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Ante-Testard PA, Carrasco-Escobar G, Benmarhnia T, Temime L, Jean K. Investigating inequalities in HIV testing in sub-Saharan Africa: spatial analysis of cross-sectional population-based surveys in 25 countries. BMJ Open 2023; 13:e072403. [PMID: 38081667 PMCID: PMC10729013 DOI: 10.1136/bmjopen-2023-072403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/31/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES We aim to explore spatial variations in socioeconomic inequalities in HIV testing uptake in sub-Saharan Africa (SSA) at different geographical scales to identify potential geographical hotspots of inequalities. Additionally, to evaluate the potential benefits of HIV testing programmes, we assess whether local levels of HIV testing match the local levels of HIV prevalence. DESIGN A multi-country analysis of population-based cross-sectional surveys in SSA. SETTING We analysed data from 25 SSA countries with Demographic and Health Surveys between 2011 and 2019. PARTICIPANTS Country-level analysis included 473 775 participants (312 104 women and 161 671 men) and cluster-level analysis included 328 283 individuals (241 084 women and 87 199 men). Women aged 15-49 years and men aged 15-54/59 years in selected households who were tested for HIV in the last 12 months were eligible. We quantified inequalities in self-reported recent HIV testing with the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII) across geographical scales to capture sex-specific within-country spatial variations. We also conducted local Getis-Ord Gi* statistics to consider the autocorrelation in fine-scale SII and RII across countries. To assess the efficiency of HIV testing programmes, we measured the correlation between recent HIV testing and HIV prevalence through Spearman correlation across geographical scales. RESULTS We observed varying inequalities in recent HIV testing in magnitude and spatial distribution on both absolute and relative scales in many countries for both sexes at national and subnational levels. Hotspots of absolute and relative inequalities were mostly observed in Western and Central Africa with a few regions in Eastern and Southern Africa. Despite significant sex-specific correlations between testing and prevalence in all countries when assessed at the national level, we report an absence of such a correlation at fine scale in 17 of 50 sex-country combinations. CONCLUSIONS We highlight the importance of investigating the spatial variability of various HIV indicators and related inequalities across different geographical levels. Results may help inform an equitable distribution of HIV testing services.
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Affiliation(s)
- Pearl Anne Ante-Testard
- Laboratoire MESuRS, Conservatoire National des Arts et Métiers, Paris, Île-de-France, France
- Unité PACRI, Institut Pasteur, Conservatoire National des Arts et Métiers, Paris, Île-de-France, France
| | - Gabriel Carrasco-Escobar
- Health Innovation Laboratory, Institute of Tropical Medicine "Alexander Von Humboldt", Universidad Peruana Cayetano Heredia, Lima, Peru
- Scripps Institution of Oceanography, University of California, San Diego, California, USA
| | - Tarik Benmarhnia
- Scripps Institution of Oceanography, University of California, San Diego, California, USA
| | - Laura Temime
- Laboratoire MESuRS, Conservatoire National des Arts et Métiers, Paris, Île-de-France, France
- Unité PACRI, Institut Pasteur, Conservatoire National des Arts et Métiers, Paris, Île-de-France, France
| | - Kévin Jean
- Laboratoire MESuRS, Conservatoire National des Arts et Métiers, Paris, Île-de-France, France
- Unité PACRI, Institut Pasteur, Conservatoire National des Arts et Métiers, Paris, Île-de-France, France
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Endalamaw A, Gilks CF, Ambaw F, Assefa Y. Socioeconomic inequality and contributors in accepting attitudes toward people living with HIV among adults in Ethiopia from 2005 to 2016: a population-based cross-sectional study. BMJ Open 2023; 13:e074694. [PMID: 38040424 PMCID: PMC10693865 DOI: 10.1136/bmjopen-2023-074694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023] Open
Abstract
