Risk Factors for Recent HIV Infections among Adults in 14 Countries in Africa Identified by Population-Based HIV Impact Assessment Surveys, 2015-2019.

Identifying persons who have newly acquired HIV infections is critical for characterizing the HIV epidemic direction. We analyzed pooled data from nationally representative Population-Based HIV Impact Assessment surveys conducted across 14 countries in Africa for recent infection risk factors. We included adults 15-49 years of age who had sex during the previous year and used a recent infection testing algorithm to distinguish recent from long-term infections. We collected risk factor information via participant interviews and assessed correlates of recent infection using multinomial logistic regression, incorporating each survey's complex sampling design. Compared with HIV-negative persons, persons with higher odds of recent HIV infection were women, were divorced/separated/widowed, had multiple recent sex partners, had a recent HIV-positive sex partner or one with unknown status, and lived in communities with higher HIV viremia prevalence. Prevention programs focusing on persons at higher risk for HIV and their sexual partners will contribute to reducing HIV incidence.

HIV Outcomes Among Women Living With HIV Who Experienced Early Sexual Violence Across Four Sub-Saharan African Countries.

BACKGROUND: Early experiences of sexual violence may influence HIV care and treatment outcomes among women living with HIV (WLHIV). We examined whether self-report by WLHIV of being forced into their first sexual experience was associated with awareness of HIV-positive status, being on antiretroviral therapy (ART) and being virologically suppressed. SETTING: We conducted a secondary analysis using nationally representative, cross-sectional Population-based HIV Impact Assessment surveys from Lesotho, Malawi, Zambia, and Zimbabwe conducted from 2015 through 2017. METHODS: Adjusted logistic regression models with survey weights and Taylor series linearization were used to measure the association between forced first sex and 3 HIV outcomes: (1) knowledge of HIV status among all WLHIV, (2) being on ART among WLHIV with known status, and (3) virological suppression among WLHIV on ART. RESULTS: Among WLHIV, 13.9% reported forced first sex. Odds of knowledge of HIV status were not different for WLHIV with forced first sex compared with those without (adjusted odds ratio [aOR], 1.17; 95% CI: 0.95 to 1.45). Women living with HIV with forced first sex had significantly lower odds of being on ART (aOR 0.74, 95% CI: 0.57 to 0.96) but did not have lower odds of virological suppression (aOR 1.06, 95% CI: 0.80 to 1.42) compared with WLHIV without forced first sex. CONCLUSIONS: While high proportions of WLHIV were on ART, report of nonconsensual first sex was associated with a lower likelihood of being on ART which may suggest that early life trauma could influence long-term health outcomes.

Patterns of gendered risk factors and associations with intimate partner violence and low educational attainment among adolescent girls and young women in Lesotho: A latent class analysis.

BACKGROUND: Globally, adolescent girls and young women (AGYW) are disproportionately impacted by economic, demographic, and social factors associated with a wide range of negative outcomes. OBJECTIVE: The objective of this study was to use latent class analysis (LCA) to identify groupings of AGYW in Lesotho based on patterns of gendered risk factors, and to assess the association between the identified groupings and intimate partner violence (IPV) and low educational attainment. PARTICIPANTS AND SETTING: Data were from the 2018 Lesotho Violence Against Children and Youth Survey. AGYW reported gendered risk factors: teen pregnancy, child marriage, intergenerational sex, early sexual debut, being HIV positive, transactional sex, endorsement of one or more negative traditional gender norms, and one or more norms supportive of violence against women. METHODS: LCA identified latent classes of eight gendered risk factors. Multivariable logistic regression assessed associations between latent classes and IPV victimization and low educational attainment. RESULTS: A three-class solution was selected, and classes were named as: Low Risk class, Behavioral Risk class, and Attitudinal Risk class. Odds of low educational attainment and IPV were higher in the Attitudinal Risk class than the Low Risk class. Odds of low educational attainment and IPV were higher in the Behavioral Risk class than the Low Risk class and the Attitudinal Risk class. CONCLUSIONS: In Lesotho, gendered risk factors form distinct classes that have variable associations with low educational attainment and IPV. LCA can be an important approach to better understand the complicated relationship gendered risk factors have with each other and with certain outcomes, to further elucidate the influence that gender has on the health of AGYW and to provide more targeted prevention programming.

