Publications
135 results found
Fellows I, Hladik W, Eaton J, et al., 2023, Improving biomarker based HIV incidence estimation in the treatment era, Epidemiology, Vol: 34, Pages: 1-12, ISSN: 1044-3983
Background: Estimating HIV-1 incidence using biomarker assays in cross-sectional surveys is important for understanding the HIV pandemic. However, the utility of these estimates has been limited by uncertainty about what input parameters to use for false recency rate (FRR) and mean duration of recent infection (MDRI) after applying a recent infection testing algorithm (RITA).Methods: This article shows how testing and diagnosis reduce both FRR and mean duration of recent infection compared to a treatment-naive population. A new method is proposed for calculating appropriate context-specific estimates of FRR and mean duration of recent infection. The result of this is a new formula for incidence that depends only on reference FRR and mean duration of recent infection parameters derived in an undiagnosed, treatment-naive, nonelite controller, non-AIDS-progressed population.Results: Applying the methodology to eleven cross-sectional surveys in Africa results in good agreement with previous incidence estimates, except in 2 countries with very high reported testing rates.Conclusions: Incidence estimation equations can be adapted to account for the dynamics of treatment and recent infection testing algorithms. This provides a rigorous mathematical foundation for the application of HIV recency assays in cross-sectional surveys.
Wolock TM, Flaxman S, Chimpandule T, et al., 2023, Subnational HIV incidence trends in Malawi: large, heterogeneous declines across space., medRxiv
The rate of new HIV infections globally has decreased substantially from its peak in the late 1990s, but the epidemic persists and remains highest in many countries in eastern and southern Africa. Previous research hypothesised that, as the epidemic recedes, it will become increasingly concentrated among sub-populations and geographic areas where transmission is the highest and that are least effectively reached by treatment and prevention services. However, empirical data on subnational HIV incidence trends is sparse, and the local transmission rates in the context of effective treatment scale-up are unknown. In this work, we developed a novel Bayesian spatio-temporal epidemic model to estimate adult HIV prevalence, incidence and treatment coverage at the district level in Malawi from 2010 through the end of 2021. We found that HIV incidence decreased in every district of Malawi between 2010 and 2021 but the rate of decline varied by area. National-level treatment coverage more than tripled between 2010 and 2021 and more than doubled in every district. Large increases in treatment coverage were associated with declines in HIV transmission, with 12 districts having incidence-prevalence ratios of 0.03 or less (a previously suggested threshold for epidemic control). Across districts, incidence varied more than HIV prevalence and ART coverage, suggesting that the epidemic is becoming increasingly spatially concentrated. Our results highlight the success of the Malawi HIV treatment programme over the past decade, with large improvements in treatment coverage leading to commensurate declines in incidence. More broadly, we demonstrate the utility of spatially resolved HIV modelling in generalized epidemic settings. By estimating temporal changes in key epidemic indicators at a relatively fine spatial resolution, we were able to directly assess, for the first time, whether the ART scaleup in Malawi resulted in spatial gaps or hotspots. Regular use of this type of analysis
Kuchukhidze S, Panagiotoglou D, Boily M-C, et al., 2023, The effects of intimate partner violence on women’s risk of HIV acquisition and engagement in the HIV treatment and care cascade: a pooled analysis of nationally representative surveys in sub-Saharan Africa, The Lancet HIV, Vol: 10, Pages: e107-e117, ISSN: 2405-4704
Background:Achieving the 95-95-95 targets for HIV diagnosis, treatment, and viral load suppression to end the HIV epidemic hinges on eliminating structural inequalities, including intimate partner violence (IPV). Sub-Saharan Africa has among the highest prevalence of IPV and HIV worldwide. We aimed to examine the effects of IPV on recent HIV infection and women's engagement in the HIV care cascade in sub-Saharan Africa.Methods:We did a retrospective pooled analysis of data from nationally representative, cross-sectional surveys with information on physical or sexual IPV (or both) and HIV testing, from Jan 1, 2000, to Dec 31, 2020. Relevant surveys were identified from data catalogues and previous large-scale reviews, and included the Demographic and Health Survey, the AIDS Indicator Survey, the Population-based HIV Impact Assessment, and the South Africa National HIV Prevalence, Incidence, Behavior and Communication Survey. Individual-level data on all female respondents who were ever-partnered (currently or formerly married or cohabiting) and aged 15 years or older were included. We used Poisson regression to estimate crude and adjusted prevalence ratios (PRs) for the association between past-year experience of physical or sexual IPV (or both), as the primary exposure, and recent HIV infection (measured with recency assays), as the primary outcome. We also assessed associations of past-year IPV with self-reported HIV testing (also in the past year), and antiretroviral therapy (ART) uptake and viral load suppression at the time of surveying. Models were adjusted for participant age, age at sexual debut (HIV recency analysis), urban or rural residency, partnership status, education, and survey-level fixed effects.Findings:57 surveys with data on self-reported HIV testing and past-year physical or sexual IPV were available from 30 countries, encompassing 280 259 ever-partnered women aged 15–64 years. 59 456 (21·2%) women had experienced phys
Laga I, Niu X, Rucinski K, et al., 2023, Mapping the number of female sex workers in countries across sub- Saharan Africa, Proceedings of the National Academy of Sciences of USA, Vol: 120, ISSN: 0027-8424
Female sex workers (FSW) are affected by individual, network, and structural risks, making them vulnerable to poor health and well-being. HIV prevention strategies and local community-based programs can rely on estimates of the number of FSW to plan and implement differentiated HIV prevention and treatment services. However, there are limited systematic assessments of the number of FSW in countries across sub-Saharan Africa to facilitate the identification of prevention and treatment gaps. Here we provide estimated population sizes of FSW and the corresponding uncertainties for almost all sub-national areas in sub-Saharan Africa. We first performed a literature review of FSW size estimates and then developed a Bayesian hierarchical model to synthesize these size estimates, resolving competing size estimates in the same area and producing estimates in areas without any data. We estimated that there are 2.5 million (95% uncertainty interval 1.9 to 3.1) FSW aged 15 to 49 in sub-Saharan Africa. This represents a proportion as percent of all women of childbearing age of 1.1% (95% uncertainty interval 0.8 to 1.3%). The analyses further revealed substantial differences between the proportions of FSW among adult females at the sub-national level and studied the relationship between these heterogeneities and many predictors. Ultimately, achieving the vision of no new HIV infections by 2030 necessitates dramatic improvements in our delivery of evidence-based services for sex workers across sub-Saharan Africa.
