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

Attrition Rates in HIV Viral Load Monitoring and Factors Associated With Overdue Testing Among Children Within South Africa's Antiretroviral Treatment Program: Retrospective Descriptive Analysis

BACKGROUND

Numerous studies in South Africa have reported low HIV viral load (VL) suppression and high attrition rates within the pediatric HIV treatment program.

OBJECTIVE

Using routine laboratory data, we evaluated HIV VL monitoring, including mobility and overdue VL (OVL) testing, within 5 priority districts in South Africa.

METHODS

We performed a retrospective descriptive analysis of National Health Laboratory Service (NHLS) data for children and adolescents aged 1-15 years having undergone HIV VL testing between May 1, 2019, and April 30, 2020, from 152 facilities within the City of Johannesburg, City of Tshwane, eThekwini, uMgungundlovu, and Zululand. HIV VL test-level data were deduplicated to patient-level data using the NHLS CDW (Corporate Data Warehouse) probabilistic record-linking algorithm and then further manually deduplicated. An OVL was defined as no subsequent VL determined within 18 months of the last test. Variables associated with the last VL test, including age, sex, VL findings, district type, and facility type, are described. A multivariate logistic regression analysis was performed to identify variables associated with an OVL test.

RESULTS

Among 21,338 children and adolescents aged 1-15 years who had an HIV VL test, 72.70% (n=15,512) had a follow-up VL test within 18 months. Furthermore, 13.33% (n=2194) of them were followed up at a different facility, of whom 3.79% (n=624) were in a different district and 1.71% (n=281) were in a different province. Among patients with a VL of ≥1000 RNA copies/mL of plasma, the median time to subsequent testing was 6 (IQR 4-10) months. The younger the age of the patient, the greater the proportion with an OVL, ranging from a peak of 52% among 1-year-olds to a trough of 21% among 14-year-olds. On multivariate analysis, 2 consecutive HIV VL findings of ≥1000 RNA copies/mL of plasma were associated with an increased adjusted odds ratio (AOR) of having an OVL (AOR 2.07, 95% CI 1.71-2.51). Conversely, patients examined at a hospital (AOR 0.86, 95% CI 0.77-0.96), those with ≥2 previous tests (AOR 0.78, 95% CI 0.70-0.86), those examined in a rural district (AOR 0.63, 95% CI 0.54-0.73), and older age groups of 5-9 years (AOR 0.56, 95% CI 0.47-0.65) and 10-14 years (AOR 0.51, 95% CI 0.44-0.59) compared to 1-4 years were associated with a significantly decreased odds of having an OVL test.

CONCLUSIONS

Considerable attrition occurs within South Africa's pediatric HIV treatment program, with over one-fourth of children having an OVL test 18 months subsequent to their previous test. In particular, younger children and those with virological failure were found to be at increased risk of having an OVL test. Improved HIV VL monitoring is essential for improving outcomes within South Africa's pediatric antiretroviral treatment program.

Areas with high HIV prevalence: A spatial analysis of nationwide claims data in Germany

OBJECTIVE

We aimed to identify spatial clusters of high HIV prevalence in Germany.

METHODS

Using nationwide outpatient claims data comprising information of about 88% of the total German population (N = 72 041 683), we examined spatial variations and spatial clusters of high HIV prevalence at the district level (N = 401). People with HIV were identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10 codes) B20, B22, and B24 (HIV disease) documented as 'confirmed'.

RESULTS

Among 72 041 683 people with statutory health insurance in Germany in 2021, 72 636 had diagnosed HIV, which corresponds to a prevalence of 101 per 100 000 individuals (0.10%). Of these, 56 895 were males (78%). At a district level, the HIV prevalence varied by a factor of 32 between 13 in a rural district in Bavaria and 417 per 100 000 individuals in the German capital, Berlin. The spatial autocorrelation coefficient was 0.24 (p < 0.0001, Global Moran's I). Several high-prevalence spatial clusters of different sizes were identified, mostly located in western Germany. The largest cluster comprised eight districts in the southern part of Hesse, including the city of Frankfurt and the city of Mainz in Rhineland-Palatinate. The second cluster consisted of four districts in North Rhine-Westphalia, including the cities of Cologne and Düsseldorf. Two districts in southern Germany (Mannheim and Ludwigshafen) formed the third cluster. Only urban districts were observed in spatial clusters of high HIV prevalence.