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

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

Progress towards the UNAIDS 90-90-90 targets among persons aged 50 and older living with HIV in 13 African countries.

INTRODUCTION: Achieving optimal HIV outcomes, as measured by global 90-90-90 targets, that is awareness of HIV-positive status, receipt of antiretroviral (ARV) therapy among aware and viral load (VL) suppression among those on ARVs, respectively, is critical. However, few data from sub-Saharan Africa (SSA) are available on older people (50+) living with HIV (OPLWH). We examined 90-90-90 progress by age, 15-49 (as a comparison) and 50+ years, with further analyses among 50+ (55-59, 60-64, 65+ vs. 50-54), in 13 countries (Cameroon, Cote d'Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe). METHODS: Using data from nationally representative Population-based HIV Impact Assessments, conducted between 2015and 2019, participants from randomly selected households provided demographic and clinical information and whole blood specimens for HIV serology, VL and ARV testing. Survey weighted outcomes were estimated for 90-90-90 targets. Country-specific Poisson regression models examined 90-90-90 variation among OPLWH age strata. RESULTS: Analyses included 24,826 HIV-positive individuals (15-49 years: 20,170; 50+ years: 4656). The first, second and third 90 outcomes were achieved in 1, 10 and 5 countries, respectively, by those aged 15-49, while OPLWH achieved outcomes in 3, 13 and 12 countries, respectively. Among those aged 15-49, women were more likely to achieve 90-90-90 targets than men; however, among OPLWH, men were more likely to achieve first and third 90 targets than women, with second 90 achievement being equivalent. Country-specific 90-90-90 regression models among OPLWH demonstrated minimal variation by age stratum across 13 countries. Among OLPWH, no first 90 target differences were noted by age strata; three countries varied in the second 90 by older age strata but not in a consistent direction; one country showed higher achievement of the third 90 in an older age stratum. CONCLUSIONS: While OPLWH in these 13 countries were slightly more likely than younger people to be aware of their HIV-positive status (first 90), this target was not achieved in most countries. However, OPLWH achieved treatment (second 90) and VL suppression (third 90) targets in more countries than PLWH <50. Findings support expanded HIV testing, prevention and treatment services to meet ongoing OPLWH health needs in SSA.

Innovations in Rwanda's health system: looking to the future.

Rwanda is making substantial progress towards improvement of health and is working towards achievement of the Millennium Development Goals, which is a challenging task because the country has had genocide in 1994, has few natural resources, is landlocked, and has high population growth. Like many impoverished sub-Saharan countries, Rwanda's health system has had an uncoordinated plethora of donors, shortage of health staff, inequity of access, and poor quality of care in health facilities. This report describes three health system developments introduced by the Rwandan government that are improving these barriers to care-ie, the coordination of donors and external aid with government policy, and monitoring the effectiveness of aid; a country-wide independent community health insurance scheme; and the introduction of a performance-based pay initiative. If these innovations are successful, they might be of interest to other sub-Saharan countries. However, Rwanda still does not have sufficient financial resources for health and will need additional external aid for some time to attain the Millennium Development Goals.

Persons living with HIV with advanced HIV disease: need for novel care models.