Eilerts H, Romero Prieto J, Ambia J, et al., 2022, Evaluating pregnancy reporting in Siaya Health and Demographic Surveillance System through record linkage with ANC clinics, International Journal of Population Data Science, Vol: 7, ISSN: 2399-4908
IntroductionHealth and Demographic Surveillance Systems (HDSS) are important sources of population health data in sub-Saharan Africa, but the recording of pregnancies, pregnancy outcomes, and early mortality is often incomplete.ObjectiveThis study assessed HDSS pregnancy reporting completeness and identified predictors of unreported pregnancies that likely ended in adverse outcomes.MethodsThe analysis utilized individually-linked HDSS and antenatal care (ANC) data from Siaya, Kenya for pregnancies in 2018-2020. We cross-checked ANC records with HDSS pregnancy registrations and outcomes. Pregnancies observed in the ANC that were missing reports in the HDSS despite a data collection round following the expected delivery date were identified as likely adverse outcomes, and we investigated the characteristics of such individuals. Clinical data were used to investigate the timing of HDSS pregnancy registration relative to care seeking and gestational age, and examine misclassification of miscarriages and stillbirths.ResultsFrom an analytical sample of 2,475 pregnancies observed in the ANC registers, 46% had pregnancy registrations in the HDSS, and 89% had retrospectively reported pregnancy outcomes. 1% of registered pregnancies were missing outcomes, compared to 10% of those lacking registration. Registered pregnancies had higher rates of stillbirth and perinatal mortality than those lacking registration. In 77% of cases, women accessed ANC prior to registering the pregnancy in the HDSS. Half of reported miscarriages were misclassified stillbirths. We identified 141 unreported pregnancies that likely ended in adverse outcomes. Such cases were more common among those who visited ANC clinics during the first trimester, made fewer overall visits, were HIV-positive, and outside of formal union.ConclusionsRecord linkage with ANC clinics revealed pregnancy underreporting in HDSS, resulting in biased measurement of perinatal mortality. Integrating records of ANC usage into rout
Nguyen VK, Eaton JW, 2022, A model for reconstructing trends and distribution in age at first sex from multiple household surveys with reporting biases, Epidemics, Vol: 40, Pages: 1-10, ISSN: 1755-4365
Age at first sex (AFS) is a key indicator for monitoring sexual behaviour risk for HIV and other sexually transmitted infections. Reporting of AFS data, however, suffers social-desirability and recall biases which obscure AFS trends and inferences from the data. We illustrated AFS reporting biases using data from nationally-representative Demographic and Health Surveys conducted between 1992 and 2019 in Ethiopia, Guinea, Senegal, and Zambia. Based on this, we proposed a time-to-event, interval censored model for the distribution of AFS that uses overlapping reports by the same birth cohort in successive surveys to adjust for reporting biases. The three-parameter log-skew-logistic distribution described the asymmetric and nonmonotonic hazard exhibited by empirical AFS data. In cross-validation analysis, incorporating a term for reporting bias as a function of age at report improved model predictions for the trend in AFS over birth cohorts. In the four example applications, the quartiles of the AFS distribution were 16 to 23 years for Ethiopian and Senegalese women and 15 to 20 years for Guinean and Zambian men. Median AFS increased by around one to 1.5 years between the 1960 and 1989 birth cohorts for all four datasets. During adolescent and young adult ages, men tended to report an earlier AFS while women tended to report an older AFS than when asked in their late twenties. Above age 30, both male and female respondents tended to report older AFS compared to when surveyed in their late twenties. Simulations validated that the model recovered the trend in AFS in the presence of reporting biases. When there were biases, at least three surveys were needed to obtain reliable estimate for a 20-year trend. Mis-specified reference age at which AFS reporting is assumed unbiased did not affect the trend estimate but resulted in biased median AFS in the most recent birth cohorts.
Revill P, Rangaraj A, Makochekanwa A, et al., 2022, Perspectives on the use of modelling and economic analysis to guide HIV programmes in sub-Saharan Africa, The Lancet HIV, Vol: 9, Pages: e517-e520, ISSN: 2352-3018
HIV modelling and economic analyses have had a prominent role in guiding programmatic responses to HIV in sub-Saharan Africa. However, there has been little reflection on how the HIV modelling field might develop in future. HIV modelling should more routinely align with national government and ministry of health priorities, recognising their legitimate mandates and stewardship responsibilities, for HIV and other wider health programmes. Importance should also be placed on ensuring collaboration between modellers, and that joint approaches to addressing modelling questions, becomes the norm rather than the exception. Such an environment can accelerate translation of modelling analyses into policy formulation because areas where models agree can be prioritised for action, whereas areas over which uncertainty prevails can be slated for additional study, data collection, and analysis. HIV modelling should increasingly be integrated with the modelling of health needs beyond HIV, particularly in allocative efficiency analyses, where focusing on one disease over another might lead to worse health overall. Such integration might also enhance partnership with national governments whose mandates extend beyond HIV. Finally, we see a need for there to be substantial and equitable investment in capacity strengthening within African countries, so that African researchers will increasingly be leading modelling exercises. Building a critical mass of expertise, strengthened through external collaboration and knowledge exchange, should be the ultimate goal.
