Population-based HIV Impact Assessment Research Articles

HIV Outcomes Among Women Living With HIV Who Experienced Early Sexual Violence Across Four Sub-Saharan African Countries.

Early experiences of sexual violence may influence HIV care and treatment outcomes among women living with HIV (WLHIV). We examined whether self-report by WLHIV of being forced into their first sexual experience was associated with awareness of HIV-positive status, being on antiretroviral therapy (ART) and being virologically suppressed. We conducted a secondary analysis using nationally representative, cross-sectional Population-based HIV Impact Assessment surveys from Lesotho, Malawi, Zambia, and Zimbabwe conducted from 2015 through 2017. Adjusted logistic regression models with survey weights and Taylor series linearization were used to measure the association between forced first sex and 3 HIV outcomes: (1) knowledge of HIV status among all WLHIV, (2) being on ART among WLHIV with known status, and (3) virological suppression among WLHIV on ART. Among WLHIV, 13.9% reported forced first sex. Odds of knowledge of HIV status were not different for WLHIV with forced first sex compared with those without (adjusted odds ratio [aOR], 1.17; 95% CI: 0.95 to 1.45). Women living with HIV with forced first sex had significantly lower odds of being on ART (aOR 0.74, 95% CI: 0.57 to 0.96) but did not have lower odds of virological suppression (aOR 1.06, 95% CI: 0.80 to 1.42) compared with WLHIV without forced first sex. While high proportions of WLHIV were on ART, report of nonconsensual first sex was associated with a lower likelihood of being on ART which may suggest that early life trauma could influence long-term health outcomes.

Prevalence and Risk Factors of HIV Drug Resistance in Zimbabwe: Evidence from Zimbabwe Population-Based HIV Impact Assessment (ZIMPHIA) 2020 Survey

(1) Background: HIV drug resistance (HIVDR) poses a significant challenge to the effectiveness of antiretroviral therapy and the overall management of HIVand AIDS. Understanding the predictors of HIVDR is critical for developing strategies to mitigate its impact. The objectives of this study were to identify the predictors of HIVDR among Zimbabwe Population-Based HIV Impact Assessment (ZIMPHIA 2020) study participants, a national population-based survey. (2) Methods: Data from people living with HIV who participated in the ZIMPHIA 2020 were used to determine the predictors of HIVDR. (3) Results: The prevalence of HIVDR was 44.9%. Acquired HIVDR was present in 76.1% of people with a virological failure and transmitted resistance is 22.6% in naïve individuals. Factors associated with HIVDR in adjusted analysis were the number of lifetime sexual partners (aOR = 1.03, 95% CI: 1.01–1.06, p = 0.017), each additional year since the first HIV positive result (aOR = 1.17, 95% CI: 1.09–1.25, p < 0.01), each additional year on ART (aOR = 1.14, 95% CI: 1.06–1.23, p = 0.001), initiating ART before 2014 (aOR = 3.08, 95% CI: 1.72–5.49, p = 0.020), ever had switched antiretrovirals (aOR = 2.47, 95% CI: 1.15–5.29, p = 0.020) or had ever had a viral load test (aOR = 2.54, 95% CI: 1.54–4.17, p < 0.001) and a CD4 count < 350 (aOR = 2.04, 95% CI: 1.48–2.83, p < 0.01), while age ≥ 50 (aOR = 0.56, 95% CI: 0.32–0.98, 32 p = 0.04), condom use at last encounter (OR: 0.49, 95%CI: 0.33–0.73, p < 0.001), and not being on ART (aOR = 0.09, 95% CI: 0.06–0.13, p < 0.01) were associated with reduced odds of HIVDR. Conclusions: HIVDR was high among the participants. There is a need to address HIVDR and enhance the mechanisms already in place. This study introduces more information that would help in developing targeted interventions to prevent HIVDR and improve patient outcomes.

HIV retesting among people living with HIV in Lesotho in 2022.

Despite widespread HIV testing in sub-Saharan Africa, regular testing among at-risk populations is crucial for effective prevention. However, reports increasingly indicate retesting among people living with HIV (PLHIV), a group that would not require additional testing since they would already have received a confirmed diagnosis. We describe the demographic characteristics of PLHIV retesters in Lesotho, report the average number of HIV tests post-diagnosis among PLHIV, and share motivations for retesting. In August 2022, a nationally representative cohort in Lesotho participated in a cell phone survey about their HIV status and testing history. Study participants were recruited from a face-to-face survey conducted in 2020, Lesotho Population Based HIV Impact Assessment survey. Of the 1523 participants called, 1111 participants responded (72.9%) and 266 reported living with HIV. We found 18.8% of people living with HIV (PLHIV) reported retesting at least once for HIV, and 58% of PLHIV who reported retesting were likely or very likely to retest for HIV in the coming year. The main reason PLHIV reported retesting was because a health care worker offered the test (61.7%) followed by self-initiated testing to confirm their status (29.1%). Among male PLHIV who had a history of retesting, 92.0% were very likely or likely to retest, compared to only 30.6% of female PLHIV. We found almost a fifth of PLHIV in Lesotho reported a history of retesting for HIV, and 58% of PLHIV were likely or very likely to retest for HIV in the coming year. Educating providers and men living with HIV could reduce retesting among PLHIV.

