Population-based HIV Impact Assessment Research Articles

Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa.

The study investigates the statistical relationship between male circumcision and HIV prevalence in Africa, in the context of the Voluntary Medical Male Circumcision (VMMC) campaigns in place since 2008. Data from the Population-based HIV Impact Assessment (PHIA) surveys conducted in African countries in 2017-2018 were utilized. Six countries with high HIV prevalence, low traditional circumcision and large VMMC programs were selected: Eswatini, Lesotho, Malawi, Namibia, Zambia, Zimbabwe. The statistical analysis investigated the relative risk (RR) of HIV prevalence by circumcision status (circumcised vs intact) among men age 20-59, and the age-incidence of HIV in the two groups among men age 20-49, defined as the linear-logistic slope of the relationship between prevalence and age. Results show that the standardized RR was not different from 1 at older ages (50-59): RR = 0.923, 95% CI = 0.769-1.108, P = 0.390. Furthermore, the age-incidence was at least as high or higher among the circumcised groups than among the intact groups. The standardized RR was lower than 1 at younger ages, and this could be explained by selection biases. HIV prevalence at age 40-59 (27.3%) was also the same in the four groups of circumcision status (intact, traditional, medical, unknown). Results matched earlier observations made in South Africa that circumcised and intact men had similar levels of HIV infection. The study questions the current strategy of large scale VMMC campaigns to control the HIV epidemic. These campaigns also raise a number of ethical issues.

Toward elimination of mother-to-child transmission of HIV in Malawi: Findings from the Malawi Population-based HIV Impact Assessment (2015-2016).

Malawi spearheaded the development and implementation of Option B+ for prevention of mother-to-child transmission of HIV (PMTCT), providing life-long ART for all HIV-positive pregnant and breastfeeding women. We used data from the 2015-2016 Malawi Population-based HIV Impact Assessment (MPHIA) to estimate progress toward 90-90-90 targets (90% of those with HIV know their HIV-positive status; of these, 90% are receiving ART; and of these, 90% have viral load suppression [VLS]) for HIV-positive women reporting a live birth in the previous 3 years. MPHIA was a nationally representative household survey; consenting eligible women aged 15-64 years were interviewed on pregnancies and outcomes, including HIV status during their most recent pregnancy, PMTCT uptake, and early infant diagnosis (EID) testing. Descriptive analyses were weighted to account for the complex survey design. Viral load (VL) results were categorized by VLS (<1,000 copies/mL) and undetectable VL (target not detected/below the limit of detection). Of the 3,153 women included in our analysis, 371 (10.1%, 95% confidence interval [CI]: 8.8%-11.3%) tested HIV positive in the survey. Most HIV-positive women (84.2%, 95% CI: 79.9%-88.6%) reported knowing their HIV-positive status; of these, 94.9% (95% CI: 91.7%-98.2%) were receiving ART; and of these, 91.2% (95% CI: 87.4%-95.0%) had VLS. Among the 371 HIV-positive women, 76.0% (95% CI: 70.4%-81.7%) had VLS and 66.5% (95% CI: 59.8%-73.2%) had undetectable VL. Among 262 HIV-exposed children, 50.8% (95% CI: 42.8%-58.8%) received EID testing within 2 months of birth, whereas 17.9% (95% CI: 11.9%-23.8%) did not receive EID testing. Of 190 HIV-exposed children with a reported HIV test result, 2.1% (95% CI: 0.0%-4.6%) had positive results. MPHIA data demonstrate high PMTCT uptake at a population level. However, our results identify some gaps in VLS in postpartum women and EID testing.

The global burden of HIV-associated cryptococcal infection in adults in 2020: a modelling analysis

