodiscordant couples an opportunity to maintain reproductive health, prevent HIV/STI transmission, and achieve their reproductive goals while timing conception. Re-thinking the traditional view of the condom and incorporating a broader reproductive health perspective of HIV-affected couples into MPT methodologies will impact demand, acceptability and uptake of these future technologies.

AN ASSOCIATION BETWEEN NEIGHBOURHOOD WEALTH INEQUALITY AND HIV PREVALENCE IN SUB-SAHARAN AFRICA

This paper investigates whether community-level wealth inequality predicts HIV serostatus using DHS household survey and HIV biomarker data for men and women ages 15-59 pooled from six sub-Saharan African countries with HIV prevalence rates exceeding 5%. The analysis relates the binary dependent variable HIV-positive serostatus and two weighted aggregate predictors generated from the DHS Wealth Index: the Gini coefficient, and the ratio of the wealth of households in the top 20% wealth quintile to that of those in the bottom 20%. In separate multilevel logistic regression models, wealth inequality is used to predict HIV prevalence within each statistical enumeration area, controlling for known individual-level demographic predictors of HIV serostatus. Potential individual-level sexual behaviour mediating variables are added to assess attenuation, and ordered logit models investigate whether the effect is mediated through extramarital sexual partnerships. Both the cluster-level wealth Gini coefficient and wealth ratio significantly predict positive HIV serostatus: a 1 point increase in the cluster-level Gini coefficient and in the cluster-level wealth ratio is associated with a 2.35 and 1.3 times increased likelihood of being HIV positive, respectively, controlling for individual-level demographic predictors, and associations are stronger in models including only males. Adding sexual behaviour variables attenuates the effects of both inequality measures. Reporting eleven plus lifetime sexual partners increases the odds of being HIV positive over five-fold. The likelihood of having more extramarital partners is significantly higher in clusters with greater wealth inequality measured by the wealth ratio. Disaggregating logit models by sex indicates important risk behaviour differences. Household wealth inequality within DHS clusters predicts HIV serostatus, and the relationship is partially mediated by more extramarital partners. These results emphasize the importance of incorporating higher-level contextual factors, investigating behavioural mediators, and disaggregating by sex in assessing HIV risk in order to uncover potential mechanisms of action and points of preventive intervention.

Does the ‘inverse equity hypothesis’ explain how both poverty and wealth can be associated with HIV prevalence in sub-Saharan Africa?

Whether it is relative wealth or relative poverty that drives the HIV epidemic in sub-Saharan Africa, is a controversial aspect of HIV/AIDS epidemiology. We suggest that the social epidemiology of...

National HIV prevalence estimates for sub-Saharan Africa: controlling selection bias with Heckman-type selection models

ObjectivesPopulation-based HIV testing surveys have become central to deriving estimates of national HIV prevalence in sub-Saharan Africa. However, limited participation in these surveys can lead to selection bias. We control...

The relationship between orphanhood and child fostering in sub-Saharan Africa, 1990s–2000s

In countries most afflicted by HIV/AIDS in sub-Saharan Africa, orphanhood has increased dramatically, but the potential consequences of the increase have been mitigated by the ability of households to absorb orphans. This paper examines what the rising levels of orphanhood mean for the common practice of non-orphan child fostering in regions of high and low HIV prevalence in sub-Saharan Africa, which has a long history of child fostering. Using Demographic and Health Survey data from 135 regions within 14 sub-Saharan countries that undertake HIV testing and have had at least two surveys, we examine changes in fostering patterns. In most regions, we find a more accommodating relationship between orphan and non-orphan fostering: communities are able to absorb the demand for both orphans and non-orphans. Where HIV prevalence exceeds 10 per cent there is some evidence that the need to care for orphans is beginning to reduce opportunities for non-orphan fostering.