Predicting harmful alcohol use prevalence in Sub-Saharan Africa between 2015 and 2019: Evidence from population-based HIV impact assessment.

Harmful alcohol use is associated with significant risks to public health outcomes worldwide. Although data on harmful alcohol use have been collected by population-based HIV Impact Assessment (PHIA), there is a dearth of analysis on the effect of HIV/ART status on harmful alcohol use in the Sub-Saharan Africa (SSA) countries with PHIA surveys. A secondary analysis of the PHIA surveys: Namibia (n = 27,382), Tanzania (n = 1807), Zambia (n = 2268), Zimbabwe (n = 3418), Malawi (n = 2098), Namibia (n = 27,382), and Eswatini (n = 2762). Using R version 4.2, we analysed the uptake and correlates of harmful alcohol consumption in SSA. The cutoff point for statistically significant was P<0.05. Of the 12,460 persons, 15% used alcohol harmfully. Harmful alcohol use varied by countries and ranged from 8.7% in Malawi to 26.1% in Namibia (P<0.001). Being female or HIV-positive and on ART were associated with less-likelihood of harmful alcohol consumption however persons that were HIV-positive and not on ART was associated with higher likelihood of harmful alcohol use (OR = 1.49, 95% CI: 1.32-1.69, P<0.001). The best performing models were Lasso or Super Learner or Random Forest were the best performing models while gradient boosting models or sample mean did not perform well. Harmful alcohol use was high. Harmful alcohol use varied by countries, sex, age, HIV/ART status and marital status. Therefore, there is a need to introduce or enforce harmful alcohol use control policies in SSA through taking into account these characteristics.

Influenza-Like Illness in Lesotho From July 2020 to July 2021: Population-Based Participatory Surveillance Results.

Participatory surveillance involves at-risk populations reporting their symptoms using technology. In Lesotho, a landlocked country of 2 million people in Southern Africa, laboratory and case-based COVID-19 surveillance systems were complemented by a participatory surveillance system called "LeCellPHIA" (Lesotho Cell Phone Population-Based HIV Impact Assessment Survey). This report describes the person, place, and time characteristics of influenza-like illness (ILI) in Lesotho from July 15, 2020, to July 15, 2021, and reports the risk ratio of ILI by key demographic variables. LeCellPHIA employed interviewers to call participants weekly to inquire about ILI. The average weekly incidence rate for the year-long period was created using a Quasi-Poisson model, which accounted for overdispersion. To identify factors associated with an increased risk of ILI, we conducted a weekly data analysis by fitting a multilevel Poisson regression model, which accounted for 3 levels of clustering. The overall response rate for the year of data collection was 75%, which resulted in 122,985 weekly reports from 1776 participants. ILI trends from LeCellPHIA mirrored COVID-19 testing data trends, with an epidemic peak in mid to late January 2021. Overall, any ILI symptoms (eg, fever, dry cough, and shortness of breath) were reported at an average weekly rate of 879 per 100,000 (95% CI 782-988) persons at risk. Compared to persons in the youngest age group (15-19 years), all older age groups had an elevated risk of ILI, with the highest risk of ILI in the oldest age group (≥60 years; risk ratio 2.6, 95% CI 1.7-3.8). Weekly data were shared in near real time with the National COVID-19 Secretariat and other stakeholders to monitor ILI trends, identify and respond to increases in reports of ILI, and inform policies and practices designed to reduce COVID-19 transmission in Lesotho. LeCellPHIA, an innovative and cost-effective system, could be replicated in countries where cell phone ownership is high but internet use is not yet high enough for a web- or app-based surveilance system.

Development and calibration of a mathematical model of HIV outcomes among Rwandan adults: informing equitable achievement of targets in Rwanda.