INTRODUCTION The public's accepting attitude toward people living with HIV is crucial in reducing HIV-related stigma and discrimination, increasing people's access to HIV service. This study examines the inequalities in accepting attitudes toward people living with HIV in Ethiopia from 2005 to 2016. METHODS This cross-sectional study was based on the 2005, 2011 and 2016 Ethiopian Demographic Health Surveys. A total of 17 075, 28 478 and 25 542 adults were included in the 2005, 2011 and 2016 surveys, respectively. Socioeconomic inequality was investigated using the concentration curve and Erreygers' concentration index (ECI), which is scaled from -1 (pro-poor) to +1 (pro-rich). The ECI was decomposed to identify the contributors to socioeconomic inequality using generalised linear regression with the logit link function. RESULTS Accepting attitude toward people living with HIV was 17.9% (95% CI: 16.6%, 19.3%) in 2005, which increased to 33.5% (95% CI: 31.8%, 35.3%) in 2011 and 39.6% (95% CI: 37.6%, 41.9%) in 2016. ECI was 0.342 (p<0.001), 0.436 (p<0.001) and 0.388 (p<0.001), respectively, for 2005, 2011 and 2016. The trend line illustrates socioeconomic inequality seems diverging over time, with an increasing ECI of 0.005 every year (r=0.53; p=0.642; slope=0.005). CONCLUSIONS The current study found that there was pro-rich inequality from 2005 to 2016. People with higher socioeconomic status had a better attitude toward people living with HIV. Comprehensive knowledge about HIV/AIDS, education status, residence, and access to electronic and paper-based media, as well as HIV testing, contribute to a better accepting attitude toward people living with HIV. It is of utmost importance for the country to enhance accepting attitude toward people living with HIV to reduce stigma and discrimination. This requires whole-system response according to the primary healthcare approach toward ending the epidemic of HIV/AIDS in the country.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, the University of Queensland, Brisbane, Queensland, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Amhara, Ethiopia
| | - Charles F Gilks
- School of Public Health, the University of Queensland, Brisbane, Queensland, Australia
| | - Fentie Ambaw
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Amhara, Ethiopia
| | - Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Queensland, Australia
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Endalamaw A, Gilks CF, Ambaw F, Khatri RB, Assefa Y. Socioeconomic inequality in knowledge about HIV/AIDS over time in Ethiopia: A population-based study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002484. [PMID: 37906534 PMCID: PMC10617701 DOI: 10.1371/journal.pgph.0002484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/23/2023] [Indexed: 11/02/2023]
Abstract
Socioeconomic inequality in comprehensive knowledge about HIV/AIDS can hinder progress towards ending the epidemic threat of this disease. To address the knowledge gap, it is essential to investigate inequality in HIV/AIDS services. This study aimed to investigate socioeconomic inequality, identify contributors, and analyze the trends in inequality in comprehensive knowledge about HIV/AIDS among adults in Ethiopia. A cross-sectional study was conducted using 2005, 2011, and 2016 population-based health survey data. The sample size was 18,818 in 2005, 29,264 in 2011, and 27,261 in 2016. Socioeconomic inequality in comprehensive knowledge about HIV/AIDS was quantified by using a concentration curve and index. Subsequently, the decomposition of the concentration index was conducted using generalised linear regression with a logit link function to quantify covariates' contribution to wealth-based inequality. The Erreygers' concentration index was 0.251, 0.239, and 0.201 in 2005, 2011, and 2016, respectively. Watching television (24.2%), household wealth rank (21.4%), ever having been tested for HIV (15.3%), and education status (14.3%) took the significant share of socioeconomic inequality. The percentage contribution of watching television increased from 4.3% in 2005 to 24.2% in 2016. The household wealth rank contribution increased from 14.6% in 2005 to 21.38% in 2016. Education status contribution decreased from 16.2% to 14.3%. The percentage contribution of listening to the radio decreased from 16.9% in 2005 to -2.4% in 2016. The percentage contribution of residence decreased from 7.8% in 2005 to -0.5% in 2016. This study shows comprehensive knowledge about HIV/AIDS was concentrated among individuals with a higher socioeconomic status. Socioeconomic-related inequality in comprehensive knowledge about HIV/AIDS is woven deeply in Ethiopia, though this disparity has been decreased minimally. A combination of individual and public health approaches entangled in a societal system are crucial remedies for the general population and disadvantaged groups. This requires comprehensive interventions according to the primary health care approach.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Charles F. Gilks
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Fentie Ambaw
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Resham B. Khatri
- School of Public Health, The University of Queensland, Brisbane, Australia
- Health Social Science and Development Research Institute, Kathmandu, Nepal
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, Australia