Cryptococcal meningitis is the most common cause of meningitis in adults living with HIV in sub-Saharan Africa. The estimates of national, regional, and global burden of cryptococcal meningitis are essential to guide prevention strategies and determine needs for diagnostic tests and treatments. We present a 2020 estimate of the global burden of HIV-associated cryptococcal infection (antigenaemia), cryptococcal meningitis, and cryptococcal-associated deaths. We defined advanced HIV disease as adults with a CD4 count of less than 200 cells/μL, as this group is at highest risk for cryptococcosis. We used UNAIDS estimates (2019-20) and population-based HIV impact assessment surveys (2016-18) to estimate the number of adults with CD4 counts of less than 200 cells/μL at risk for cryptococcosis, by country and region. Secondly, we summarised cryptococcal antigenaemia prevalence in those with a CD4 count of less than 200 cells/μL by reviewing published literature. Thereafter, we calculated the number of cryptococcal antigen (CrAg)-positive people in each country and region by multiplying the number with advanced HIV disease at risk for cryptococcal infection by the cryptococcal antigenaemia prevalence of the respective country or region. We estimated progression from cryptococcal antigenaemia to meningitis or death based on estimates from the published literature. We estimated that there were 4·3 million (IQR 3·0-4·8) adults with HIV and CD4 counts of less than 200 cells/μL globally in 2020. We calculated a mean global cryptococcal antigenaemia prevalence of 4·4% (95% CI 1·6-7·4) among HIV-positive people with CD4 counts of less than 200 cells/μL, corresponding to 179 000 cases (IQR 133 000-219 000) of cryptococcal antigenaemia globally in 2020. Annually, we estimated that there are 152 000 cases (111 000-185 000) of cryptococcal meningitis, resulting in 112 000 cryptococcal-related deaths (79 000-134 000). Globally, cryptococcal disease accounts for 19% (13-24) of AIDS-related mortality. Despite a reduction in the estimated absolute global burden of HIV-associated cryptococcal meningitis compared with 2014, likely to be due to antiretroviral therapy expansion, cryptococcal disease still accounts for 19% of AIDS-related deaths, similar to 2014 estimates. To end cryptococcal meningitis deaths by 2030, cryptococcal diagnostics, meningitis treatments, and implementation of preventive screening are urgently needed. None.

Associations Between Mobility, Food Insecurity, and Transactional Sex Among Women in Cohabitating Partnerships: An Analysis From 6 African Countries 2016-2017.

Mobile women are at risk of HIV infection in sub-Saharan Africa, although we lack evidence for HIV risk among women in mobile partnerships, especially in the context of household food insecurity, a growing concern in the region. Women aged 15-59 years with a cohabitating male partner who participated in population-based HIV impact assessment surveys in Eswatini, Lesotho, Namibia, Tanzania, Uganda, and Zambia. We evaluated the association between women's and their partner's mobility (being away from home for more than 1 month or staying elsewhere) and transactional sex (selling sex or receiving money or goods in exchange for sex). We examined associations for effect measure modification by food insecurity level in the household in the past month. We used survey-weighted logistic regression, pooled and by country, adjusting for individual, partner, and household-level variables. Among women with a cohabitating male partner, 8.0% reported transactional sex, ranging from 2.7% in Lesotho to 13.4% in Uganda. Women's mobility [aOR 1.35 (95% CI: 1.08 to 1.68)], but not their partner's mobility [aOR 0.91 (0.74-1.12)], was associated with transactional sex. Food insecurity was associated with transactional sex independent of mobility [aOR 1.29 (1.10-1.52)]. Among those who were food insecure, mobility was not associated with increased odds of transactional sex. Food insecurity and women's mobility each increased the odds of transactional sex. Because transactional sex is associated with HIV risk, prevention programs can address the needs of mobile and food-insecure women, including those in cohabitating relationships.

High HIV prevalence and associated factors in Lesotho: Results from a population-based survey.

Despite extensive global efforts, sub-Saharan Africa remains disproportionately affected by the HIV epidemic. This generalized epidemic can be seen in Lesotho which in 2014 the HIV prevalence rate of those aged 15–49 years was 24.6%, with and incidence of 1.9 new infections per 100-person-year exposures. To better understand the impact of Lesotho’s national HIV response and significant predictors associated with HIV infection, the Lesotho Population-based HIV Impact Assessment was conducted. This survey provided a nationally representative sample of individuals aged 15–59 years old in which participants were tested for HIV and given an individual questionnaire that included socio-demographic and behavioral risk questions. The association of factors between survey questions and HIV incident was assessed using logistic regression. Multivariate logistic regression models for men and women were constructed for each outcome using variables known to be or plausibly associated with recent or chronic infection. Overall annualized incidence among people aged 15–49 was 1.19% (95% CI 0.73–1.65) per year. The overall prevalence of HIV was 25.6% with women having significantly higher prevalence. Multiple variables, including decreased wealth status, lower education levels, marital status, condom use at first sex, and circumcision (men only) were identified as being significantly associated with HIV infection for both men and women. In combination with improving the awareness of HIV status, an increased focus is needed on AGYW and men 35–49 years old to prevent new infections. HIV education and prevention programs should focus heavily on younger age groups prior to and soon after sexual debut to prevent HIV transmission. The findings of the survey showed significant room for improvement in increasing awareness of HIV status and reinforcing the need for continued HIV prevention and treatment efforts in Lesotho to prevent new infections.