CONCLUSIONS

The current study identified for the first time spatial clusters with high HIV prevalence in Germany. This understanding is of particular importance when planning the general and specialized medical care of patients with HIV and to support preventive measures.

Retention in care of infants diagnosed with HIV at birth: Beyond the diagnostic strategy

Background

Birth HIV point-of-care (POC) tests curtail analytical testing issues and expedite diagnosis, potentially allowing for earlier mother-infant pair engagement and improved outcomes. Many children are lost post antiretroviral therapy (ART) initiation within the first 6 months of follow-up.

Objectives

We compared 6-month retention in care, HIV viral load (VL) suppression and mortality among infants diagnosed with HIV at birth, using laboratory-based versus POC HIV PCR testing.

Method

From 2018 to 2019, infants exposed to HIV underwent birth HIV PCR POC testing at Kalafong Provincial Tertiary Hospital in Tshwane District. Their outcomes were compared to a historical control born between 2014 and 2016, who exclusively underwent laboratory-based HIV PCR testing. Both groups received comparable HIV care following national guidelines.

Results

Fifty-seven infants were studied (POC: 27; Control: 30). The POC turnaround time was significantly shorter (POC: 15.5 h [IQR: 4.3-24.7], Control: 68.3 h [IQR 46.0-93.9]; p = < 0.0001). Both populations had the same elapsed time from HIV diagnosis to ART initiation (median: 13 days, POC: IQR 8-21 days; Control: IQR 9-36 days). Six infants were never initiated (POC: 2 [7%]; Control: 4 [13%]). At 6 months, overall care retention was 72% (41/57), higher among the Control group (Control 23/30, 77%; POC: 18/27, 67%). HIV viral suppression at 6 months was higher among the POC group (POC: 14/18, 78%; Control: 9/19, 47%, p = 0.09). No deaths were reported.

Conclusion

Poor care retention at 6 months post ART initiation is concerning. Initial mother-infant visits should be effectively utilised to assess and manage potential risk factors for loss of follow-up.

Contribution

This study highlights the ongoing need to find workable solutions to improve retention in care, thereby ensuring the benefits of expedited HIV diagnosis and ART initiation.

Same-day versus rapid ART initiation in HIV-positive individuals presenting with symptoms of tuberculosis: Protocol for an open-label randomized non-inferiority trial in Lesotho and Malawi

BACKGROUND

In absence of contraindications, same-day initiation (SDI) of antiretroviral therapy (ART) is recommended for people testing HIV-positive who are ready to start treatment. Until 2021, World Health Organization (WHO) guidelines considered the presence of TB symptoms (presumptive TB) a contraindication to SDI due to the risk of TB-immune reconstitution inflammatory syndrome (TB-IRIS). To reduce TB-IRIS risk, ART initiation was recommended to be postponed until results of TB investigations were available, and TB treatment initiated if active TB was confirmed. In 2021, the WHO guidelines changed to recommending SDI even in the presence of TB symptoms without awaiting results of TB investigations based on the assumption that TB investigations often unnecessarily delay ART initiation, increasing the risk for pre-ART attrition from care, and noting that the clinical relevance of TB-IRIS outside the central nervous system remains unclear. However, this guideline change was not based on conclusive evidence, and it remains unclear whether SDI of ART or TB test results should be prioritized in people with HIV (PWH) and presumptive TB.