We developed and calibrated the Central Africa-International epidemiology Databases to Evaluate AIDS (CA-IeDEA) HIV policy model to inform equitable achievement of global goals, overall and across sub-populations, in Rwanda. We created a deterministic dynamic model to project adult HIV epidemic and care continuum outcomes, overall and for 25 subpopulations (age group, sex, HIV acquisition risk, urbanicity). Data came from the Rwanda cohort of CA-IeDEA, 2004-2020; Rwanda Demographic and Health Surveys, 2005, 2010, 2015; Rwanda Population-based HIV Impact Assessment, 2019; and the literature and reports. We calibrated the model to 47 targets by selecting the 50 best-fitting parameter sets among 20,000 simulations. Calibration targets reflected epidemic (HIV prevalence, incidence), global goals (percentage on antiretroviral therapy (ART) among diagnosed, percentage virally suppressed among on ART) and other (number on ART, percentage virally suppressed) indicators, overall and by sex. Best-fitting sets minimized the summed absolute value of the percentage deviation (AVPD) between model projections and calibration targets. Good model performance was mean AVPD ≤5% across the 50 best-fitting sets and/or projections within the target confidence intervals; acceptable was mean AVPD >5% and ≤15%. Across indicators, 1,841 of 2,350 (78.3%) model projections were a good or acceptable fit to calibration targets. For HIV epidemic indicators, 256 of 300 (85.3%) projections were a good fit to targets, with the model performing better for women (83.3% a good fit) than for men (71.7% a good fit). For global goals indicators, 96 of 100 (96.0%) projections were a good fit; model performance was similar for women and men. For other indicators, 653 of 950 (68.7%) projections were a good or acceptable fit. Fit was better for women than for men (percentage virally suppressed only) and when restricting targets for number on ART to 2013 and beyond. The CA-IeDEA HIV policy model fits historical data and can inform policy solutions for equitably achieving global goals to end the HIV epidemic in Rwanda. High-quality, unbiased population-based data, as well as novel approaches that account for calibration target quality, are critical to ongoing use of mathematical models for programmatic planning.

Prevalence of syphilis among adults and adolescents in five sub-Saharan African countries: findings from Population-based HIV Impact Assessment surveys

HIV and syphilis are common sexually transmitted infections in sub-Saharan Africa. We aimed to investigate the prevalence and distribution of active syphilis while considering HIV status, demographic characteristics, and behavioural characteristics. The Population-based HIV Impact Assessment surveys used a cross-sectional, two-stage, stratified cluster sample design to collect data in Ethiopia, Tanzania, Uganda, Zambia, and Zimbabwe from 2015 to 2018. Eligible participants were aged 15 years and older and provided demographic information, behavioural information, and blood specimens for HIV and syphilis testing. Active syphilis was defined as the presence of both treponemal and non-treponemal antibodies, measured using an antigen-based rapid test. Multivariable logistic regression models with survey weights were applied. The estimated number of participants with active syphilis in each country was calculated by multiplying the survey-weighted syphilis prevalence by the corresponding participant population size from the latest national census data. The total burden across the five countries was obtained by summing these estimates. 102 831 participants enrolled in the five surveys (54 583 [57·6%] participants were female, 48 248 [42·4%] participants were male, 9036 [9·9%] participants were HIV positive). Population-based syphilis prevalence was 0·9% (95% CI 0·7-1·1) in Tanzania and Zimbabwe, 2·1% (1·9-2·4) in Uganda, and 3·0% (2·7-3·4) in Zambia. Overall, an estimated 1 027 615 (95% CI 877 243-1 158 246) participants had active syphilis across the five countries (266 383 HIV-positive and 761 232 HIV-negative individuals). Syphilis prevalence was higher among people living with HIV (range from 2·6% [95% CI 1·1-4·0] in Ethiopia to 9·6% [8·1-11·0] in Zambia) than among those without HIV (range from 0·8% [0·7-1·0] in Tanzania to 2·1% [1·8-2·4] in Zimbabwe). The odds of active syphilis were higher among people living with HIV than in those who were HIV negative (adjusted odds ratio [aOR] range from 2·5 [95% CI 1·8-3·4] in Uganda to 5·9 [3·8-9·2] in Zimbabwe), among divorced, separated, or widowed individuals (aOR range from 1·5 [1·1-2·0] in Uganda to 2·7 [1·7-4·3] in Zimbabwe), and among those reporting two or more sexual partners in the previous 12 months (aOR range from 1·1 [CI 0·8-1·5] in Uganda to 1·9 [1·1-3·3] in Zimbabwe). This study shows the high burden of syphilis in five sub-Saharan African countries, with a correlation between HIV and active syphilis, underscoring the need for integrated sexual health services and targeted diagnosis, prevention, and treatment strategies to address this public health challenge. The President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

Association Between Early Sexual Debut and New HIV Infections Among Adolescents and Young Adults in 11 African Countries