Methods for conducting trends analysis: roadmap for comparing outcomes from three national HIV Population-based household surveys in Kenya (2007, 2012, and 2018)

BackgroundFor assessing the HIV epidemic in Kenya, a series of independent HIV indicator household-based surveys of similar design can be used to investigate the trends in key indicators relevant to HIV prevention and control and to describe geographic and sociodemographic disparities, assess the impact of interventions, and develop strategies. We developed methods and tools to facilitate a robust analysis of trends across three national household-based surveys conducted in Kenya in 2007, 2012, and 2018.MethodsWe used data from the 2007 and 2012 Kenya AIDS Indicator surveys (KAIS 2007 and KAIS 2012) and the 2018 Kenya Population-based HIV Impact Assessment (KENPHIA 2018). To assess the design and other variables of interest from each study, variables were recoded to ensure that they had equivalent meanings across the three surveys. After assessing weighting procedures for comparability, we used the KAIS 2012 nonresponse weighting procedure to revise normalized KENPHIA weights. Analyses were restricted to geographic areas covered by all three surveys. The revised analysis files were then merged into a single file for pooled analysis. We assessed distributions of age, sex, household wealth, and urban/rural status to identify unexpected changes between surveys.To demonstrate how a trend analysis can be carried out, we used continuous, binary, and time-to-event variables as examples. Specifically, temporal trends in age at first sex and having received an HIV test in the last 12 months were used to demonstrate the proposed analytical approach. These were assessed with respondent-specific variables (age, sex, level of education, and marital status) and household variables (place of residence and wealth index). All analyses were conducted in SAS 9.4, but analysis files were created in Stata and R format to support additional analyses.ResultsThis study demonstrates trends in selected indicators to illustrate the approach that can be used in similar settings. The incidence of early sexual debut decreased from 11.63 (95% CI: 10.95–12.34) per 1,000 person-years at risk in 2007 to 10.45 (95% CI: 9.75–11.2) per 1,000 person-years at risk in 2012 and to 9.58 (95% CI: 9.08–10.1) per 1,000 person-years at risk in 2018. HIV-testing rates increased from 12.6% (95% CI: 11.6%–13.6%) in 2007 to 56.1% (95% CI: 54.6%–57.6%) in 2012 but decreased slightly to 55.6% [95% CI: 54.6%–56.6%) in 2018. The decrease in incidence of early sexual debut could be convincingly demonstrated between 2007 and 2012 but not between 2012 and 2018. Similarly, there was virtually no difference between HIV Testing rates in 2012 and 2018.ConclusionsOur approach can be used to support trend comparisons for variables in HIV surveys in low-income settings. Independent national household surveys can be assessed for comparability, adjusted as appropriate, and used to estimate trends in key indicators. Analyzing trends over time can not only provide insights into Kenya’s progress toward HIV epidemic control but also identify gaps.

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

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

Intersection of alcohol use, HIV infection, and the HIV care continuum in Zambia: nationally representative survey

ABSTRACT Through a nationally-representative household survey, we measured the prevalence and correlates of unhealthy alcohol use (UAU) in Zambia and its association with the HIV care continuum. Adolescent and adult (ages 15–59 years) data, including the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), from the 2016 Zambia Population-based HIV Impact Assessment, were analyzed. UAU was defined as AUDIT-C of 3 + points for women and 4 + for men. Among 20,923 participants, 15.3% had UAU; this was 21.6% among people living with HIV (PLWH). Male sex, increasing age, being employed, urban residence, and having HIV were independent correlates of UAU (all P < 0.05). Among PLWH, UAU was associated with reduced HIV diagnosis (adjusted odds ratio [AOR]: 0.66, 95% CI 0.50–0.88) and non-significant trends toward reduced ART use if diagnosed (AOR: 0.73, 95% CI 0.73–1.10) and reduced viral suppression (VS) if on ART (AOR: 0.91, 95% CI 0.57–1.44). Overall, UAU was linked to 25% lower odds of VS compared to abstinence. UAU in Zambia disproportionately affects certain groups including PLWH. Achieving and sustaining HIV epidemic control in Zambia will require evidence-based approaches to screen and treat UAU.