Nguyen VK, Eaton J, 2022, Trends and country-level variation in age at first sex in sub-Saharan Africa among birth cohorts entering adulthood between 1985 and 2020, BMC Public Health, Vol: 22, ISSN: 1471-2458
Background:Debuting sexual intercourse marks exposure to pregnancy or fatherhood and sexually transmitted infections (STIs), including HIV. In sub-Saharan Africa (SSA), sexual debut varies according to cultural, religious, and economic factors, and encouraging delay has been a longstanding component of behavioural HIV prevention strategies. Age at first sex (AFS) is routinely collected in national household surveys, but data are affected by reporting biases, limiting utility to monitor trends and guide sexual health interventions.Methods:We collated individual-level data from nationally-representative household surveys to analyse timing and national trends in AFS in 42 SSA countries. We used a log-skew-logistic distribution to characterize the time to AFS in a Bayesian spatio-temporal model, providing estimates of the sexual debut rate by sex, age, time, and country. We statistically adjusted for reporting biases by comparing AFS reported by the same birth cohorts in multiple survey rounds, allowing different reporting biases by sex and country.Results:Median AFS in 2015 ranged from 15.8 among Angolan women to 25.3 among men in Niger. AFS was younger for women than men in 37/40 countries. The gap was largest for Sahel region countries and minimal in southern African countries. The distribution of female AFS was asymmetric with half debuting sex in an age range of 3.9 years [IQR 3.4–5.0 across countries]. Median AFS increased slightly between 1985 and 2020, ranging 0.84 years [IQR 0.11–1.55] and 0.79 [IQR -0.23–1.98] for females and males, respectively. The gender gap changed little over time in most countries. Female teens often reported higher AFS compared to when asked in their late twenties while male teens reported lower AFS; both sexes recalled a higher AFS in older ages compared to their thirties.Conclusions:AFS increased slightly in most SSA countries, but changes were modest relative to large and persistent variation between c
Edun O, Shenderovich Y, Zhou S, et al., 2022, Predictors and consequences of HIV status disclosure to adolescents living with HIV in Eastern Cape, South Africa: a prospective cohort study, Journal of the International AIDS Society, Vol: 25, Pages: 1-11, ISSN: 1758-2652
IntroductionThe World Health Organization recommends full disclosure of HIV-positive status to adolescents who acquired HIV perinatally (APHIV) by age 12. However, even among adolescents (aged 10–19) already on antiretroviral therapy (ART), disclosure rates are low. Caregivers often report the child being too young and fear of disclosure worsening adolescents’ mental health as reasons for non-disclosure. We aimed to identify the predictors of disclosure and the association of disclosure with adherence, viral suppression and mental health outcomes among adolescents in sub-Saharan Africa.MethodsAnalyses included three rounds (2014–2018) of data collected among a closed cohort of adolescents living with HIV in Eastern Cape, South Africa. We used logistic regression with respondent random-effects to identify factors associated with disclosure, and assess differences in ART adherence, viral suppression and mental health symptoms between adolescents by disclosure status. We also explored differences in the change in mental health symptoms and adherence between study rounds and disclosure groups with logistic regression.ResultsEight hundred and thirteen APHIV were interviewed at baseline, of whom 769 (94.6%) and 729 (89.7%) were interviewed at the second and third rounds, respectively. The proportion aware of their HIV-positive status increased from 63.1% at the first round to 85.5% by the third round. Older age (adjusted odds ratio [aOR]: 1.27; 1.08–1.48) and living in an urban location (aOR: 2.85; 1.72–4.73) were associated with disclosure between interviews. There was no association between awareness of HIV-positive status and ART adherence, viral suppression or mental health symptoms among all APHIV interviewed. However, among APHIV not aware of their status at baseline, adherence decreased at the second round among those who were disclosed to (N = 131) and increased among those not disclosed to (N = 151) (interaction aOR: 0.39; 0.19&ndash
Moorhouse L, Schaefer R, Eaton JW, et al., 2022, Male partners' influence on adolescent girls and young women's use of combination HIV prevention: insights from analysis of HIV-prevention cascade data collected in a general-population survey in Manicaland, Zimbabwe, AIDS 2022
Telford CT, Tessema Z, Msukwa M, et al., 2022, Geospatial transmission hotspots of recent HIV infection — Malawi, October 2019–March 2020, MMWR. Morbidity and Mortality Weekly Report, Vol: 71, Pages: 329-334, ISSN: 0149-2195
What is already known about this topic?A novel HIV infection surveillance initiative was implemented in Malawi to collect data on recent HIV infections among new diagnoses to characterize the epidemic and guide the public health response.What is added by this report?Higher proportions of recent infections were identified among females, persons aged <30 years, and clients at maternal and child health and youth clinics. Spatial analysis identified three hotspots of health facilities with significantly higher rates of recent infection than expected across five districts.What are the implications for public health practice?Geospatial analysis of recent HIV infection surveillance data can identify potential transmission hotspots. This information could be used to tailor program activities to strengthen HIV testing, prevention, and treatment services and ultimately interrupt transmission.