We investigated the association between early sexual debut and HIV infection among adolescents and young adults. Analyzing data from nationally representative Population-Based HIV Impact Assessment (PHIA) surveys in 11 African countries, the research employed a multivariate logistic regression model to assess the relationship between the early sexual debut and new HIV infections in the age group of 10–24 years. The results revealed a significant and robust association, indicating that young individuals who experienced early sexual debut were approximately 2.65 times more likely to contract HIV than those who did not, even after accounting for other variables. These findings align with prior research suggesting that early initiation of sexual activity may increase vulnerability to HIV infection due to factors such as biological susceptibility and risky behaviors like low condom use and multiple sexual partners. The implications of these findings for HIV prevention strategies are substantial, suggesting that interventions aimed at delaying sexual debut could be an effective component in reducing HIV risk for this population. Targeted sex education programs that address the risks of early sexual debut may play a pivotal role in these prevention efforts. By employing a comprehensive approach, there is a possibility to advance efforts towards ending AIDS by 2030.

Nationwide survey of Helicobacter pylori seropositivity and gastric atrophy in Zambia.

Helicobacter pylori (H. pylori) is a common bacterial infection which predominately drives upper gastrointestinal pathology. We carried out a nationwide serological survey in response to the deficiency of robust African data on H. pylori prevalence, age of acquisition, socio-geographic determinants, and impact on gastric physiology. This was a cross-sectional study of archival plasma samples collected during the Zambia Population-based HIV impact Assessment (ZAMPHIA) 2016 survey. ZAMPHIA used a two-stage door-to-door stratified cluster sample approach to collect samples from adults and children from age 0 to 59 years (n = 24,266). We randomly retrieved one fifth of these samples from each of Zambia's 10 provinces and used ELISA to test for H. pylori IgG antibodies, pepsinogen 1 and 2 and gastrin-17. A pepsinogen 1:2 ratio of <3 was used to define gastric atrophy. The analysis of 4050 plasma samples (30% <16 years, 53% females) revealed an overall H. pylori seroprevalence of 79%. By the age of 10 years, more than 75% of the children had H. pylori. Urban residence was associated with increased odds (OR 1.8, 95% CI 1.5-2.2, p < 0.001) and HIV infection was associated with reduced odds (OR 0.7, 95% CI 0.5-0.9, p = 0.02) of H. pylori seropositivity. Gastric atrophy was detected in 6% of H. pylori seropositive adults below 45 years of age and 9% in those between 45 and 59 years. We have confirmed a high prevalence of H. pylori seropositivity in Zambia, predominantly in urban settings. The prevalence of gastric atrophy is broadly consistent with other populations around the globe, but our sample did not include adults over 60 years.

Heavy alcohol use and the HIV care continuum in Kenya: a population-based study

ABSTRACT Heavy alcohol use (HAU) can destabilize engagement along the HIV care continuum. Population-based studies assessing associations of HAU with HIV treatment outcomes are lacking, especially in sub-Saharan Africa. We leveraged data from the Kenya Population-based HIV Impact Assessment to identify associations of self-reported HAU, assessed using two items measuring the frequency and quantity of past-year alcohol consumption, with serum biomarkers for HIV serostatus unawareness, antiretroviral therapy (ART) non-use, and HIV viremia (≥1000 RNA copies/mL). Overall and sex-stratified survey-weighted logistic regression with jackknife variance estimation modeled adjusted odds ratios (adjOR) of HIV treatment indicators by HAU. Overall, 1491 persons living with HIV aged 15–64 years (68.4% female) were included. The prevalence of HAU was 8.9% (95% confidence interval [95%CI]: 6.8–11.0%) and was significantly more pronounced in males than females (19.6% vs. 4.0%, p < 0.001). In multivariable analysis, HAU was significantly (p < 0.001) associated with HIV serostatus unawareness (adjOR = 3.65, 95%CI: 2.14–6.23), ART non-use (adjOR = 3.81, 95%CI: 2.25–6.43), and HIV viremia (adjOR = 3.13, 95%CI: 1.85–5.32). Incorporating sex-specific alcohol use screening into HIV testing and treatment services in populations where HAU is prevalent could optimize clinical outcomes along the HIV care continuum.