Confluence of crises: COVID-19, "gassings", blood draws and the continued importance of community engagement in Zambia.

Background: Nationally representative, household-based, health-related surveys are an invaluable source of health information, but face implementation challenges. In sub-Saharan Africa, these challenges are exacerbated when surveys include the collection of biological specimens. In this study, we describe the potential implementation challenges identified during field practice leading up to the 2020 Zambia Population-based HIV Impact Assessment (ZAMPHIA) survey, and explore the role of two crises on community mistrust of, and apprehension to, participate in the survey. Methods: Using focus group methodology to better understand the influence of crises on ZAMPHIA participation, we conducted 12 focus group discussions (FGDs) in five districts across two provinces. FGDs were conducted with three purposively sampled study groups: recognized household heads, community leaders, and young adults aged 18-24 years. We used reflexive thematic analysis to develop themes from across the FGDs. Results: We identified two key themes: the ever-present threat a stranger posed to the community is enhanced by crises, and endorsement of community awareness through sensitization can mitigate outsider challenges in medical research. Conclusion: We argue that these crises emphasized underlying mistrust that can only be addressed with substantial investment in community engagement efforts to build trust and partnership in medical research endeavors. Our findings underline the importance of prioritizing community engagement through substantial investment in varied and extensive approaches to sensitization to facilitate community engagement toward community acceptance of ZAMPHIA and similar studies.

Causal Structural Learning on MPHIA Individual Dataset

The Population-based HIV Impact Assessment (PHIA) is an ongoing project that conducts nationally representative HIV-focused surveys for measuring national and regional progress toward UNAIDS’ 90-90-90 targets, the primary strategy to end the HIV epidemic. We believe the PHIA survey offers a unique opportunity to better understand the key factors that drive the HIV epidemics in the most affected countries in sub-Saharan Africa. In this article, we propose a novel causal structural learning algorithm to discover important covariates and potential causal pathways for 90-90-90 targets. Existing constraint-based causal structural learning algorithms are quite aggressive in edge removal. The proposed algorithm preserves more information about important features and potential causal pathways. It is applied to the Malawi PHIA (MPHIA) dataset and leads to interesting results. For example, it discovers age and condom usage to be important for female HIV awareness; the number of sexual partners to be important for male HIV awareness; and knowing the travel time to HIV care facilities leads to a higher chance of being treated for both females and males. We further compare and validate the proposed algorithm using BIC and using Monte Carlo simulations, and show that the proposed algorithm achieves improvement in true positive rates in important feature discovery over existing algorithms. Supplementary materials for this article are available online.

Community Mobilization Approaches for Large-Scale Public Health Surveys: Experiences from the Population-based HIV Impact Assessment (PHIA) Project.

Community mobilization is an integral process of raising awareness and increasing participation in a specific program. Communities with long-standing mistrust of health research may otherwise be reluctant to participate in surveys originating outside of their locality, particularly when asked to share personal information, provide blood samples, or undergo medical examinations. Here we discuss the community mobilization approaches undertaken by the Population-based HIV Impact Assessment (PHIA) project to optimize participation in surveys across 13 countries of sub-Saharan Africa. The PHIA Project developed a community mobilization strategy to address anticipated community concerns. In each country, a trained cadre of Community Mobilization Coordinators (CMCs) facilitated (1) ongoing communication with leadership and stakeholders at national, provincial/district and local levels; (2) door-to-door visits and group meetings; (3) promotional material dissemination through radio and television jingles and mass social/community media; and (4) the use of public address systems to enhance survey awareness and promote participation. Response rates (RR) were recorded from each survey. The PHIA surveys' mobilization efforts cultivated a receptive environment for data collection. The average household response rate for 13 PHIA surveys was 90.4% and interview RR were consistently over 80%, with women more likely to conduct an interview in all countries except Cote d'Ivoire. 89% of eligible women consented to a blood draw and 81.1% of eligible men consented. The robust and contextualized community mobilization approaches in PHIA were critical for engaging communities in large-scale public health surveys and contributed to high RR in participant interviews and blood draw.