Hodgins C, Stannah J, Kuchukhidze S, et al., 2022, Population sizes, HIV prevalence, and HIV prevention among men who paid for sex in sub-Saharan Africa (2000-2020): a meta-analysis of 87 population-based surveys, PLoS Medicine, Vol: 19, ISSN: 1549-1277
BACKGROUND: Key populations, including sex workers, are at high risk of HIV acquisition and transmission. Men who pay for sex can contribute to HIV transmission through sexual relationships with both sex workers and their other partners. To characterize the population of men who pay for sex in sub-Saharan Africa (SSA), we analyzed population size, HIV prevalence, and use of HIV prevention and treatment. METHODS AND FINDINGS: We performed random-effects meta-analyses of population-based surveys conducted in SSA from 2000 to 2020 with information on paid sex by men. We extracted population size, lifetime number of sexual partners, condom use, HIV prevalence, HIV testing, antiretroviral (ARV) use, and viral load suppression (VLS) among sexually active men. We pooled by regions and time periods, and assessed time trends using meta-regressions. We included 87 surveys, totaling over 368,000 male respondents (15-54 years old), from 35 countries representing 95% of men in SSA. Eight percent (95% CI 6%-10%; number of surveys [Ns] = 87) of sexually active men reported ever paying for sex. Condom use at last paid sex increased over time and was 68% (95% CI 64%-71%; Ns = 61) in surveys conducted from 2010 onwards. Men who paid for sex had higher HIV prevalence (prevalence ratio [PR] = 1.50; 95% CI 1.31-1.72; Ns = 52) and were more likely to have ever tested for HIV (PR = 1.14; 95% CI 1.06-1.24; Ns = 81) than men who had not paid for sex. Men living with HIV who paid for sex had similar levels of lifetime HIV testing (PR = 0.96; 95% CI 0.88-1.05; Ns = 18), ARV use (PR = 1.01; 95% CI 0.86-1.18; Ns = 8), and VLS (PR = 1.00; 95% CI 0.86-1.17; Ns = 9) as those living with HIV who did not pay for sex. Study limitations include a reliance on self-report of sensitive behaviors and the small number of surveys with information on ARV use and VLS. CONCLUSIONS: Paying for sex is prevalent, and men who ever paid for sex were 50% more likely to be living with HIV compared to other men in the
Nsanzimana S, Rwibasira G, Malamba SS, et al., 2022, 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, International Journal of Infectious Diseases, Vol: 116, Pages: 245-254, ISSN: 1201-9712
ObjectivesThe 2018–19 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 three 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.
Jia K, Eilerts H, Edun O, et al., 2022, Risk scores for predicting HIV incidence among adult heterosexual populations in sub-Saharan Africa: a systematic review and meta-analysis, Journal of the International AIDS Society, Vol: 25, ISSN: 1758-2652
Introduction: Several HIV risk scores have been developed to identify individuals for prioritised HIV prevention in sub-Saharan Africa. We systematically reviewed HIV risk scores to: (i) identify factors that consistently predicted incident HIV infection, (ii) review inclusion of community-level HIV risk in predictive models, and (iii) examine predictive performance. Methods: We searched nine databases from inception until February 15, 2021 for studies developing and/or validating HIV risk scores among the heterosexual adult population in sub-Saharan Africa. Studies not prospectively observing seroconversion or recruiting only key populations were excluded. Record screening, data extraction, and critical appraisal were conducted in duplicate. We used random-effects meta-analysis to summarise hazard ratios and the area under the receiver-operating characteristic curve (AUC-ROC). Results: From 1563 initial search records, we identified 14 risk scores in 13 studies. Seven studies were among sexually active women using contraceptives enrolled in randomised-controlled trials, three among adolescent girls and young women (AGYW), and three among cohorts enrolling both men and women. Consistently identified HIV prognostic 51 factors among women were younger age (pooled adjusted hazard ratio: 1.62 [95% 52 Confidence Interval: 1.17, 2.23], compared to above-25), single/not cohabiting with primary partners (2.33 [1.73, 3.13]) and having sexually transmitted infections (STIs) at baseline (HSV-2: 1.67 [1.34, 2.09]; curable STIs: 1.45 [1.17; 1.79]). Among AGYW only STIs were consistently associated with higher incidence, but studies were limited (n=3). Community-level HIV prevalence or unsuppressed viral load strongly predicted incidence but were only considered in three of 11 multi-site studies. The AUC-ROC ranged from 0.56 to 0.79 on the model development sets. Only the VOICE score was externally validated by multiple studies, with pooled AUC-ROC 0.626 [0.588, 0.663] (I2: 64.0
Nguyen VK, Eaton JW, 2021, A model for reconstructing trends and distribution in age at first sex from multiple household surveys with reporting biases