Why is there a gap in self-rated health among people with hypertension in Zambia? A decomposition of determinants and rural‒urban differences

BackgroundHypertension affects over one billion people globally and is one of the leading causes of premature death. Low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from more affluent and urban populations towards poorer and rural communities. Our study examined inequalities in self-rated health (SRH) among people with hypertension and whether there is a rural‒urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa.MethodsWe utilized the Zambia Household Health Expenditure and Utilization Survey for data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) survey. We applied the Linear Probability Model to assess the association between self-rated health and independent variables as a preliminary step. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups.ResultsAdvanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (73.6%), district HIV prevalence (30.8%) and household expenditure (4.8%) being the most important determinants that explain the health gap.ConclusionsUrban hypertension patients have better SRH than rural patients in Zambia. Education, district HIV prevalence and household expenditure were the most important determinants of the health gap between rural and urban hypertension patients. Policies aimed at promoting educational interventions, improving access to financial resources and strengthening hypertension health services, especially in rural areas, can significantly improve the health of rural patients, and potentially reduce health inequalities between the two regions.

HIV risk behaviour, viraemia, and transmission across HIV cascade stages including low-level viremia: Analysis of 14 cross-sectional population-based HIV Impact Assessment surveys in sub-Saharan Africa.

As antiretroviral treatment (ART) coverage for people living with HIV (PLHIV) increases, HIV programmes require up-to-date information about evolving HIV risk behaviour and transmission risk, including those with low-level viremia (LLV; >50 to ≤1000 copies/mL), to guide prevention priorities. We aimed to assess differences in sexual risk behaviours, distribution of viral load (VL) and proportion of transmission across PLHIV subgroups. We analysed data from Population-based HIV Impact Assessment surveys in 14 sub-Saharan African countries during 2015-2019. We estimated adjusted prevalence ratios (aPR) of self-reported HIV high-risk behaviour (multiple partners and condomless sex) across cascade stages via generalised estimation equations. We modelled the proportions of transmission from each subgroup using relative self-reported sexual risk, a Hill function for transmission rate by VL, and proportions within cascade stages from surveys and UNAIDS country estimates for 2010-2020. Compared to PLHIV with undetectable VL (≤50 copies/mL), undiagnosed PLHIV (aPR women: 1.28 [95% CI: 1.08-1.52]; men: 1.61 [1.33-1.95]) and men diagnosed but untreated (2.06 [1.52-2.78]) were more likely to self-report high-risk sex. High-risk behaviour was not significantly associated with LLV. Mean VL was similar among undiagnosed, diagnosed but untreated, and on ART but non-suppressed sub-groups. Across surveys, undiagnosed and diagnosed but untreated contributed most to transmission (40-91% and 1-41%, respectively), with less than 1% from those with LLV. Between 2010 and 2020, the proportion of transmission from individuals on ART but non-suppressed increased. In settings with high ART coverage, effective HIV testing, ART linkage, and retention remain priorities to reduce HIV transmission. Persons with LLV are an increasing share of PLHIV but their contribution to HIV transmission was small. Improving suppression among PLHIV on ART with VL ≥1000 copies/mL will become increasingly important.

Brief Report: Self-Reported HIV-Positive Status but Subsequent HIV-Negative Test Results in Population-Based HIV Impact Assessment Survey Participants-11 Sub-Saharan African Countries, 2015-2018.

HIV testing is a critical step to accessing antiretroviral therapy (ART) because early diagnosis can facilitate earlier initiation of ART. This study presents aggregated data of individuals who self-reported being HIV-positive but subsequently tested HIV-negative during nationally representative Population-Based HIV Impact Assessment surveys conducted in 11 countries from 2015 to 2018. Survey participants aged 15 years or older were interviewed by trained personnel using a standard questionnaire to determine HIV testing history and self-reported HIV status. Home-based HIV testing and counseling using rapid diagnostic tests with return of results were performed by survey staff according to the respective national HIV testing services algorithms on venous blood samples. Laboratory-based confirmatory HIV testing for all participants identified as HIV-positives and self-reported positives, irrespective of HIV testing results, was conducted and included Geenius HIV-1/2 and DNA polymerase chain reaction if Geenius was negative or indeterminate. Of the 16,630 participants who self-reported as HIV-positive, 16,432 (98.6%) were confirmed as HIV-positive and 198 (1.4%) were HIV-negative by subsequent laboratory-based testing. Participants who self-reported as HIV-positive but tested HIV-negative were significantly younger than 30 years, less likely to have received ART, and less likely to have received a CD4 test compared with participants who self-reported as HIV-positive with laboratory-confirmed infection. A small proportion of self-reported HIV-positive individuals could not be confirmed as positive, which could be due to initial misdiagnosis, deliberate wrong self-report, or misunderstanding of the questionnaire. As universal ART access is expanding, it is increasingly important to ensure quality of HIV testing and confirmation of HIV diagnosis before ART initiation.