Characteristics of users of HIV self-testing in Kenya, outcomes, and factors associated with use: results from a population-based HIV impact assessment, 2018

Background and settingAbout 20% of persons living with HIV aged 15–64 years did not know their HIV status in Kenya, by 2018. Kenya adopted HIV self-testing (HIVST) to help close this gap. We examined the sociodemographic characteristics and outcomes of self-reported users of HIVST as our primary outcome.MethodsWe used data from a 2018 population-based cross-sectional household survey in which we included self-reported sociodemographic and behavioral characteristics and HIV test results. To compare weighted proportions, we used the Rao-Scott χ-square test and Jackknife variance estimation. In addition, we used logistic regression to identify associations of sociodemographic, behavioral, and HIVST utilization.ResultsOf the 23,673 adults who reported having ever tested for HIV, 937 (4.1%) had ever self-tested for HIV. There were regional differences in HIVST, with Nyanza region having the highest prevalence (6.4%), p < 0.001. Factors independently associated with having ever self-tested for HIV were secondary education (adjusted odds ratio [aOR], 3.5 [95% (CI): 2.1–5.9]) compared to no primary education, being in the third (aOR, 1.7 [95% CI: 1.2–2.3]), fourth (aOR, 1.6 [95% CI: 1.1–2.2]), or fifth (aOR, 1.8 [95% CI: 1.2–2.7]) wealth quintiles compared to the poorest quintile and having one lifetime sexual partner (aOR, 1.8 [95% CI: 1.0–3.2]) or having ≥ 2 partners (aOR, 2.1 [95% CI: 1.2–3.7]) compared to none. Participants aged ≥ 50 years had lower odds of self-testing (aOR, 0.6 [95% CI: 0.4–1.0]) than those aged 15–19 years.ConclusionKenya has made progress in rolling out HIVST. However, geographic differences and social demographic factors could influence HIVST use. Therefore, more still needs to be done to scale up the use of HIVST among various subpopulations. Using multiple access models could help ensure equity in access to HIVST. In addition, there is need to determine how HIVST use may influence behavior change towardsaccess to prevention and HIV treatment services.

Access to Social Protection by People Living with, at Risk of, or Affected by HIV in Eswatini, Malawi, Tanzania, and Zambia: Results from Population-Based HIV Impact Assessments

We aimed to measure social protection coverage among the general population, women and men living with HIV (WLHIV, MLHV), female and male sex workers (FSW, MSW), men who have sex with men (MSM), adolescent girls young women (AGYW), and orphans vulnerable children (OVC) in Eswatini, Malawi, Tanzania, and Zambia. We used Population-Based HIV Impact Assessment data. We operationalised social protection benefits as external economic support from private and public sources to the household in the last three or 12 months. We estimated survey-weighted proportions and 95% confidence intervals (CI) for each population receiving social protection benefits. The sample size ranged from 10,233 adults ages 15–59 years in Eswatini to 29,638 in Tanzania. In the surveyed countries, social protection coverage among the general population was lower than the global average of 45%, ranging from 7.7% (95% CI 6.7%–8.8%) in Zambia to 39.6% (95% CI 36.8%–42.5%) in Eswatini. In Malawi and Zambia, social protection coverage among OVC, AGYW, SW, MSM, and people living with HIV (PLHIV) was similar to the general population. In Eswatini, more AGWY reported receiving social projection benefits than older women and more men not living with HIV reported receiving social protection benefits than MLHIV. In Tanzania, more WLHIV than women not living with HIV, MLHIV than men not living with HIV, and FSW than women who were not sex workers reported receiving social protection benefits. More data on access to social protection benefits by PLHIV or affected by HIV are needed to estimate better their social protection coverage.

Factors associated with active syphilis among men and women aged 15 years and older in the Zimbabwe Population-based HIV Impact Assessment (2015-2016).