DESIGN AND METHODS

SaDAPT is an open-label, pragmatic, parallel, 1:1 individually randomized, non-inferiority trial comparing two strategies for the timing of ART initiation in PWH with presumptive TB ("ART first" versus "TB results first"). PWH in Lesotho and Malawi, aged 12 years and older (re)initiating ART who have at least one TB symptom (cough, fever, night sweats or weight loss) and no signs of intracranial infection are eligible. After a baseline assessment, participants in the "ART first" arm will be offered SDI of ART, while those in the "TB results first" arm will be offered ART only after active TB has been confirmed or refuted. We hypothesize that the "ART first" approach is safe and non-inferior to the "TB results first" approach with regard to HIV viral suppression (<400 copies/ml) six months after enrolment. Secondary outcomes include retention in care and adverse events consistent with TB-IRIS.

EXPECTED OUTCOMES

SaDAPT will provide evidence on the safety and effects of SDI of ART in PWH with presumptive TB in a pragmatic clinical trial setting.

TRIAL REGISTRATION

The trial has been registered on clinicaltrials.gov (NCT05452616; July 11 2022).

Substantial but spatially heterogeneous progress in male circumcision for HIV prevention in South Africa

BACKGROUND

Voluntary medical male circumcision (VMMC) reduces the risk of male HIV acquisition by 60%. Programmes to provide VMMCs for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Traditional circumcision is also a long-standing male coming-of-age ritual, but practices vary considerably across populations. Accurate estimates of circumcision coverage by age, type, and time at subnational levels are required for planning and delivering VMMCs to meet targets and evaluating their impacts on HIV incidence.

METHODS

We developed a Bayesian competing risks time-to-event model to produce region-age-time-type specific probabilities and coverage of male circumcision with probabilistic uncertainty. The model jointly synthesises data from household surveys and health system data on the number of VMMCs conducted. We demonstrated the model using data from five household surveys and VMMC programme data to produce estimates of circumcision coverage for 52 districts in South Africa between 2008 and 2019.

RESULTS

Nationally, in 2008, 24.1% (95% CI: 23.4-24.8%) of men aged 15-49 were traditionally circumcised and 19.4% (18.9-20.0%) were medically circumcised. Between 2010 and 2019, 4.25 million VMMCs were conducted. Circumcision coverage among men aged 15-49 increased to 64.0% (63.2-64.9%) and medical circumcision coverage to 42% (41.3-43.0%). Circumcision coverage varied widely across districts, ranging from 13.4 to 86.3%. The average age of traditional circumcision ranged between 13 and 19 years, depending on local cultural practices.

CONCLUSION

South Africa has made substantial, but heterogeneous, progress towards increasing medical circumcision coverage. Detailed subnational information on coverage and practices can guide programmes to identify unmet need to achieve national and international targets.

Improved Indicators for Subnational Unmet Antiretroviral Therapy Need in the Health System: Updates to the Naomi Model in 2023

BACKGROUND

Quantifying subnational need for antiretroviral therapy (ART) for HIV is challenging because people living with HIV (PLHIV) access health facilities in areas that may differ from their residence. We defined and demonstrated new indicators for PLHIV treatment needed to guide health system target setting and resource allocation.

SETTING

Botswana.

METHODS

We extended Naomi, a Bayesian small-area model for estimating district-level HIV indicators from national household survey and HIV service delivery data. We used model outputs for ART seeking probabilities in neighboring districts to define the "PLHIV (attending)" indicator representing the estimated number of PLHIV who would seek treatment at health facilities in a district, and "Untreated PLHIV attending" representing gaps in ART service provision. Botswana 2021 district HIV estimates were used to demonstrate new outputs and assess the sensitivity to uncertainty in district population sizes.

RESULTS

Across districts of Botswana, estimated adult ART coverage in December 2021 ranged 90%-96%. In the capital city Gaborone, there were 50,400 resident PLHIV and 64,200 receiving ART, of whom 24% (95% CI: 20 to 32) were estimated to reside in neighboring districts. Applying ART attendance probabilities gave a "PLHIV attending" denominator of 68,300 and unmet treatment need of 4100 adults (95% CI: 3000 to 5500) for Gaborone health facilities. The facility-based "PLHIV attending" denominator was less-sensitive to fluctuations in district population size assumptions.

CONCLUSIONS

New indicators provided more consistent targets for HIV service provision, but are limited by ART data quality. This challenge will increase as treatment coverage reaches high levels and treatment gaps are smaller.