Missed opportunities for TB diagnostic testing among people living with HIV in Zimbabwe: Cross-sectional analysis of the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey 2015–16

BackgroundUsing data from the Zimbabwe Population-based HIV Impact Assessment survey 2015–2016, we examined the TB care cascade and factors associated with not receiving TB diagnostic testing among adult PLHIV with TB symptoms. MethodsStatistical Analysis was limited to PLHIV aged 15 years and older in HIV care. Weighted logistic regression with not receiving TB testing as outcome was adjusted for covariates with crude odd ratios (ORs) with p < 0.25. All analyses accounted for multistage survey design. ResultsAmong 3507 adult PLHIV in HIV care, 2288 (59.7 %, 95 % CI:58.1–61.3) were female and 2425 (63.6 %, 95 % CI:61.1–66.1) lived in rural areas. 1197(48.7 %, 95 % CI:46.5–51.0) reported being screened for TB symptoms at their last HIV care visit. In the previous 12 months, 639 (26.0 %, 95 % CI:23.9–28.1) reported having symptoms and of those, 239 (37.8 %, 95 % CI:33.3–42.2) received TB testing. Of PLHIV tested for TB, 36 (49.5 %, 95 % CI:35.0–63.1) were diagnosed with TB; 32 (90.3 %, 95 % CI:78.9–100) of those diagnosed with TB received treatment. Never having used IPT was associated with not receiving TB testing. ConclusionThe results suggest suboptimal utilization of TB screening and diagnostic testing among PLHIV. New approaches are needed to reach opportunities missed in the HIV/TB integrated services.

Age-disparate and intergenerational sex partnerships and HIV: the role of gender norms among adolescent girls and young women in Malawi

BackgroundAge-mixing (age-disparate [5–9 years difference] and intergenerational [≥ 10 years difference]) partnerships are hypothesized drivers of HIV in adolescent girls and young women (AGYW; 15–24 years). These partnerships are often associated with increased gender inequities which undermine women’s agency and assertiveness. We assessed whether age-mixing partnerships were associated with HIV in Malawi and if endorsement of inequitable gender norms modifies this relationship.MethodsWe analyzed data from the Malawi Population-based HIV Impact Assessment, a nationally representative household survey conducted in 2015–2016. Participants underwent HIV testing and completed questionnaires related to actively endorsed gender norms and sexual risk behavior. We used multivariate logistic regression and multiplicative interaction to assess associations among AGYW who reported the age of their primary sex partner from the last year.ResultsThe analysis included 1,958 AGYW (mean age = 19.9 years, SD = 0.1), 459 (23.4%) and 131 (6.7%) of whom reported age-disparate and intergenerational partnerships, respectively. AGYW in age-mixing partnerships accounted for 13% of all AGYW and were older, more likely to reside in urban areas, to be married or cohabitating with a partner, and to have engaged in riskier sexual behavior compared with AGYW in age-concordant partnerships (p < 0.05). HIV prevalence among AGYW in age-disparate and intergenerational partnerships was 6.1% and 11.9%, respectively, compared with 3.2% in age-concordant partnerships (p < 0.001). After adjusting for residence, age, education, employment, wealth quintile, and ever been married or cohabitated as married, AGYW in age-disparate and intergenerational partnerships had 1.9 (95% CI: 1.1–3.5) and 3.4 (95% CI: 1.6–7.2) greater odds of HIV, respectively, compared with AGYW in age-concordant partnerships. Among the 614 (31% of the study group) who endorsed inequitable gender norms, AGYW in age-disparate and intergenerational partnerships had 3.5 (95% CI: 1.1–11.8) and 6.4 (95% CI: 1.5–27.8) greater odds of HIV, respectively, compared with AGYW in age-concordant partnerships.ConclusionsIn this Malawi general population survey, age-mixing partnerships were associated with increased odds of HIV among AGYW. These findings highlight inequitable gender norms as a potential focus for HIV prevention and could inform interventions targeting structural, cultural, and social constraints of this key group.

Investigating the Associations between Drought, Poverty, High-Risk Sexual Behaviours, and HIV Incidence in Sub-Saharan Africa: A Cross-Sectional Study