Ulcerative STIs, including syphilis, increase the risk for HIV acquisition and transmission due to the presence of ulcers/chancres that serve as a point-of-entry and exit for HIV. In Zimbabwe, diagnosis of syphilis often occurs in pregnant women who seek ANC services where syphilis testing is offered, and among men and women who seek health care for STIs. Zimbabwe's national syphilis estimates are based on these diagnosed cases, with little information available about the prevalence of untreated syphilis among the general population. This analysis uses data from ZIMPHIA (2015-2016) to describe factors associated with active syphilis among men and women ages 15 years and older. ZIMPHIA collected blood specimens for HIV and syphilis testing from 22,501 consenting individuals (ages 15 years and older). Household HIV testing used the national HIV rapid-testing algorithm with HIV-positive results confirmed at satellite laboratories using Geenius HIV-1/2 rapid test (Bio-rad, Hercules, California, USA). Point-of-care non-Treponemal and Treponemal syphilis testing was performed using Chembio's Dual-Path Platform Syphilis Screen & Confirm Assay. Factors associated with active syphilis were explored using multiple variable, weighted logistic regression and were stratified by gender. The likelihood of active syphilis in HIV-positive females was 3.7 times greater in HIV-positive females than HIV-negative females (aOR: 3.7, 95% CI 2.3-5.9). Among males odds of having active syphilis was 5 times higher among those that engaged in transactional sex than those who did not have sex or transactional sex (aOR: 5.3, 95% CI 1.9-14.7), and 6 times higher if HIV positive versus negative (aOR: 5.9, 95% CI 3.0-12.0). Urban residence, province, education (highest attended), marital status, number of sex partners, consistency of condom use, pregnancy status (females), and circumcision status (males) were not significant in the adjusted model for either females or males. HIV status was found to be the only factor associated with active syphilis in both females and males. Given the persistent link between HIV and active syphilis, it is prudent to link individuals' diagnoses and treatments, as recommended by the WHO. Enhanced integration of STI and HIV services in health delivery points such as ANC, reproductive services, or male circumcision clinics, combined with consistent, targeted outreach to high-risk populations and their partners, may assist the MOHCC to eliminate active syphilis in Zimbabwe.

Explaining external economic support inequality among households affected by HIV/AIDS in Tanzania: an Oaxaca Blinder decomposition analysis

BackgroundHIV/AIDS remains the leading cause of death in sub-Saharan Africa. Due to multiple constraints experienced by households that seem to be disproportionally affected, families generally seek assistance from the community and external economic support. Previous researchers studied socioeconomic and gender inequality in HIV/AIDS prevalence in sub-Saharan African countries. However, very few researchers have paid attention to the external economic support for HIV/AIDS affected households in Tanzania. This study investigates the difference in economic support among households affected or not affected by the HIV/AIDS epidemic in Tanzania.MethodsData used stemmed from the Tanzania HIV Impact Survey 2016–2017 (THIS) of the Population-based HIV Impact Assessment (PHIA) project, collected between 2016 and 2017 in Tanzania. The study population were the heads of households (adults) with age greater than 15. The dependent variable for the study was economic support. This consisted of both material and non-material assistance obtained from outside the household. Socio-demographic (economics) characteristics constituted the predictors of the study. Descriptive statistics and econometric modelling were used to analyse determinants associated with external economic support. Oaxaca-Blinder decomposition method was also performed to investigate the difference in economic support depending on households’ serological status in Tanzania.ResultsA total of 12,008 households were included. Almost 11% of the household heads indicated that their households received economic support. HIV/AIDS affected 7% of households. The mean age of the household heads was 45 years (SD ± 15) with a range of 16–80. The majority of household heads were men (72%). Being a household head affected by HIV/AIDS increases the probability to receive external economic support (p < 0.05). The difference in external economic support between the two groups (HIV/AIDS and no- HIV/AIDS households) was - 0.032 (p < 0.01). This gap was observed to favour households affected by HIV/AIDS. Almost 72% (− 0.023/− 0.032) of this difference was explained by characteristics such as the wealth index (p < 0.01), residence area (urban) (p < 0.01), marital status (widowed (p < 0.05) and divorced or separated) (p < 0.1) and age (p < 0.01).ConclusionThe difference in economic support across households affected or not affected by HIV/AIDS was explained by wealth index, residence area, marital status and age. These findings represent important implications for health policy regarding future economic support strategies for HIV/AIDS-affected households.