INTRODUCTION: Despite increasing focus on test and treat strategies for people living with HIV (PLHIV), many continue to enrol late in care and initiate antiretroviral therapy (ART) when they have advanced HIV disease. METHODS: We analyzed PLHIV ≥15 years of age starting ART in Ethiopia, Kenya, Mozambique and Tanzania from 2005 to 2015 based on CD4+ groups at ART initiation (≥200, 100 to 199, 50 to 99 and <50 cells/mm3 ) to examine attrition (loss to follow-up (LTF) and death) using Kaplan-Meier estimators and Cox proportional hazards models. LTF was defined as no clinic visit >6 months; deaths were ascertained from medical records. RESULTS AND DISCUSSION: A total of 305,443 PLHIV were included in the analysis: 118,580 (38.8%) CD4+ ≥200, 91,788 (30.1%) CD4+ 100 to 199, 44,029 (14.4%) CD4+ 50 to 99 and 51,046 (16.7%) CD4+ <50 cells/mm3 . At 12 months after ART initiation, attrition for those with CD4+ ≥200, 100 to 199, 50 to 99 and <50 cells/mm3 was 21.3% (95% CI 21.1 to 21.6), 21.8% (95% CI 21.6 to 22.1), 27.3% (95% CI 26.9 to 27.7) and 33.6% (95% CI 33.2 to 34.0) respectively. In multivariable models, compared to PLHIV with CD4+ ≥200 cells/mm3 , those with CD4+ 50 to 99 cells/mm3 had 29% increased risk of attrition (adjusted hazard ratio (AHR) 1.29, 95% CI 1.27 to 1.32) and those with <50 cells/mm3 had 56% increased risk of attrition (AHR 1.56, 95% CI 1.53 to 1.58). Men had higher attrition compared to women across all CD4+ groups and overall were 28% more likely to experience attrition (AHR 1.28, 95% CI 1.26 to 1.29). Even after ART initiation, PLHIV with advanced disease had notably inferior outcomes with substantial gradient within the low CD4+ strata highlighting the need for targeted interventions for these populations. CONCLUSIONS: Greater efforts, including the identification of effective differentiated service delivery models, are needed to ensure that all PLHIV starting treatment can garner the benefits from ART and achieve favourable outcomes.

Implementation and Operational Research: Evolution of Couples' Voluntary Counseling and Testing for HIV in Rwanda: From Research to Public Health Practice.

BACKGROUND: Couples' voluntary HIV counseling and testing (CVCT) is a WHO-recommended intervention for prevention of heterosexual HIV transmission which very few African couples have received. We report the successful nationwide implementation of CVCT in Rwanda. METHODS: From 1988 to 1994 in Rwanda, pregnant and postpartum women were tested for HIV and requested testing for their husbands. Partner testing was associated with more condom use and lower HIV and sexually transmitted infection rates, particularly among HIV-discordant couples. After the 1994 genocide, the research team continued to refine CVCT procedures in Zambia. These were reintroduced to Rwanda in 2001 and continually tested and improved. In 2003, the Government of Rwanda (GoR) established targets for partner testing among pregnant women, with the proportion rising from 16% in 2003 to 84% in 2008 as the prevention of mother-to-child transmission program expanded to >400 clinics. In 2009, the GoR adopted joint posttest counseling procedures, and in 2010 a quarterly follow-up program for discordant couples was established in government clinics with training and technical assistance. An estimated 80%-90% of Rwandan couples have now been jointly counseled and tested resulting in prevention of >70% of new HIV infections. CONCLUSIONS: Rwanda is the first African country to have established CVCT as standard of care in antenatal care. More than 20 countries have sent providers to Rwanda for CVCT training. To duplicate Rwanda's success, training and technical assistance must be part of a coordinated effort to set national targets, timelines, indicators, and budgets. Governments, bilateral, and multilateral funding agencies must jointly prioritize CVCT for prevention of new HIV infections.

Determinants of nonadherence to a single-dose nevirapine regimen for the prevention of mother-to-child HIV transmission in Rwanda.