Climate change is increasing the likelihood of drought in sub-Saharan Africa, where HIV prevalence is high. Drought could increase HIV transmission through various mediating mechanisms; we investigated these associations. We used data on people aged 15–59 from Population-Based HIV Impact Assessment surveys from 2016 in Eswatini, Lesotho, Tanzania, Uganda, and Zambia. Survey data were geospatially linked to precipitation data for 2014–2016, with local droughts defined as cumulative rainfall between 2014 and 2016 being in < 15th percentile of all 2-year periods over 1981–2016. Using multivariable logistic regression, stratified by sex and rural/urban residence, we examined associations between (a) drought and poverty, (b) wealth quintiles and sexual behaviours (transactional, high-risk, and intergenerational sex), (c) sexual behaviours and recently acquiring HIV, and (d) drought and recent HIV. Among 102,081 people, 31.5% resided in areas affected by drought during 2014–2016. Experiencing drought was positively associated with poverty for women and men in rural, but not urban, areas. For each group, increasing wealth was negatively associated with transactional sex. For rural women, intergenerational sex was positively associated with wealth. Women reporting each sexual behaviour had higher odds of recent HIV, with strong associations seen for high-risk sex, and, for urban women, intergenerational sex, with weaker associations among men. Women in rural areas who had been exposed to drought had higher odds of having recently acquired HIV (2.10 [95%CI: 1.17–3.77]), but not women in urban areas, or men. Droughts could potentially increase HIV transmission through increasing poverty and then sexual risk behaviours, particularly among women in rural areas.

Comparison of HIV prevalence, incidence, and viral load suppression in Zambia population-based HIV impact assessments from 2016 and 2021.

The Zambian government has implemented a public health response to control the HIV epidemic in the country. Zambia conducted a population-based HIV impact assessment (ZAMPHIA) survey in 2021 to assess the status of the HIV epidemic to guide its public health programs. ZAMPHIA 2021 was a cross-sectional two-stage cluster sample household survey among persons aged ≥15 years conducted in Zambia across all 10 provinces. Consenting participants were administered a standardized questionnaire and whole blood was tested for HIV according to national guidelines. HIV-1 viral load (VL), recent HIV infection, and antiretroviral medications were tested for in HIV-seropositive samples. Viral load suppression (VLS) was defined as <1000 copies/ml. ZAMPHIA 2021 results were compared to ZAMPHIA 2016 for persons aged 15-59 years (i.e., the overlapping age ranges). All estimates were weighted to account for nonresponse and survey design. During ZAMPHIA 2021, of 25 483 eligible persons aged ≥15 years, 18 804 (73.8%) were interviewed and tested for HIV. HIV prevalence was 11.0% and VLS prevalence was 86.2% overall, but was <80% among people living with HIV aged 15-24 years and in certain provinces. Among persons aged 15-59 years, from 2016 to 2021, HIV incidence declined from 0.6% to 0.3% ( P -value: 0.07) and VLS prevalence increased from 59.2% to 85.7% ( P -value: <0.01). Zambia has made substantial progress toward controlling the HIV epidemic from 2016 to 2021. Continued implementation of a test-and-treat strategy, with attention to groups with lower VLS in the ZAMPHIA 2021, could support reductions in HIV incidence and improve overall VLS in Zambia.

Characteristics of TPT initiation and completion among people living with HIV.

TB preventive treatment (TPT) reduces morbidity and mortality among people living with HIV (PLHIV). Despite the successful scale-up of TPT in Malawi, monitoring and evaluation have been suboptimal. We utilized the Malawi Population-Based HIV Impact Assessment (MPHIA) 2020-2021 survey data to estimate TPT uptake and completion among self-reported HIV-positive persons. We estimated the proportion of HIV-positive respondents who had ever undergone TPT, and determined the percentage of those currently on TPT who had completed more than 6 months of treatment. Bivariate and multivariable logistic regression were performed to calculate the odds ratios for factors associated with ever-taking TPT. All variables were self-reported, and the analysis was weighted and accounted for in the survey design. Of the HIV+ respondents, 38.8% (95% CI 36.4-41.3) had ever taken TPT. The adjusted odds of ever taking TPT were 8.0 and 5.2 times as high in the Central and Southern regions, respectively, compared to the Northern region; 1.9 times higher among those in the highest wealth quintile, and 2.1 times higher for those on antiretroviral therapy >10 years. Of those currently taking TPT, 56.2% completed >6 months of TPT. These results suggest low TPT uptake and >6 months' completion rates among self-reported HIV+ persons. Initiatives to create demand and strengthen adherence would improve TPT uptake.

Spatial distribution and characteristics of women reporting cervical cancer screening in Malawi: An analysis of the 2020 to 2021 Malawi Population-based HIV Impact Assessment survey data.