Prevalence of and factors associated with late diagnosis of HIV in Malawi, Zambia, and Zimbabwe: Results from population-based nationally representative surveys.

Late diagnosis of HIV (LD) increases the risk of morbidity, mortality, and HIV transmission. We used nationally representative data from population-based HIV impact assessment (PHIA) surveys in Malawi, Zambia, and Zimbabwe (2015-2016) to characterize adults at risk of LD and to examine associations between LD and presumed HIV transmission to cohabiting sexual partners. We estimated the prevalence of LD, defined as CD4 count <350 cells/μL, among adults newly diagnosed with HIV during the surveys and odds ratios for associated factors. We linked newly diagnosed adults (index cases) to their household sexual partners and calculated adjusted odds ratios for associations between LD of the index case, viral load of the index case, and duration of HIV exposure in the relationship, and the HIV status of the household sexual partner. Of 1,804 adults who were newly diagnosed with HIV in the surveys, 49% (882) were diagnosed late. LD was associated with male sex, older age, and almost five times the odds of having an HIV-positive household sexual partner (adjusted odds ratio [aOR], 4.65 [95% confidence interval: 2.56-8.45]). Longer duration of HIV exposure in a relationship and higher viral load of the index case were both independently associated with higher odds of having HIV-positive household sexual partners. Individuals with HIV exposure of more than 5 years had more than three times (aOR 3.42 [95% CI: 1.63-7.18]) higher odds of being HIV positive than those with less than 2 years HIV exposure. The odds of being HIV positive were increased in individuals who were in a relationship with an index case with a viral load of 400-3499 copies/mL (aOR 4.06 [95% CI 0.45-36.46]), 3,500-9,999 copies/mL (aOR 11.32 [95% CI: 4.08-31.39]), 10,000-49,999 copies/mL (aOR 17.07 [95% CI: 9.18-31.72]), and ≥50,000 copies/mL (aOR 28.41 [95% CI: 12.18-66.28]) compared to individuals who were in a relationship with an index case with a viral load of <400 copies/mL. LD remains a challenge in Southern Africa and is strongly associated with presumed HIV transmission to household sexual partners. Our study underscores the need for earlier HIV diagnosis, particularly among men and older adults, and the importance of index testing.

Estimating district HIV prevalence in Zambia using small-area estimation methods (SAE)

BackgroundThe HIV/AIDS pandemic has had a very devastating impact at a global level, with the Eastern and Southern African region being the hardest hit. The considerable geographical variation in the pandemic means varying impact of the disease in different settings, requiring differentiated interventions. While information on the prevalence of HIV at regional and national levels is readily available, the burden of the disease at smaller area levels, where health services are organized and delivered, is not well documented. This affects the targeting of HIV resources. There is need, therefore, for studies to estimate HIV prevalence at appropriate levels to improve HIV-related planning and resource allocation.MethodsWe estimated the district-level prevalence of HIV using Small-Area Estimation (SAE) technique by utilizing the 2016 Zambia Population-Based HIV Impact Assessment Survey (ZAMPHIA) data and auxiliary data from the 2010 Zambian Census of Population and Housing and the HIV sentinel surveillance data from selected antenatal care clinics (ANC). SAE models were fitted in R Programming to ascertain the best HIV predicting model. We then used the Fay–Herriot (FH) model to obtain weighted, more precise and reliable HIV prevalence for all the districts.ResultsThe results revealed variations in the district HIV prevalence in Zambia, with the prevalence ranging from as low as 4.2% to as high as 23.5%. Approximately 32% of the districts (n = 24) had HIV prevalence above the national average, with one district having almost twice as much prevalence as the national level. Some rural districts have very high HIV prevalence rates.ConclusionsHIV prevalence in Zambian is highest in districts located near international borders, along the main transit routes and adjacent to other districts with very high prevalence. The variations in the burden of HIV across districts in Zambia point to the need for a differentiated approach in HIV programming within the country. HIV resources need to be prioritized toward districts with high population mobility.

Estimates of the prevalence of undiagnosed HIV among children living with HIV in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Zambia, and Zimbabwe from 2015 to 2017: an analysis of data from the cross-sectional Population-based HIV Impact Assessment surveys.