Comparison of Empirically Derived and Model-Based Estimates of Key Population HIV Incidence and the Distribution of New Infections by Population Group in Sub-Saharan Africa

BACKGROUND

The distribution of new HIV infections among key populations, including female sex workers (FSWs), gay men and other men who have sex with men (MSM), and people who inject drugs (PWID) are essential information to guide an HIV response, but data are limited in sub-Saharan Africa (SSA). We analyzed empirically derived and mathematical model-based estimates of HIV incidence among key populations and compared with the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates.

METHODS

We estimated HIV incidence among FSW and MSM in SSA by combining meta-analyses of empirical key population HIV incidence relative to the total population incidence with key population size estimates (KPSE) and HIV prevalence. Dynamic HIV transmission model estimates of HIV incidence and percentage of new infections among key populations were extracted from 94 country applications of 9 mathematical models. We compared these with UNAIDS-reported distribution of new infections, implied key population HIV incidence and incidence-to-prevalence ratios.

RESULTS

Across SSA, empirical FSW HIV incidence was 8.6-fold (95% confidence interval: 5.7 to 12.9) higher than total population female 15-39 year incidence, and MSM HIV incidence was 41.8-fold (95% confidence interval: 21.9 to 79.6) male 15-29 year incidence. Combined with KPSE, these implied 12% of new HIV infections in 2021 were among FSW and MSM (5% and 7% respectively). In sensitivity analysis varying KPSE proportions within 95% uncertainty range, the proportion of new infections among FSW and MSM was between 9% and 19%. Insufficient data were available to estimate PWID incidence rate ratios. Across 94 models, median proportion of new infections among FSW, MSM, and PWID was 6.4% (interquartile range 3.2%-11.7%), both much lower than the 25% reported by UNAIDS.

CONCLUSION

Empirically derived and model-based estimates of HIV incidence confirm dramatically higher HIV risk among key populations in SSA. Estimated proportions of new infections among key populations in 2021 were sensitive to population size assumptions and were substantially lower than estimates reported by UNAIDS.

Triangulation of Routine Antenatal HIV Prevalence Data and Adjusted HIV Estimates in Mozambique

BACKGROUND

Routine health system data are central to monitoring HIV trends. In Mozambique, the reported number of women receiving antenatal care (ANC) and antiretroviral therapy for prevention of mother-to-child transmission (PMTCT) has exceeded the Spectrum-estimated number of pregnant women since 2017. In some provinces, reported HIV prevalence in pregnant women has declined faster than epidemiologically plausible. We hypothesized that these issues are linked and caused by programmatic overenumeration of HIV-negative pregnant women at ANC.

METHODS

We triangulated program-reported ANC client numbers with survey-based fertility estimates and facility birth data adjusted for the proportion of facility births. We used survey-reported ANC attendance to produce adjusted time series of HIV prevalence in pregnant women, adjusted for hypothesized program double counting. We calibrated the Spectrum HIV estimation models to adjusted HIV prevalence data to produce adjusted adult and pediatric HIV estimates.

RESULTS

ANC client numbers were not consistent with facility birth data or modeled population estimates indicating ANC data quality issues in all provinces. Adjusted provincial ANC HIV prevalence in 2021 was median 45% [interquartile range 35%-52% or 2.3 percentage points (interquartile range 2.5-3.5)] higher than reported HIV prevalence. In 2021, calibrating to adjusted antenatal HIV prevalence lowered PMTCT coverage to less than 100% in most provinces and increased the modeled number of new child infections by 35%. The adjusted results better reconciled adult and pediatric antiretroviral treatment coverage and antenatal HIV prevalence with regional fertility estimates.

CONCLUSIONS

Adjusting HIV prevalence in pregnant women using nationally representative household survey data on ANC attendance produced estimates more consistent with surveillance data. The number of children living with HIV in Mozambique has been substantially underestimated because of biased routine ANC prevalence. Renewed focus on HIV surveillance among pregnant women would improve PMTCT coverage and pediatric HIV estimates.