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Schneider J, Coutinho R, Hatcher AM, Larmarange J, Letendre S, Paraskevis D, Strathdee S, Vance DE, Martínez E. Stimulating dissemination of research that addresses the social and contextual drivers of HIV prevention and treatment in the journal AIDS. AIDS 2023; 37:1021. [PMID: 37139648 PMCID: PMC10840992 DOI: 10.1097/qad.0000000000003582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- John Schneider
- Department of Medicine and Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| | - Roel Coutinho
- Universitair Medisch Centrum Utrecht, Utrecht, the Netherlands
| | - Abigail M. Hatcher
- The Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Scott Letendre
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Dimitrios Paraskevis
- Department of Hygiene and Epidemiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Steffanie Strathdee
- Department of Medicine and Public Health Sciences, University of Chicago, Chicago, Illinois, USA
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - David E. Vance
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Esteban Martínez
- Department of Medicine, University of Barcelona, Barcelona, Spain
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Teshale AB, Tesema GA. Socioeconomic Inequality in Knowledge About HIV and Its Contributing Factors Among Women of Reproductive Age in Sub-Saharan Africa: A Multicountry and Decomposition Analysis. HIV AIDS (Auckl) 2023; 15:53-62. [PMID: 36883177 PMCID: PMC9985886 DOI: 10.2147/hiv.s392548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
Aim To examine the socioeconomic inequality in knowledge about HIV and its contributing factors among women of reproductive age in sub-Saharan Africa. Methods We have used the most recent demographic and health survey data of the 15 sub-Saharan African countries. 204,495 women of reproductive age made up the entire weighted sample. Erreygers normalized concentration index (ECI) was utilized to evaluate socioeconomic inequality in knowledge about HIV. The variables that contributed to the observed socioeconomic inequality were determined using decomposition analysis. Results We found the pro-rich inequality in knowledge about HIV (the weighted ECI was 0.16 with a Standard error = 0.007 and P value< 0.001). The decomposition analysis indicated that educational status (46.10%), wealth status (30.85%), listening to the radio (21.73%), and reading newspapers (7.05%) were among the contributors to the pro-rich socioeconomic inequalities in knowledge about HIV. Conclusion Having knowledge about HIV is concentrated among rich reproductive-age women. Educational status, wealth status, and media exposure were the major contributors and should be a priority for interventions to reduce the inequality in knowledge about HIV.
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Affiliation(s)
- Achamyeleh Birhanu Teshale
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Getayeneh Antehunegn Tesema
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Understanding the pathways leading to socioeconomic inequalities in HIV testing uptake in 18 sub-Saharan African countries. AIDS 2022; 36:1707-1716. [PMID: 35848589 PMCID: PMC9451839 DOI: 10.1097/qad.0000000000003316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To better understand the different pathways linking socioeconomic position and HIV testing uptake in 18 sub-Saharan African countries. DESIGN We used cross-sectional population-based surveys between 2010 and 2018. METHODS Using a potential outcomes framework and the product method, we decomposed the total effect linking wealth and recent (<12 months) HIV testing into direct effects, and indirect effects, via internal (related to individual's ability to perceive need for and to seek care) or external (ability to reach, pay for and engage in healthcare) mediators to calculate the proportion mediated (PM) by each mediator. RESULTS High levels of inequalities were observed in nine and 15 countries among women and men, respectively. The mediator indirect effect varied greatly across countries. The PM tended to be higher for internal than for external mediators. For instance, among women, HIV-related knowledge was estimated to mediate up to 12.1% of inequalities in Côte d'Ivoire; and up to 31.5% for positive attitudes towards people with HIV (PWH) in Senegal. For the four external mediators, the PM was systematically below 7%. Similar findings were found when repeating analyses on men for the internal mediators, with higher PM by attitudes towards PWH (up to 39.9% in Senegal). CONCLUSIONS Our findings suggest that wealth-related inequalities in HIV testing may be mediated by internal more than external characteristics, with important variability across countries. Overall, the important heterogeneities in the pathways of wealth-related inequalities in HIV testing illustrate that addressing inequalities requires tailored efforts and upstream interventions.
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