Evidence of sociodemographic heterogeneity across the HIV treatment cascade and progress towards 90‐90‐90 in sub‐Saharan Africa – a systematic review and meta‐analysis

Abstract

Introduction Heterogeneity of sociodemographics and risk behaviours across the HIV treatment cascade could influence the public health impact of universal ART in sub‐Saharan Africa if those not virologically suppressed are more likely to be part of a risk group contributing to onward infections. Sociodemographic and risk heterogeneity across the treatment cascade has not yet been comprehensively described or quantified and we seek to systematically review and synthesize research on this topic among adults in Africa. Methods We conducted a systematic review of peer‐reviewed literature in Embase and MEDLINE databases as well as grey literature sources published in English between 2014 and 2018. We included studies that included people living with HIV (PLHIV) aged ≥15 years, and reported a 90‐90‐90 outcome: awareness of HIV‐positive status, ART use among those diagnosed or viral suppression among those on ART. We summarized measures of association between sociodemographics, within each outcome, and as a composite measure of population‐wide viral suppression. Results and discussion From 3533 screened titles, we extracted data from 92 studies (50 peer‐reviewed, 42 grey sources). Of included studies, 32 reported on awareness, 53 on ART use, 32 on viral suppression and 23 on population‐wide viral suppression. The majority of studies were conducted in South Africa, Uganda, and Malawi and reported data for age and gender. When stratified, PLHIV ages 15 to 24 years had lower median achievement of the treatment cascade (60‐49‐81), as compared to PLHIV ≥25 years (70‐63‐91). Men also had lower median achievement of the treatment cascade (66‐72‐85), compared to women (79‐76‐89). For population‐wide viral suppression, women aged ≥45 years had achieved the 73% target, while the lowest medians were among 15‐ to 24‐year‐old men (37%) and women (49%). Conclusions Considerable heterogeneity exists by age and gender for achieving the HIV 90‐90‐90 treatment goals. These results may inform delivery of HIV testing and treatment in sub‐Saharan Africa, as targeting youth and men could be a strategic way to maximize the population‐level impact of ART.

An Emerging Syndemic of Smoking and Cardiopulmonary Diseases in People Living with HIV in Africa

“…In response to the disproportionately high number of PWH, national programs have been implemented to decrease the infection rate and to increase access to combination antiretroviral therapy (cART). Although these programs have had remarkable success in Africa, the number of people on cART fails to meet the “90–90–90” goal established by UNAIDS to significantly curtail the spread of HIV worldwide [ 13 , 14 , 15 ]. The 90–90–90 goal projects that by 2020 (i) 90% of all people with HIV should know their HIV status, (ii) 90% of all people who know their status should be on cART, and (iii) 90% of all people receiving cART should have achieved viral suppression [ 16 ].…”

“…Moreover, the variability in the data to estimate the incidence rates for PWH in different countries highlights the challenges and failures of characterizing and implementing broad transnational intervention programs to reduce the burden of HIV. Furthermore, tailored programs to address the evolving nature of the HIV epidemic are needed to achieve health equity [ 15 , 17 ].…”

“…South Africa has the largest population of PWH who also smoke; the high prevalence of smoking among PWH contributes to higher rates of COPD among seropositive individuals ( Table 2 ). The greater smoking prevalence among PWH has been linked to higher COPD and hypertension prevalence among PWH compared to uninfected individuals in Uganda and Nigeria, although robust data are presently lacking [ 8 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ].…”

“…Advances in the treatment regimens for HIV have significantly increased the life expectancy for PWH. Widespread testing and diagnosis, with linkage to follow-up healthcare (e.g., cART initiation and retention) via established HIV treatment cascades, have enabled low and undetectable viral loads [ 15 , 55 ]. Undetectable viral loads, in turn, effectively disrupt the transmission of HIV [ 95 , 96 ].…”

Reducing stigma and discrimination: new evidence and its implications

“…The impact of stigma and discrimination continues to be seen in the variable uptake of HIV-testing and access to care and support [10,11]. The heterogeneity in response to universal test and treat initiatives, and the role different types of stigma play in this response, has been seen in many settings [12]. Context matters in the effectiveness of stigma-reduction interventions as men and women, older and younger, respond differently to efforts to address stigma and discrimination [13].…”