Updated Data and Methods for the 2023 UNAIDS HIV Estimates

ABSTRACT

Each year, supported by the Joint United Nations Programme on HIV/AIDS (UNAIDS), country teams across the globe produce estimates that chart the state of their HIV epidemics. In 2023, HIV estimates were available for 174 countries, accounting for 99% of the global population, of which teams from 150 countries actively engaged in this process. The methods used to derive these estimates are developed under the guidance of the UNAIDS Reference Group on Estimates, Modeling, and Projections (www.epidem.org). Updates to these methods and epidemiological analyses that inform parameters and assumptions are documented in this supplement.

Temporal Trends and Determinants of HIV Testing at Antenatal Care in Sub-Saharan Africa: A Pooled Analysis of Population-Based Surveys (2005-2021)

BACKGROUND

In sub-Saharan Africa (SSA), integrating HIV testing into antenatal care (ANC) has been crucial toward reducing mother-to-child transmission of HIV. With the introduction of new testing modalities, we explored temporal trends in HIV testing within and outside of ANC and identified sociodemographic determinants of testing during ANC.

METHODS

We analyzed data from 139 nationally representative household surveys conducted between 2005 and 2021, including more than 2.2 million women aged 15-49 years in 41 SSA countries. We extracted data on women's recent HIV testing history (<24 months), by modality (ie, at ANC versus outside of ANC) and sociodemographic variables (ie, age, socioeconomic status, education level, number of births, urban/rural). We used Bayesian generalized linear mixed models to estimate HIV testing coverage and the proportion of those that tested as part of ANC.

RESULTS

HIV testing coverage (<24 months) increased substantially between 2005 and 2021 from 8% to 38%, with significant variations between countries and subregions. Two percent of women received an HIV test in the 24 months preceding the survey interview as part of ANC in 2005 and 11% in 2021. Among women who received an HIV test in the 24 months preceding the survey, the probability of testing at ANC was significantly greater for multiparous, adolescent girls, rural women, women in the poorest wealth quintile, and women in West and Central Africa.

CONCLUSION

ANC testing remains an important component to achieving high levels of HIV testing coverage and benefits otherwise underserved women, which could prove instrumental to progress toward universal knowledge of HIV status in SSA.

HIV prevalence in transgender populations and cisgender men who have sex with men in sub-Saharan Africa 2010-2022: a meta-analysis

Introduction

The Global AIDS Strategy 2021-2026 calls for equitable and equal access to HIV prevention and treatment programmes for all populations to reduce HIV incidence and end HIV/AIDS as a public health threat by 2030. Transgender populations (TGP), including transmen (TGM) and transwomen (TGW) are populations that have been marginalised and are at high risk of HIV infection in sub-Saharan Africa (SSA). Limited surveillance data on HIV among TGP are available in the region to guide programmatic responses and policymaking. Surveillance data on cisgender men who have sex with men (cis-MSM) are comparatively abundant and may be used to infer TGP HIV prevalence.

Methods

Data from key population surveys conducted in SSA between 2010-2022 were identified from existing databases and survey reports. Studies that collected HIV prevalence on both TGP and cis-MSM populations were analysed in a random effect meta-analysis to estimate the ratio of cis-MSM:TGW HIV prevalence.

Results

Eighteen studies were identified encompassing 8,052 TGW and 19,492 cis-MSM. TGW HIV prevalence ranged from 0-71.6% and cis-MSM HIV prevalence from 0.14-55.7%. HIV prevalence in TGW was 50% higher than in cis-MSM (prevalence ratio (PR) 1.50 95% CI 1.26-1.79). TGW HIV prevalence was highly correlated with year/province-matched cis-MSM HIV prevalence (R2 = 0.62), but poorly correlated with year/province-matched total population HIV prevalence (R2 = 0.1). Five TGM HIV prevalence estimates were identified ranging from 1-24%. Insufficient TGM data were available to estimate cis-MSM:TGM HIV prevalence ratios.