OBJECTIVES: To describe experiences, and identify factors associated with nonadherence to a single-dose nevirapine (SD-NVP) regimen for the prevention of mother-to-child transmission (PMTCT) of HIV in Rwanda. METHODS: In April to May 2006, using a case-control design at 12 PMTCT sites, we interviewed HIV-infected women who did not adhere (n = 111) and who adhered (n = 125) to the PMTCT prophylaxis regimen. Nonadherence was defined as mother and/or infant not ingesting SD-NVP at the recommended time or not at all and adherence as mother-infant pairs who ingested it as recommended. RESULTS: Only 61% of nonadherent women had received SD-NVP during pregnancy or delivery. Among nonadherent women who received SD-NVP, 80% ingested it at the recommended time, representing 49% of all nonadherent women. Only 7% of their newborns ingested SD-NVP. Multivariate logistic regression showed that unmarried women, less educated women, women who made 2 or less antenatal care visits, and those offered HIV testing after their first antenatal care visit were more likely to be nonadherent to PMTCT prophylaxis. Not disclosing one's HIV status to someone aside from a partner was also associated with nonadherence in mother-infant pairs. CONCLUSIONS: Sociodemographic factors, health services delivery factors, and a lack of communication and social support contributed to nonadherence to PMTCT prophylaxis in Rwanda.

Pregnancy desires, and contraceptive knowledge and use among prevention of mother-to-child transmission clients in Rwanda.

OBJECTIVE: To understand pregnancy intentions and contraception knowledge and use among HIV-positive and negative women in the national prevention of mother-to-child transmission (PMTCT) program in Rwanda. DESIGN: A cross-sectional survey of 236 HIV-positive and 162 HIV-negative postpartum women interviewed within 12 months of their expected delivery date in 12 randomly selected public-sector health facilities providing PMTCT services. METHODS: : Bivariate analyses explored fertility intentions, and family planning knowledge and use by HIV status. Multivariate analysis identified socio-demographic and service delivery-related predictors of reporting a desire for additional children and modern family planning use. RESULTS: HIV-positive women were less likely to report wanting additional children than HIV-negative women (8 vs. 49%, P < 0.001), and although a majority of women reported discussing family planning with a health worker during their last pregnancy (HIV-positive 79% vs. HIV-negative 69%, P = 0.057), modern family planning use remained low in both groups (HIV-positive 43% vs. HIV-negative 12%, P < 0.001). Condoms were the most commonly used method among HIV-positive women (31%), whereas withdrawal was most frequently reported among HIV-negative women (19%). In multivariate analysis, HIV-negative women were 16 times more likely to report wanting additional children and nearly 85% less likely to use modern family planning. Women who reported making two or less antenatal care visits were 77% less likely to use modern family planning. CONCLUSION: Our results highlight success in provision of family planning counseling in PMTCT services in Rwanda. As family planning use was low among HIV-positive and negative women, further efforts are needed to improve uptake of modern methods, including dual protection, in Rwandan PMTCT settings.

Adult clinical and immunologic outcomes of the national antiretroviral treatment program in Rwanda during 2004-2005.

BACKGROUND: By December 2007, over 48,000 persons had initiated antiretroviral treatment (ART) at 171 clinics in Rwanda. Assessing national ART program outcomes is essential to determine whether programs have the desired impact. METHODS: We conducted a retrospective cohort study to assess key 6- and 12-month outcomes among a nationally representative, stratified, random sample of 3194 adults (> or =15 years) who initiated ART from January 1, 2004, through December 31, 2005. FINDINGS: At ART initiation, the median patient age was 37 years and 65% were female. Overall, the baseline median CD4 cell count was 141 cells per microliter. At 6 and 12 months after ART initiation, 92% and 86% of patients, respectively, remained on ART at their original site. By 6 months, 3.6% were dead and 3.4% were lost to follow-up; by 12 months, 4.6% were dead and 4.9% were lost to follow-up. Among patients with available follow-up CD4 cell count data, median CD4 cell counts increased by 98 cells per microliter and 119 cells per microliter at 6 and 12 months after ART initiation, respectively. CONCLUSIONS: Rwanda's national ART program achieved excellent 6- and 12-month retention and immunologic outcomes during the first 2 years of rapid scale-up. Routine supervision is required to improve compliance with clinical guidelines and data quality.