<jats:title>Abstract</jats:title><jats:p>Age at first sex (AFS) is a key indicator for monitoring sexual behaviour risk for HIV and sexually transmitted diseases. Reporting of AFS data, however, suffer social-desirability and recall biases which obscure AFS trends and inferences constructed from it. We illustrated examples of the biases using data from multiple nationally-representative Demographic and Health Surveys household surveys conducted between 1992 and 2019 in Ethiopia (4 surveys), Guinea (4 surveys), Senegal (8 surveys), and Zambia (8 surveys). Based on this, we proposed a time-to-event, interval censored model for the AFS that uses overlapping reports by the same birth cohort in successive surveys to adjust reporting biases. The three-parameter log-skew-logistic distribution described the asymmetric and nonmonotonic hazard exhibited by empirical AFS data. In cross-validation analysis, incorporating a term for AFS reporting bias as a function of age improved model predictions for the trend of AFS over birth cohorts. The interquartile range for the AFS was 16 years to 23 years for Ethiopian and Senegalese women and 15 years to 20 years for Guinean and Zambian men. Median AFS increased by around one to 1.5 years between the 1960 and 1989 birth cohorts for all four datasets. Younger male respondents tended to report a younger AFS while female respondents tended to report an older AFS than when asked in later surveys. Above age 30, both male and female respondents tended to report older AFS compared to when surveyed in their late twenties. Simulations validated that the model recovers the trend in AFS over birth cohorts in the presence of reporting biases. At least three surveys are needed to obtain reliable trend estimate for a 20-years trend. Mis-specified reference age at which reporting is assumed unbiased did not affect the trend estimate but resulted in biased estimates for the median AFS in the most recent birth cohorts.</jats:p>
Edun O, Shenderovich Y, Zhou S, et al., 2021, Predictors and consequences of HIV status disclosure to adolescents living with HIV in Eastern Cape, South Africa
<jats:title>Abstract</jats:title><jats:sec><jats:title>Introduction</jats:title><jats:p>The World Health Organization recommends full disclosure of HIV-positive status to adolescents who acquired HIV perinatally (APHIV) by age 12. However, even among adolescents (aged 10-19) already on antiretroviral therapy (ART), disclosure rates are low. Caregivers often report the child being too young and fear of disclosure worsening adolescents’ mental health as reasons for non-disclosure. Evidence is limited about predictors of disclosure and its association with adherence, viral suppression, and mental health outcomes among adolescents in sub-Saharan Africa.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Analyses included three rounds (2014-2018) of data collected among a closed cohort of adolescents living with HIV in Eastern Cape, South Africa. We used logistic regression with respondent random-effects to identify factors associated with disclosure, and assess differences in ART adherence, viral suppression, and mental health symptoms between adolescents by disclosure status. We also explored differences in the change in mental health symptoms and ART adherence between study rounds and disclosure groups with logistic regression.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>813 APHIV were interviewed at baseline, of whom 769 (94.6%) and 729 (89.7%) were interviewed at the second and third rounds, respectively. The proportion aware of their HIV-positive status increased from 63.1% at the first round to 85.5% by the third round. Older age (adjusted odds ratio (aOR): 1.24; 1.07 – 1.43) and living in an urban location (aOR: 2.76; 1.67 – 4.45) were associated with disclosure between interviews. There was no association between awareness of HIV-positive status and ART adherence, viral suppression, or mental hea
Stapley J, Davis K, Dadirai T, et al., 2021, Impact of community-level ART coverage on HIV-related stigmatising attitude within a general population cohort in Manicaland, east Zimbabwe; a longitudinal study, 12th Annual International Conference on Stigma
Tlhajoane M, Dzamatira F, Kadzura N, et al., 2021, Incidence and predictors of attrition among patients receiving ART in eastern Zimbabwe before, and after the introduction of universal ‘treat-all’ policies: A competing risk analysis, PLOS Global Public Health, Vol: 1, Pages: 1-15
As HIV treatment is expanded, attention is focused on minimizing attrition from care. We evaluated the impact of treat-all policies on the incidence and determinants of attrition amongst clients receiving ART in eastern Zimbabwe. Data were retrospectively collected from the medical records of adult patients (aged≥18 years) enrolled into care from July 2015 to June 2016—pre-treat-all era, and July 2016 to June 2017—treat-all era, selected from 12 purposively sampled health facilities. Attrition was defined as an absence from care >90 days following ART initiation. Survival-time methods were used to derive incidence rates (IRs), and competing risk regression used in bivariate and multivariable modelling. In total, 829 patients had newly initiated ART and were included in the analysis (pre-treat-all 30.6%; treat-all 69.4%). Incidence of attrition (per 1000 person-days) increased between the two time periods (pre-treat-all IR = 1.18 (95%CI: 0.90–1.56) versus treat-all period IR = 1.62 (95%CI: 1.37–1.91)). In crude analysis, patients at increased risk of attrition were those enrolled into care during the treat-all period, <34 years of age, WHO stage I at enrolment, and had initiated ART on the same day as HIV diagnosis. After accounting for mediating clinical characteristics, the difference in attrition between the pre-treat-all, and treat-all periods ceased to be statistically significant. In a full multivariable model, attrition was significantly higher amongst same-day ART initiates (aSHR = 1.47, 95%CI:1.05–2.06). Implementation of treat-all policies was associated with an increased incidence of ART attrition, driven largely by ART initiation on the same day as HIV diagnosis which increased significantly in the treat all period. Differentiated adherence counselling for patients at increased risk of attrition, and improved access to clinical monitoring may improve retention in care.