Conclusion

Transgender women experience a significantly greater HIV burden than cis-MSM in SSA. Bio-behavioural surveys designed and powered to measure determinants of HIV infection, treatment coverage, and risk behaviours among transgender populations, distinct from cis-MSM, will improve understanding of HIV risk and vulnerabilities among TGP and support improved programmes.

Workplace wellbeing among health care workers providing HIV services in primary care in Johannesburg: a mixed methods study

Background

Burnout among Health Care workers (HCWs) impacts on provider-patient relations and quality of care. Anova Health Institute (Anova) is a large South African non-profit organization and PEPFAR/USAID implementing partner. We conducted a study among HCWs providing HIV-related services in primary care settings in Johannesburg, South Africa, to examine levels of burnout, understand factors affecting workplace wellbeing, and explore strategies to prevent burnout.

Methods

We used a sequential mixed-method approach. Data were collected between February and April 2022. The first phase consisted of a survey using the Maslach Burnout Inventory Human Services Survey (MBI-HSS) to measure levels of burnout. We then interviewed a subset of survey participants to understand the experiences that may affect wellbeing. We used descriptive statistics to quantify burnout rates for each MBI dimension (emotional exhaustion, personal accomplishment, and depersonalization). Qualitative data analysis was guided by the Job Demands-Resources Framework that explores the interactions between demands and resources in the workplace.

Results

Survey findings (n = 194) revealed that although depersonalization rates were low at 6%, 21% of participants had high emotional exhaustion and 24% reported low professional accomplishment. Less than half (41%, n = 80) had scores in the high category for any one of the three MBI-HSS dimensions. The MBI-HSS dimensions differed significantly by type of work and job title. Roving positions (HCW working in more than one health facility) were more likely to experience higher emotional exhaustion and lower professional accomplishment. Qualitative findings (n = 25) indicate that a number of job demands, including high workload, inadequate mental health support, and challenging relationships with stakeholders, had a negative effect on HCWs' wellbeing. However, finding meaningfulness in their work, working as a team, and practicing autonomy were experienced as resources that reduced the negative effect of these demands.

Conclusion

While measured burnout syndrome rates were low, various experiences negatively impacted at least one in five HCW. We identified key resources that provided buffering against workplace stressors. We recommend that as well as addressing key drivers of burnout, access to these resources should be fostered, for example by strengthening interventions that offer recognition, and promoting team interactions through social activities and support groups.

Impact of Community-Wide Tuberculosis Active Case Finding and Human Immunodeficiency Virus Testing on Tuberculosis Trends in Malawi

BACKGROUND

Tuberculosis case-finding interventions are critical to meeting World Health Organization End TB strategy goals. We investigated the impact of community-wide tuberculosis active case finding (ACF) alongside scale-up of human immunodeficiency virus (HIV) testing and care on trends in adult tuberculosis case notification rates (CNRs) in Blantyre, Malawi.

METHODS

Five rounds of ACF for tuberculosis (1-2 weeks of leafleting, door-to-door enquiry for cough and sputum microscopy) were delivered to neighborhoods ("ACF areas") in North-West Blantyre between April 2011 and August 2014. Many of these neighborhoods also had concurrent HIV testing interventions. The remaining neighborhoods in Blantyre City ("non-ACF areas") provided a non-randomized comparator. We analyzed TB CNRs from January 2009 until December 2018. We used interrupted time series analysis to compare tuberculosis CNRs before ACF and after ACF, and between ACF and non-ACF areas.

RESULTS

Tuberculosis CNRs increased in Blantyre concurrently with start of ACF for tuberculosis in both ACF and non-ACF areas, with a larger magnitude in ACF areas. Compared to a counterfactual where pre-ACF CNR trends continued during ACF period, we estimated there were an additional 101 (95% confidence interval [CI] 42 to 160) microbiologically confirmed (Bac+) tuberculosis diagnoses per 100 000 person-years in the ACF areas in 3 and a half years of ACF. Compared to a counterfactual where trends in ACF area were the same as trends in non-ACF areas, we estimated an additional 63 (95% CI 38 to 90) Bac + diagnoses per 100 000 person-years in the same period.

