Planning and sustaining HIV response in the countries of the "risky middle"

This paper focusses on high-HIV middle-income countries termed the "risky middle", i.e. characterised by a typology based on HIV burden and gross national income (GNI), according to which seven countries - Lesotho, Eswatini, Kenya, Zimbabwe, Tanzania, Namibia and Zambia - are identified. There is particular concern for "people left behind", the factors determining a country's ability to mobilise resources in the context of multiple development needs - including economic disparities; the political economy of fiscal decision-making; levels of health investment; health and community systems; political will; and currency fluctuations. While donors will support lower-income countries and higher-income countries can compensate from domestic resources, there is a risk that some high-burden, lower middle-income countries will be unable to sustain a response. Continued growth means that there are countries transitioning to higher World Bank income classification - an important criterion for allocating development assistance for health. Our concern is that countries may face external funding reduction once their income category improves, and those in the risky middle will be unable to compensate from domestic resources. We conclude, with guidance from UNAIDS, the international community should step up support for "risky middle" countries. In addition these countries need to recognise the threat and develop measures to counter it, including improved accountability. Funding declines should be reversed through funding benchmarks that relate to both GDP and HIV prevalence. Finally, risky middle countries could constitute themselves as a special interest group, to protect their HIV funding and AIDS response.

Widespread changes in sexual behaviour in eastern and southern Africa: Challenges to achieving global HIV targets? Longitudinal analyses of nationally representative surveys

INTRODUCTION

Sexual behaviour change contributed to reductions in HIV incidence in eastern and southern Africa between 1990 and 2010. More recently, there are indications that non-regular partnerships have increased. However, the effect of these increases on population-level risks for HIV and other sexually transmitted infections could have been reduced by simultaneous increases in condom use. We describe recent trends in sexual behaviour and condom use within the region and assess their combined effects on population levels of sexual risk.

METHODS

Nationally representative Demographic and Health Survey data on sexually active males and females (15 to 49 years) were used for 11 eastern and southern African countries (≥3 surveys for each country; 1999 to 2016) to describe trends in sexual behaviour (multiple, non-regular, and casual sexual partnerships; condom use; age at first sex). Logistic regressions tested for statistical significance of changes. Analyses were stratified by sex.

RESULTS

Recent increases in multiple, non-regular, and/or casual partnerships can be found for males in 10 countries and, for females, in nine countries; five countries exhibited recent decreases in age of sexual debut. Reduction in sex without condoms with non-regular partners was observed in six countries for males and eight for females. Changes in the proportion of the overall population reporting condomless sex with non-regular partners varied between countries, with declines in six countries and increases in three.

CONCLUSIONS

Extensive change in sexual behaviour occurred across eastern and southern Africa during the period of scale-up of antiretroviral therapy programmes. This includes increasing multiple and non-regular partnerships, but their potential effects on population-level sexual risks were often offset by parallel increases in condom use. Strengthening condom programmes and reintegrating communication about behavioural dimensions into combination prevention programmes could help countries to meet international targets for reductions in HIV incidence.