Jahagirdar D, Walters MK, Novotney A, et al., 2021, Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990–2019, for 204 countries and territories: the Global Burden of Diseases Study 2019, The Lancet HIV, Vol: 8, Pages: e633-e651, ISSN: 2352-3018
BackgroundThe sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic.MethodsTo estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0).FindingsIn 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stabl
Jia KM, Eilerts H, Edun O, et al., 2021, Risk scores for predicting HIV incidence among adult heterosexual populations in sub-Saharan Africa: a systematic review and meta-analysis
<jats:title>Abstract</jats:title><jats:sec><jats:title>Introduction</jats:title><jats:p>Several HIV risk scores have been developed to identify individuals for prioritised HIV prevention in sub-Saharan Africa. We systematically reviewed HIV risk scores to: (i) identify factors that consistently predicted incident HIV infection, (ii) review inclusion of community-level HIV risk in predictive models, and (iii) examine predictive performance.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We searched nine databases from inception until February 15, 2021 for studies developing and/or validating HIV risk scores among the heterosexual adult population in sub-Saharan Africa. Studies not prospectively observing seroconversion or recruiting only key populations were excluded. Record screening, data extraction, and critical appraisal were conducted in duplicate. We used random-effects meta-analysis to summarise hazard ratios and the area under the receiver-operating characteristic curve (AUC-ROC).</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>From 1563 initial search records, we identified 14 risk scores in 13 studies. Seven studies were among sexually active women using contraceptives enrolled in randomised-controlled trials, three among adolescent girls and young women (AGYW), and three among cohorts enrolling both men and women. Consistently identified HIV prognostic factors among women were younger age (pooled adjusted hazard ratio: 1.62 [95% Confidence Interval: 1.17, 2.23], compared to above-25), single/not cohabiting with primary partners (2.33 [1.73, 3.13]) and having sexually transmitted infections (STIs) at baseline (HSV-2: 1.67 [1.34, 2.09]; curable STIs: 1.45 [1.17; 1.79]). Among AGYW only STIs were consistently associated with higher incidence, but studies were limited (n=3). Community-level HIV prevalence or uns
Eaton J, Dwyer-Lindgren L, Gutreuter S, et al., 2021, Naomi: a new modelling tool for estimating HIV epidemic indicators at the district level in Sub-Saharan Africa, Journal of the International AIDS Society, Vol: 24, Pages: 1-13, ISSN: 1758-2652
Introduction: HIV planning requires granular estimates for the number of people living withHIV (PLHIV), antiretroviral treatment (ART) coverage and unmet need, and new HIVinfections by district, or equivalent subnational administrative level. We developed aBayesian small-area estimation model, called Naomi, to estimate these quantities stratifiedby subnational administrative units, sex, and five-year age groups.Methods: Small-area regressions for HIV prevalence, ART coverage, and HIV incidencewere jointly calibrated using subnational household survey data on all three indicators,routine antenatal service delivery data on HIV prevalence and ART coverage amongpregnant women, and service delivery data on the number of PLHIV receiving ART.Incidence was modelled by district-level HIV prevalence and ART coverage. Model outputsof counts and rates for each indicator were aggregated to multiple geographic anddemographic stratifications of interest. The model was estimated in an empirical Bayesframework, furnishing probabilistic uncertainty ranges for all output indicators. Exampleresults were presented using data from Malawi during 2016 to 2018.Results: Adult HIV prevalence in September 2018 ranged from 3.2% to 17.1% acrossMalawi’s districts and was higher in southern districts and in metropolitan areas. ARTcoverage was more homogenous, ranging from 75% to 82%. The largest number of PLHIVwere among ages 35-39 for both women and men, while the most untreated PLHIV wereamong ages 25-29 for women and 30-34 for men. Relative uncertainty was larger for theuntreated PLHIV than the number on ART or total PLHIV. Among clients receiving ART atfacilities in Lilongwe City, an estimated 71% (95% CI 61–79%) resided in Lilongwe City, 20%(14–27%) in Lilongwe district outside the metropolis, and 9% (6–12%) in neighbouring Dowadistrict. Thirty-eight percent (26–50%) of Lilongwe Rural residents and 39% (27–50%) ofDowa residents received treatment at facilit
Mahiane SG, Eaton J, Glaubius R, et al., 2021, Updates to Spectrum’s Case Surveillance and Vital Registration tool for HIV estimates and projections, Journal of the International AIDS Society, Vol: 24, Pages: 1-9, ISSN: 1758-2652
Introduction: The Case Surveillance and Vital Registration (CSAVR) model within Spectrum estimates HIV incidence trends from surveillance data on numbers of new HIV diagnoses and HIV-related deaths. This article describes developments of the CSAVR tool to more flexibly model diagnosis rates over time, estimate incidence patterns by sex and age group, and by key population group. Methods: We modelled HIV diagnosis rate trends as a mixture of three factors, including temporal and opportunistic infection components. The tool was expanded to estimate incidence rate ratios by sex and age for countries with disaggregated reporting of new HIV diagnoses and AIDS deaths, and to account for information on key populations such as men who have sex with men (MSM), males who inject drugs (MWID), female sex workers (FSW) and females who inject drugs (FWID). We used a Bayesian framework to calibrate the tool in 71 high-income or low HIV burden countries. Results: Across countries, an estimated median 89% (interquartile range [IQR] 78%-96%) of HIV-positive adults knew their status in 2019. Mean CD4 counts at diagnosis were stable over time, with a median of 456 cells/μl (IQR: 391-508) across countries in 2019. In European countries reporting new HIV diagnoses among key populations median estimated proportions of males that are MSM and MWID was 1.3% (IQR: 0.9%- 2.0%) and 0.56% (IQR: 0.51%- 0.64%), respectively. The median estimated proportions of females that are FSW and FWID were 0.36% (IQR: 0.27%-0.45%) and 0.14 (IQR: 0.13%- 0.15%), respectively. HIV incidence per 100 person-year increased among MSM with median estimates reaching 0.43 (IQR: 0.29-1.73) in 2019, but remained stable in MWID, FSW and FWID, at around 0.12 (IQR: 0.04-1.9), 0.09 (IQR: 0.06-0.69) and 0.13% (IQR: 0.08%-0.91%) in 2019, respectively. Knowledge of HIV status among HIV-positive adults gradually increased since the early 1990s to exceed 75% in more than 75% of countries in 2019 among each key population. Con
Glaubius R, Kothegal N, Birhanu S, et al., 2021, Disease progression and mortality with untreated HIV infection: evidence synthesis of HIV seroconverter cohorts, antiretroviral treatment clinical cohorts, and population-based survey data, Journal of the International AIDS Society, Vol: 24, Pages: 1-11, ISSN: 1758-2652