Malawi has one of the highest incidence and mortality rates of cervical cancer in the world. Despite a national strategic plan and the roll-out of VIA and screen-and-treat services, cervical cancer screening coverage in Malawi remains far below the national target.Using a nationally representative sample of women enumerated in the Malawi Population-based Impact Assessment (MPHIA) survey we estimated the prevalence and spatial distribution of self-reported cervical cancer screening as a proxy for uptake in Malawi. MPHIA was a nationally representative household survey in Malawi, targeting adults aged 15 and above, that employed a cross-sectional, two-stage, cluster design. The primary aim of MPHIA was to assess the regional prevalence of viral load suppression and the progress towards achieving the UNAIDS 95-95-95 goals among adults aged 15 and above. The survey was carried out between January 2020 and April 2021. Prevalence of self-reported cervical cancer screening by different characteristics was estimated accounting for the survey design using the Taylor series approach. We used univariable and multivariable logistic regression approaches to examine associations between the prevalence of cervical cancer screening and demographic characteristics. A total of 13,067 adult (15 years and older) female individuals were surveyed during the MPHIA 2020 to 2021 survey, corresponding to a weighted total of 5,604,578. The prevalence of self-reported cervical cancer screening was 16.5% (95% CI 15.5-18.0%), with women living with HIV having a higher prevalence of 37.8% (95% CI 34.8-40.9) compared to 14.0% (95% CI 13.0-15.0) in HIV negative women. The highest prevalence of screening was reported in the Southwest zone (SWZ) (24.1%, 95% CI 21.3-26.9) and in major cities of Blantyre (25.9%, 95% CI 22.9-29.0), and Lilongwe (19.6%, 95% CI 18.0-21.3). Higher self-reported screening was observed in women who resided in urban regions ((22.7%; 95% CI 21.4-24.0) versus women who resided in rural areas (15.2%; 95% CI 14.0-16.8). Cervical cancer screening was strongly associated with being HIV positive (aOR 2.83; 95% CI 2.29-3.50), ever having been pregnant (aOR 1.93; 95% CI 1.19-3.14), attaining higher education level than secondary education (aOR 2.74; 95% CI 1.67-4.52) and being in the highest wealth quintile (aOR 2.86; 95% CI 2.01-4.08). The coverage of cervical cancer screening in Malawi remains low and unequal by region and wealth/education class. Current screening efforts are largely being focussed on women accessing HIV services. There is need for deliberate interventions to upscale cervical cancer screening in both HIV negative women and women living with HIV.

Prevalence of hepatitis B virus infection in Kenya: A study nested in the Kenya Population-based HIV Impact Assessment 2018.

Sub-Saharan Africa region bears the highest chronic hepatitis B virus (HBV) infection burden worldwide. National estimates of HBV burden are necessary for a viral hepatitis program planning. This study estimated the national prevalence of HBV infection in Kenya among people aged 15-64 years. Of 27,745 participants age 15-64 years in the Kenya Population-based HIV Impact Assessment (KENPHIA) 2018 household survey, we analyzed data for all persons living with HIV (PLHIV; n = 1,521) and a random sample of HIV-negative persons (n = 1,551), totaling to 3,072 participants. We tested whole blood samples for hepatitis B surface antigen (HBsAg) using Determine™ HBsAg rapid test and used population projections to estimate national disease burden. Pearson chi square was performed and the weighted prevalence proportions presented. Of the 3,072 participants,124 tested HBsAg positive, resulting in a weighted national HBV prevalence of 3.0% (95% CI: 2.2-3.9%). This translated to an HBV infection burden of 810,600 (95% CI: 582,700-1,038,600) persons age 15-64 years in Kenya. Distribution of HBV prevalence varied widely (p<0.001) by geography, ranging from 0.1% in Eastern Kenya regions to over 5% in northern and western Kenya. Prevalence of HBV infection was higher in PLHIV (4.7%; 95% CI: 3.3-6.0%) compared to HIV-negative persons (3.0%; 95% CI: 2.1-3.9%), and was highest among persons: age 45-54 years (6.4%; 95% CI: 3.3-9.5%), those who reported no formal education (10.7%; 95% CI: 5.1-16.4%), in polygamous marriages (6.8%; 95% CI: 1.7-11.8%), and in the lowest wealth quintile (5.3%; 95% CI: 2.8-7.7). When adjusted for covariates, lack of formal education (aOR = 4.2; 95% CI: 1.5-12.6) was significantly associated with HBV infection. In stratified analysis by HIV status, residing in rural areas and history of blood transfusion were independently associated with HBV infection among PLHIV, while lack of formal education and no history of blood transfusion were associated with HBV infection among HIV-negative participants (p<0.05). HBV prevalence among persons aged 15-64 years in Kenya was 3.0%. Higher prevalence was documented among persons without formal education, in the lowest wealth quintile, and those living in Kenya's North-Eastern, Rift Valley-North and Nyanza regions. Targeted programmatic measures to strengthen interventions against HBV infections including newborn vaccination and treatment of infected adults to limit mother-to-child transmission, would be helpful in reducing burden of HBV-associated viral hepatitis.