Population-based HIV Impact Assessment Research Articles

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.

Equity of the HIV epidemic response in 13 African countries

For over 25 years, new programs to attempt to stem the HIV epidemic have been developed in Africa by country governments as well as external donors. These programs and activities have built and operated facilities, trained clinicians, financed drugs and commodities, supported and helped finance government health planning and operations, and contributed in other ways. Who has benefited from this massive mobilization? While some single country and narrowly focused studies have been done, the issue of equity of HIV programs for vulnerable populations has not been examined in a large set of countries. Using Population-based HIV Impact Assessment (PHIA) data, we examine equity of the HIV programs in 13 African countries to determine if vulnerable groups (such as those with low wealth, rural populations, young adults, and females) have achieved comparable levels of access to HIV program services. In contrast, we also compare the equity of the HIV response to rural and low-wealth populations with the equity of corresponding domestic health systems using Demographic and Health Survey data. This study found that in over half of the countries, the HIV response indicators were equitable for vulnerable population segments including the low-wealth population (in seven countries) and rural population segment (in nine countries). In no country was the domestic health system equitable for these two groups. However, HIV programming does show some clear patterns of inequity for low-wealth and rural populations in some countries. For gender and young adults, the HIV response indicators show that in all 13 countries men and young adults are consistently underserved relative to their counterparts.

Prevalence of Monoclonal Gammopathy of Undetermined Significance in Eswatini: A Study of an African Population

Multiple myeloma and its precursor, monoclonal gammopathy of undetermined significance (MGUS), both occur twice as often within Black populations compared to White populations, suggesting that racial factors may influence the development of MGUS, not the progression from MGUS to malignancy. The landmark epidemiologic study that described the natural history of MGUS was conducted among 21,463 of the 28,000 residents in Olmsted County, Minnesota, a 97% White population, and found the age-standardized prevalence (including light-chain, LC, MGUS) to be 4.2% (Dispenzieri, et al, Lancet, 2010). Although MGUS disproportionately affects Black individuals, few studies have been conducted on MGUS in Africa, and no prior study has evaluated MGUS in a Black African cohort inclusive of both sexes. Using a population-based biorepository from Eswatini, a small country in southern Africa, we further explored the racial disparities related to plasma cell dyscrasias. Our primary objective was to determine the prevalence of MGUS in Eswatini, as compared to that found in Olmsted County. Additionally, we aimed to determine the association between MGUS and HIV status. From 2016 to 2017, over 15,000 individuals from a nationally representative selection of households participated in the Second Eswatini Population-based HIV Impact Assessment survey, SHIMS2 (phia.icap.columbia.edu/countries/eswatini). After providing informed consent, interviews were conducted and blood samples were collected. Samples were tested for HIV, and if positive, also for CD4+ cell counts and the serologic presence of antiretroviral therapy (ART). The remaining plasma aliquots were stored and linked to their de-identified corresponding survey data for future research endeavors. For our current study, all adults over the age of 35 years who had SHIMS2 specimens stored were included in the sampling frame. We randomly selected 515 plasma samples from the sampling frame, with the sample size determined to produce a two-sided 95% confidence interval (CI) with a width of 0.05 and power &amp;gt;80% for MGUS prevalence and comparison by HIV status. We performed protein electrophoresis with reflex immunofixation, as well as free light chain and creatinine quantification, and defined MGUS cases by the same criteria as the Olmsted County studies. If creatinine was greater than the upper limit of normal, then the renal reference range was used for free-light-chain ratios . Historical proportions and means were compared with z-tests and t-tests, respectively. To determine associations between categorical variables, odds ratios (OR) were calculated with logistic regressions or Fisher Exact tests. The study cohort (n=515) was 60% female (n=309) with a median age of 50 years (range 35-80); 199 (38.6%) were HIV-positive, of whom 82.4% (n=164) were on ART, and 8.5% (n=17) had a CD4+ cell count of &amp;lt;200 cells/ul. These numbers reflected the overall national estimates (Kingdom of Eswatini, SHIMS2 Final Report, 2019). The MGUS prevalence (including LC-MGUS) standardized for age and sex was 13.2% (95%CI: 10.5-16.5) (n=68), which was significantly greater than Olmsted County (RR 3.1, p&amp;lt;0.0001). Most (84%, n=57) MGUS cases were LC. Prevalence of non-light-chain (NLC) MGUS was 2.1% (n=11), which was similar to Olmsted County. Of the 11 participants with NLC MGUS, 4 were considered very low risk for progression to malignancy, 6 low risk, 1 intermediate risk, and 0 high risk by Mayo stratification (Rajkumar, et al., Blood, 2005). HIV status was not found to be significantly associated with MGUS (OR: 1.05, 95%CI: 0.62-1.77). However, within the HIV-positive cohort, the odds of MGUS were 69% lower among those on ART (OR: 0.31, 95%CI: 0.11-0.82) when adjusted for age, sex, and wealth quintile. Furthermore, MGUS was 2.8 times more frequent in those with untreated HIV when compared to those with treated HIV (95%CI: 1.1-7.2, p=0.031), and 2.3 times more frequent when compared to non-HIV (95%CI: 1.0-5.6, p=0.056); treated HIV was not significantly different from non-HIV (data not shown). In conclusion, the MGUS prevalence in Eswatini was more than three-fold higher than that in Olmsted County, largely due to those with LC-MGUS. The high rate of HIV in Eswatini did not explain the high prevalence of MGUS, as the majority of those with HIV were on ART and only untreated HIV was significantly associated with MGUS.

Risk Factors for Recent HIV Infections among Adults in 14 Countries in Africa Identified by Population-Based HIV Impact Assessment Surveys, 2015-2019.