Background: Model-based estimates of key HIV indicators depend on past epidemic trends that arederived based on assumptions about HIV disease progression and mortality in the absence ofantiretroviral treatment (ART). Population-based HIV Impact Assessment (PHIA) household surveysconducted between 2015 and 2018 found substantial numbers of respondents living with untreated HIVinfection. CD4 cell counts measured in these individuals provide novel information to estimate HIVdisease progression and mortality rates off ART.Methods: We used Bayesian multi-parameter evidence synthesis to combine data on i) cross-sectionalCD4 cell counts among untreated adults living with HIV from ten PHIA surveys, ii) survival after HIVseroconversion in East African seroconverter cohorts, and iii) post-seroconversion CD4 counts and iv)mortality rates by CD4 count predominantly from European, North American, and Australianseroconverter cohorts. We used Incremental Mixture Importance Sampling to estimate HIV naturalhistory and ART uptake parameters used in the Spectrum software. We validated modeled trends in CD4count at ART initiation against ART initiator cohorts in sub-Saharan Africa.Results: Median untreated HIV survival decreased with increasing age at seroconversion, from 12.5years (95% credible interval [CrI]: 12.1-12.7) at ages 15-24 to 7.2 years (95% CrI: 7.1-7.7) at ages 45-54.Older age was associated with lower initial CD4 counts, faster CD4 count decline and higher HIV-relatedmortality rates. Our estimates suggested a weaker association between ART uptake and HIV-relatedmortality rates than previously assumed in Spectrum. Modeled CD4 counts in untreated people livingwith HIV matched recent household survey data well, though some intercountry variation in frequenciesof CD4 counts above 500 cells/mm3 was not explained. Trends in CD4 counts at ART initiation werecomparable to data from ART initiator cohorts. An alternate model that stratified progression andmortality rates by sex di
Godin A, Eaton J, Giguere K, et al., 2021, Inferring population HIV incidence trends from surveillance data of recent HIV infection among HIV testing clients, AIDS, Vol: 35, Pages: 2383-2388, ISSN: 0269-9370
Background: Measuring recent HIV infections from routine surveillance systems could allow timely and granular monitoring of HIV incidence patterns. We evaluated the relationship of two recent infection indicators with alternative denominators to true incidence patterns.Methods: We used a mathematical model of HIV testing behaviors, calibrated to population-based surveys and HIV testing services program data, to estimate the number of recent infections diagnosed annually from 2010 to 2019 in Côte d’Ivoire, Malawi, and Mozambique. We compared two different denominators to interpret recency data: i) those at risk of HIV acquisition (HIV-negative tests plus recent infections) and ii) all people testing HIV positive. Sex- and age-specific longitudinal trends in both interpretations were then compared to modeled trends in HIV incidence, testing efforts, and HIV positivity among HIV testing services clients.Results: Over 2010–2019, the annual proportion of the eligible population tested increased in all countries, while positivity decreased. The proportion of recent infections among those at risk of HIV acquisition decreased, similar to declines in HIV incidence among adults (≥15 years old). Conversely, the proportion of recent infections among HIV-positive tests increased. The female-to-male ratio of the proportion testing recent among those at risk was closer to 1 than the true incidence sex ratio.Conclusion: The proportion of recent infections among those at risk of HIV acquisition is more indicative of HIV incidence than the proportion among HIV-positive tests. However, interpreting the observed patterns as surrogate measures for incidence patterns may still be confounded by different HIV testing rates between population groups or over time.
Risher K, Cori A, Reniers G, et al., 2021, Age patterns of HIV incidence in eastern and southern Africa: a collaborative analysis of observational general population cohort studies, The Lancet HIV, Vol: 8, Pages: e429-e439, ISSN: 2405-4704
Background: As the HIV epidemic in sub-Saharan Africa matures, evidence about the age distribution of new HIV infections and how this has changed over the epidemic is needed to guide HIV prevention. We assessed trends in age-specific HIV incidence in six population-based cohort studies in eastern and southern Africa, reporting changes in average age at infection, age distribution of new infections, and birth cohort cumulative incidence. Methods: We used a Bayesian model to reconstruct age-specific HIV incidence from repeated observations of individuals’ HIV serostatus and survival collected among population HIV cohorts in rural Malawi, South Africa, Tanzania, Uganda, and Zimbabwe. The HIV incidence rate by age, time and sex was modelled using smooth splines functions. Incidence trends were estimated separately by sex and study. Estimated incidence and prevalence results for 2000-2017, standardised to study population distribution, were used to estimate average age at infection and proportion of new infections by age. Findings: Age-specific incidence declined at all ages, though the timing and pattern of decline varied by study. The average age at infection was higher in men (cohort means: 27·8-34·6 years) than women (cohort means: 24·8-29·6 years). Between 2000 and 2017, the average age at infection increased slightly: cohort means 0·5-2·8 years among men and -0·2-2·5 years among women. Across studies, between 38-63%(cohort means)of women’s infections were among 15-24-year-olds and between 30-63% of men’s infections were in 20-29-year-olds. Lifetime risk of HIV declined for successive birth cohorts. Interpretation: HIV incidence declined in all age groups and shifted slightly, but not dramatically, to older ages. Disproportionate new HIV infections occur among 15-24-year-old 4women and20-29-year-oldmen, supporting focused prevention in these groups. But 40-60% of infections were outside these
Wolock T, Flaxman S, Risher K, et al., 2021, Evaluating distributional regression strategies for modelling self-reported sexual age-mixing, eLife, Vol: 10, Pages: 1-38, ISSN: 2050-084X
The age dynamics of sexual partnership formation determine patterns of sexually transmitted disease transmission and have long been a focus of researchers studying human immunodeficiency virus. Data on self-reported sexual partner age distributions are available from a variety of sources. We sought to explore statistical models that accurately predict the distribution of sexual partner ages over age and sex. We identified which probability distributions and outcome specifications best captured variation in partner age and quantified the benefits of modelling these data using distributional regression. We found that distributional regression with a sinh-arcsinh distribution replicated observed partner age distributions most accurately across three geographically diverse data sets. This framework can be extended with well-known hierarchical modelling tools and can help improve estimates of sexual age-mixing dynamics.