CONCLUSIONS

Tuberculosis ACF was associated with a rapid increase in people diagnosed with tuberculosis in Blantyre.

Spatio-temporal estimates of HIV risk group proportions for adolescent girls and young women across 13 priority countries in sub-Saharan Africa

The Global AIDS Strategy 2021-2026 identifies adolescent girls and young women (AGYW) as a priority population for HIV prevention, and recommends differentiating intervention portfolios geographically based on local HIV incidence and individual risk behaviours. We estimated prevalence of HIV risk behaviours and associated HIV incidence at health district level among AGYW living in 13 countries in sub-Saharan Africa. We analysed 46 geospatially-referenced national household surveys conducted between 1999-2018 across 13 high HIV burden countries in sub-Saharan Africa. Female survey respondents aged 15-29 years were classified into four risk groups (not sexually active, cohabiting, non-regular or multiple partner[s] and female sex workers [FSW]) based on reported sexual behaviour. We used a Bayesian spatio-temporal multinomial regression model to estimate the proportion of AGYW in each risk group stratified by district, year, and five-year age group. Using subnational estimates of HIV prevalence and incidence produced by countries with support from UNAIDS, we estimated new HIV infections in each risk group by district and age group. We then assessed the efficiency of prioritising interventions according to risk group. Data consisted of 274,970 female survey respondents aged 15-29. Among women aged 20-29, cohabiting (63.1%) was more common in eastern Africa than non-regular or multiple partner(s) (21.3%), while in southern countries non-regular or multiple partner(s) (58.9%) were more common than cohabiting (23.4%). Risk group proportions varied substantially across age groups (65.9% of total variation explained), countries (20.9%), and between districts within each country (11.3%), but changed little over time (0.9%). Prioritisation based on behavioural risk, in combination with location- and age-based prioritisation, reduced the proportion of population required to be reached in order to find half of all expected new infections from 19.4% to 10.6%. FSW were 1.3% of the population but 10.6% of all expected new infections. Our risk group estimates provide data for HIV programmes to set targets and implement differentiated prevention strategies outlined in the Global AIDS Strategy. Successfully implementing this approach would result in more efficiently reaching substantially more of those at risk for infections.

Modeling DREAMS impact: trends in new HIV diagnoses among women attending antenatal care clinics in DREAMS countries

OBJECTIVES

To understand the impact of United States President's Emergency Plan for AIDS Relief (PEPFAR's) DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) Partnership on new HIV diagnoses among women in antenatal care (ANC) settings in 10 African countries from 2015 to 2020.

DESIGN

We modeled spatiotemporal changes in new HIV diagnoses among women in ANC settings using PEPFAR data. Statistical tests were performed in R to compare differences in new diagnoses rates between DREAMS and non-DREAMS subnational units (SNUs) and to explore predictors of new diagnoses declines within DREAMS SNUs.

METHODS

We used a predictive geospatial model to forecast the rate of new diagnoses for each time period in a 5 km grid cell (n = 861 SNUs). Linear model analyses were conducted using predictor variables: urbanicity, DREAMS geographic footprint, 'layering' proxy, and community-level male viral load suppression.

RESULTS

New HIV diagnoses in ANC from 2015 to 2020 declined in nearly all SNUs. 'Always' DREAMS SNUs reported declines of 45% while 'Never' DREAMS SNUs reported a decline of only 37% (F = 8.1, 1 and 829 DF, P < 0.01). Within Always DREAMS SNUs, greater declines were seen in areas with a higher number of minimum services in their DREAMS primary package (t = 2.77, P < 0.01).

CONCLUSION

New HIV diagnoses among women are declining in both DREAMS and non-DREAMS SNUs; mirroring HIV incidence decreases and reflecting increasing community viral load suppression and voluntary male medical circumcision rates. DREAMS programming may have contributed to accelerated declines of new HIV diagnoses in DREAMS SNUs compared with non-DREAMS SNUs. Increased progress is needed to further reduce the disparities between adolescent girls and young women (AGYW) and young men to achieve epidemic control.