In 2020, there were an estimated 1·7 million children younger than 15 years living with HIV worldwide, but there are few data on the proportion of children living with HIV who are undiagnosed. We aimed to estimate the prevalence of undiagnosed HIV among children living with HIV in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Zambia, and Zimbabwe. We conducted an analysis of data from the cross-sectional Population-based HIV Impact Assessment (PHIA) surveys from 2015 to 2017. PHIAs are nationally representative surveys measuring HIV outcomes. HIV rapid test data (with PCR confirmatory testing for children aged <18 months) were used to measure HIV prevalence among children in each country (Eswatini, Lesotho, Malawi, Namibia, Tanzania, Zambia, and Zimbabwe). Mothers or guardians reported previous HIV testing of children and previous results. Detection of antiretroviral medications was done using dried blood spots. Children who tested positive in the PHIA with previous negative or unknown HIV test results and without detectable antiretroviral medication blood concentrations were considered previously undiagnosed; all other children who tested positive were considered previously diagnosed. Survey weights with jackknife variance were used to generate national estimates of HIV prevalence and undiagnosed HIV in children aged 1-14 years. We also report the prevalence (weighted proportions) of antiretroviral therapy coverage and viral load suppression (<400 copies per mL). Between 2015 and 2017, 42 248 children aged 1-14 years were included in the surveys, of whom 594 were living with HIV. Across the seven countries, the estimated weighted HIV prevalence was 0·9% (probability band 0·7-1·1) and we estimated that there were 425 000 (probability band 365 000-485 000) children living with HIV. Among all children living with HIV, 61·0% (n=259 000 [probability band 216 000-303 000]) were previously diagnosed and 39·0% (n=166 000 [128 000-204 000]) had not been previously diagnosed with HIV. Among previously diagnosed children living with HIV, 88·4% had detectable antiretroviral medication blood concentrations and 48·3% had viral load suppression. Among all children living with HIV (regardless of previous diagnosis status), 54·7% had detectable antiretroviral medication blood concentrations and 32·6% had viral load suppression. Our findings show the uneven coverage of paediatric HIV testing across these seven countries and underscore the urgent need to address gaps in diagnosis and treatment for all children living with HIV. None.

A need to accelerate HIV testing and treatment for children.

Despite improved coverage in HIV testing and treatment for children living with HIV globally, major gaps between countries remain and hinder attainment of global targets. In The Lancet HIV, Chloe Teasdale and colleagues1 report an analysis of data from the Population-based HIV Impact Assessment surveys from 2015 to 2017 and estimate the proportion of undiagnosed children living with HIV in seven African countries (Eswatini, Lesotho, Malawi, Namibia, Tanzania, Zambia, and Zimbabwe).

HIV incidence and prevalence among adults aged 15-64 years in Rwanda: Results from the Rwanda Population-based HIV Impact Assessment (RPHIA) and District-level Modeling, 2019

ObjectivesThe 2018–2019 Rwanda Population–based HIV Impact Assessment (RPHIA) was conducted to measure national HIV incidence and prevalence. District-level estimates were modeled to inform resources allocation. MethodsRPHIA was a nationally representative cross-sectional household survey. Consenting adults were interviewed and tested for HIV using the national diagnostic algorithm followed by laboratory-based confirmation of HIV status and testing for viral load (VL), limiting antigen (LAg) avidity, and presence of antiretrovirals. Incidence was calculated using normalized optical density ≤ 1·5, VL ≥ 1,000 copies/mL, and undetectable antiretrovirals. Survey and programmatic data were used to model district-level HIV incidence and prevalence. ResultsOf 31,028 eligible adults, 98·7% participated in RPHIA and 934 tested HIV positive. HIV prevalence among adults in Rwanda was 3·0% (95% CI:2·7–3·3). National HIV incidence was 0·08% (95% CI:0·02–0·14) and 0·11% (95% CI:0·00–0·26) in the City of Kigali (CoK). Based on district-level modeling, HIV incidence was greatest in the 3 CoK districts (0·11% to 0·15%) and varied across other districts (0·03% to 0·10%). ConclusionsHIV prevalence among adults in Rwanda is 3.0%; HIV incidence is low at 0.08%. District-level modeling has identified disproportionately affected urban hotspots: areas to focus resources.