Sartorius B, VanderHeide JD, Yang M, et al., 2021, Subnational mapping of HIV incidence and mortality among individuals aged 15–49 years in sub-Saharan Africa, 2000–18: a modelling study, The Lancet HIV, Vol: 8, Pages: e363-e375, ISSN: 2352-3018
BackgroundHigh-resolution estimates of HIV burden across space and time provide an important tool for tracking and monitoring the progress of prevention and control efforts and assist with improving the precision and efficiency of targeting efforts. We aimed to assess HIV incidence and HIV mortality for all second-level administrative units across sub-Saharan Africa.MethodsIn this modelling study, we developed a framework that used the geographically specific HIV prevalence data collected in seroprevalence surveys and antenatal care clinics to train a model that estimates HIV incidence and mortality among individuals aged 15–49 years. We used a model-based geostatistical framework to estimate HIV prevalence at the second administrative level in 44 countries in sub-Saharan Africa for 2000–18 and sought data on the number of individuals on antiretroviral therapy (ART) by second-level administrative unit. We then modified the Estimation and Projection Package (EPP) to use these HIV prevalence and treatment estimates to estimate HIV incidence and mortality by second-level administrative unit.FindingsThe estimates suggest substantial variation in HIV incidence and mortality rates both between and within countries in sub-Saharan Africa, with 15 countries having a ten-times or greater difference in estimated HIV incidence between the second-level administrative units with the lowest and highest estimated incidence levels. Across all 44 countries in 2018, HIV incidence ranged from 2·8 (95% uncertainty interval 2·1–3·8) in Mauritania to 1585·9 (1369·4–1824·8) cases per 100 000 people in Lesotho and HIV mortality ranged from 0·8 (0·7–0·9) in Mauritania to 676·5 (513·6–888·0) deaths per 100 000 people in Lesotho. Variation in both incidence and mortality was substantially greater at the subnational level than at the national level and the highest estimated ra
Ehrenkranz P, Rosen S, Boulle A, et al., 2021, The revolving door of HIV care: revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals, PLoS Medicine, Vol: 18, Pages: 1-10, ISSN: 1548-7091
Giguere K, Eaton J, Marsh K, et al., 2021, Trends in knowledge of HIV status and efficiency of HIV testing services in sub-Saharan Africa, 2000-20: a modelling study using survey and HIV testing programme data, The Lancet HIV, Vol: 8, Pages: 284-293, ISSN: 2405-4704
Background: Monitoring knowledge of HIV status (KOS) among people living with HIV (PLHIV) is essential for an effective national HIV response. This study estimates progress and gaps in reaching the UNAIDS 2020 target of 90% KOS, and the efficiency of HIV testing services (HTS) in sub-Saharan Africa (SSA), where two thirds of all PLHIV live. Methods: We used data from 183 population-based surveys (N=2·7 million participants) and national HTS programs (N=315 country-years) from 40 countries as inputs into a mathematical model to examine trends in KOS among PLHIV, median time from HIV infection to diagnosis, HIV testing positivity, and proportion of new diagnoses among all positive tests, adjusting for retesting.Findings: Across SSA, KOS steadily increased from 6% (95% credible interval [95%CrI]: 5% to 7%) in 2000 to 84% (95%CrI: 82% to 86%) in 2020. Twelve countries and one region, Southern Africa, reached the 90% target. In 2020, KOS was lower among men (79%) than women (87%) across SSA. PLHIV aged 15-24 years were the least likely to know their status (65%), but the largest gap in terms of absolute numbers was among men aged 35-49 years, with over 700,000 left undiagnosed. As KOS increased from 2000 to 2020, the median time to diagnosis decreased from 10 to 3 years, HIV testing positivity declined from 9% to 3%, and the proportion of first-time diagnoses among all positive tests dropped from 89% to 42%.Interpretation: On the path towards the next UNAIDS target of 95% diagnostic coverage by 2030, and in a context of declining positivity and yield of first-time diagnoses, we need to focus on addressing disparities in KOS. Increasing KOS and treatment coverage among older men could be critical to reduce HIV incidence among women in SSA, and by extension, reducing mother-to-child transmission.
Eaton JW, Sands A, Barr-DiChiara M, et al., 2021, Accuracy and performance of the WHO 2015 and WHO 2019 HIV testing strategies across epidemic settings
<jats:title>Abstract</jats:title><jats:sec><jats:title>Background</jats:title><jats:p>WHO 2019 HIV testing guidelines recommended a standard HIV testing strategy consisting of three consecutively HIV-reactive test results on serology assays to diagnose HIV infection. National HIV programmes in high prevalence settings currently using the strategy consisting of only two consecutive HIV-reactive tests should consider when to implement the new guideline recommendations.</jats:p></jats:sec><jats:sec><jats:title>Methods and Findings</jats:title><jats:p>We implemented a probability model to simulate outcomes of WHO 2019 and the two strategies recommended by WHO 2015 guidelines on HIV testing services. Each assay in the strategy was assumed independently 99% sensitivity and 98% specificity, the minimal thresholds required for WHO prequalification. For each strategy and positivity ranging 20% to 0.2%, we calculated the number of false-negative, false-positive, and inconclusive results; positive and negative predictive value (PPV, NPV); number of each assay used, and testing programme costs. We found that the NPV was above 99.9% for all scenarios modelled. Under the WHO 2015 two-test strategy, the PPV was below the 99% target threshold when positivity fell below 5%. For the WHO 2019 strategy, the PPV was above 99% for all positivity levels. The number reported ‘inconclusive’ was higher under the WHO 2019 strategy. Implementing the WHO 2019 testing strategy in Malawi, would require around 89,000 A3 tests in 2021, compared to 175,000 A2 tests and over 4.5 million A1 tests per year. The incremental cost of the WHO 2019 strategy was less than 2% in 2021 and declined to 0.9% in 2025.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>As positivity among persons testing for HIV reduces below 5% in nearly all settings, implementation of the W
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