Identifying persons who have newly acquired HIV infections is critical for characterizing the HIV epidemic direction. We analyzed pooled data from nationally representative Population-Based HIV Impact Assessment surveys conducted across 14 countries in Africa for recent infection risk factors. We included adults 15-49 years of age who had sex during the previous year and used a recent infection testing algorithm to distinguish recent from long-term infections. We collected risk factor information via participant interviews and assessed correlates of recent infection using multinomial logistic regression, incorporating each survey's complex sampling design. Compared with HIV-negative persons, persons with higher odds of recent HIV infection were women, were divorced/separated/widowed, had multiple recent sex partners, had a recent HIV-positive sex partner or one with unknown status, and lived in communities with higher HIV viremia prevalence. Prevention programs focusing on persons at higher risk for HIV and their sexual partners will contribute to reducing HIV incidence.

Awareness of and willingness to use oral pre-exposure prophylaxis (PrEP) for HIV prevention among sexually active adults in Malawi: results from the 2020 Malawi population-based HIV impact assessment

BackgroundThe World Health Organization recommends Pre-Exposure Prophylaxis (PrEP) for all populations at substantial risk of HIV infection. Understanding PrEP awareness and interest is crucial for designing PrEP programs; however, data are lacking in sub-Saharan Africa. In Malawi, oral PrEP was introduced in 2018. We analyzed data from the 2020 Malawi Population-based HIV Impact Assessment (MPHIA) to assess PrEP awareness and factors associated with PrEP interest in Malawi.MethodsMPHIA 2020 was a national cross-sectional household-based survey targeting adults aged 15 + years. Oral PrEP was first described to the survey participants as taking a daily pill to reduce the chance of getting HIV. To assess awareness, participants were asked if they had ever heard of PrEP and to assess interest, were asked if they would take PrEP to prevent HIV, regardless of previous PrEP knowledge. Only sexually active HIV-negative participants are included in this analysis. We used multivariable logistic regression to assess sociodemographic factors and behaviors associated with PrEP interest. All results were weighted.ResultsWe included 13,995 HIV-negative sexually active participants; median age was 29 years old. Overall, 15.0%, 95% confidence interval (CI): 14.2–15.9% of participants were aware of PrEP. More males (adjusted odds ratio (aOR): 1.3, 95% CI: 1.2–1.5), those with secondary (aOR: 1.5, 95% CI: 1.2-2.0) or post-secondary (aOR: 3.4, 95% CI: 2.4–4.9) education and the wealthiest (aOR: 1.6, 95% CI: 1.2-2.0) were aware of PrEP than female, those without education and least wealthy participants, respectively. Overall, 73.0% (95% CI: 71.8–74.1%) of participants were willing to use PrEP. Being male (aOR: 1.2; 95% CI: 1.1–1.3) and having more than one sexual partner (aOR: 1.7 95% CI: 1.4–1.9), were associated higher willingness to use PrEP.ConclusionsIn this survey, prior PrEP knowledge and use were low while PrEP interest was high. High risk sexual behavior was associated with willingness to use PrEP. Strategies to increase PrEP awareness and universal access, may reduce HIV transmission.

Geospatial patterns of progress towards UNAIDS ‘95-95-95’ targets and community vulnerability in Zambia: insights from population-based HIV impact assessments

IntroductionIn sub-Saharan Africa, HIV/AIDS remains a leading cause of death. The UNAIDS established the ‘95-95-95’ targets to improve HIV care continuum outcomes. Using geospatial data from the Zambia Population-based HIV...

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.

How does HIV-related stigma correlate with HIV prevalence in African countries? Distinct perspectives from individuals living with and living without HIV

BackgroundPopulation-level research evaluating HIV-related stigma among countries with varied national HIV prevalence is scarce. To better understand HIV-related stigma and mitigate its potential negative effects, it is necessary to evaluate its relationship with HIV prevalence, as well as the mechanisms that influence it. This study aimed to analyze how HIV-related stigma correlates with subnational HIV prevalence in three African countries with varied HIV epidemics.MethodsThis paper used data from the nationally representative Population-based HIV Impact Assessment (PHIA) surveys conducted from 2015–2017 in Malawi, Zambia, and Tanzania. Each country's sub-national geographic divisions were used to categorize them as low (0–5.4%), middle (5.5–11.2%), and high (11.3–17.1%) HIV prevalence regions in the main analysis. Questions from the survey stigma module were used to measure HIV-related stigma. Logistic regression and multilevel models were performed to assess the associations between the level of sub-national HIV prevalence and HIV-related stigma measures among persons living with, and without, HIV.ResultsThe results show that the odds of people living without HIV expressing stigmatizing behavior towards PLWH was significantly lower in regions of middle (OR = 0.80, 90%CI = (0.68–0.96)) and high (OR = 0.65, 90%CI = (0.53–0.80)) HIV prevalence when compared to low prevalence regions. The odds of reporting discriminatory attitudes were also lower for those in middle (OR = 0.87, 90%CI = (0.78–0.98)) and high (OR = 0.64, 90%CI = (0.56–0.73)) HIV prevalence regions compared to others. Living in middle and high HIV prevalence regions was associated with lower odds of expressing prejudice toward PLWH (OR = 0.84, 90%CI = (0.71–0.99) and OR = 0.60, 90%CI = (0.45–0.80), respectively) among people living without HIV. Notably, PLWH living in high prevalence regions had higher odds of reporting internalized stigma (OR = 1.48, 90%CI = (1.02–2.14)) compared to those living in low prevalence regions.ConclusionsThe results indicate that among people not living with HIV, subnational HIV prevalence was negatively associated with discriminatory attitudes and prejudice towards PLWH, but HIV prevalence was positively associated with self-reported internalized stigma among PLWH. These results provide insight on how resources could be invested to reduce HIV related stigma among both PLWH and those not living with HIV.