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

OBJECTIVES

The 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.

METHODS

RPHIA 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.

RESULTS

Of 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%).

CONCLUSIONS

HIV 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.

Characterizing and mapping the spatial variability of HIV risk among adolescent girls and young women: A cross-county analysis of population-based surveys in Eswatini, Haiti, and Mozambique

Background

To stem the HIV epidemic among adolescent girls and young women (AGYW), prevention programs must target services towards those most at risk for HIV. This paper investigates approaches to estimate HIV risk and map the spatial heterogeneity of at-risk populations in three countries: Eswatini, Haiti and Mozambique.

Methods

We analyzed HIV biomarker and risk factor data from recent population-based household surveys. We characterized risk using three approaches: complementary log-log regression, latent class analysis (LCA), and presence of at least one risk factor. We calculated the proportion and 95 percent confidence intervals of HIV-negative AGYW at risk across the three methods and employed Chi-square tests to investigate associations between risk classification and HIV status. Using geolocated survey data at enumeration clusters and high-resolution satellite imagery, we applied algorithms to predict the number and proportion of at-risk AGYW at hyperlocal levels.

Results

The any-risk approach yielded the highest proportion of at-risk and HIV-negative AGYW across five-year age bands: 26%-49% in Eswatini, 52%-67% in Haiti, and 32%-84% in Mozambique. Using LCA, between 8%-16% of AGYW in Eswatini, 37%-62% in Haiti, and 56%-80% in Mozambique belonged to a high vulnerability profile. In Haiti and Mozambique, the regression-based profile yielded the lowest estimate of at-risk AGYW. In general, AGYW characterized as “at risk” across the three methods had significantly higher odds of HIV infection. Hyperlocal maps indicated high levels of spatial heterogeneity in HIV risk prevalence and population density of at-risk AGYW within countries.

Conclusion

Characterizing risk among AGYW can help HIV prevention programs better understand the differential effect of multiple risk factors, facilitate early identification of high-risk AGYW, and design tailored interventions. Hyperlocal mapping of these at-risk populations can help program planners target prevention interventions to geographic areas with populations at greatest risk for HIV to achieve maximal impact on HIV incidence reduction.

Progress towards 2020 global HIV impact and treatment targets

INTRODUCTION

Over the past 20 years, the response to the HIV epidemic has achieved remarkable results. These results have often been motivated by targets adopted by countries through United Nations (UN) Political Declarations on HIV. The 2016 political declaration included two impact targets, to achieve a 75% decline in new HIV infections and AIDS-related deaths between 2010 and 2020, and to reach the 90-90-90 testing and treatment targets by 2020. Our objective is to summarize progress towards these targets using robust and comparable HIV estimates released by UNAIDS in July 2021. In addition, we comment on the importance of targets and the modelled estimates required to quantify those targets.

DISCUSSION

The UNAIDS estimates indicate that at the global and regional levels, the 2020 targets were missed: new infections declined by 31% and AIDS-related deaths declined by 47% between 2010 and 2020, compared to a target of 75% decline for both indicators. Similarly, no region achieved the 90-90-90 testing and treatment targets. Some countries, in diverse settings, achieved these targets showing that the targets were not overly ambitious if the right funding, policies and evidence-informed interventions at the right scale were in place. The 2021 UN Political Declaration on HIV, adopted on 8 June 2021, has set out a new set of ambitious but achievable targets for 2025. The 2025 targets and the required actions to reach those targets are described in the Global AIDS Strategy 2021-2026, which provides a framework to reprioritize HIV responses by reducing inequalities and building on the achievements of multiple Sustainable Development Goals. The Strategy encourages countries to monitor progress against targets for different geographic areas and populations to maximize equitable services and ensure accountability and also to understand why targets are being missed.

CONCLUSIONS

The UNAIDS epidemiological estimates provide information that promote accountability and estimate progress towards global targets at the national level. Additional strategic information and analyses are required to identify the populations that are furthest from the targets and the programmes and policies that are keeping countries from meeting their targets.