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

Abstract

Summary Background Monitoring knowledge of HIV status among people living with HIV is essential for an effective national HIV response. This study estimates progress and gaps in reaching the UNAIDS 2020 target of 90% knowledge of status, and the efficiency of HIV testing services in sub-Saharan Africa, where two thirds of all people living with HIV reside. Methods For this modelling study, we used data from 183 population-based surveys (including more than 2·7 million participants) and national HIV testing programme reports (315 country-years) from 40 countries in sub-Saharan Africa as inputs into a mathematical model to examine trends in knowledge of status among people living with HIV, median time from HIV infection to diagnosis, HIV testing positivity, and proportion of new diagnoses among all positive tests, adjusting for retesting. We included data from 2000 to 2019, and projected results to 2020. Findings Across sub-Saharan Africa, knowledge of status steadily increased from 5·7% (95% credible interval [CrI] 4·6–7·0) in 2000 to 84% (82–86) in 2020. 12 countries and one region, southern Africa, reached the 90% target. In 2020, knowledge of status was lower among men (79%, 95% CrI 76–81) than women (87%, 85–89) across sub-Saharan Africa. People living with HIV aged 15–24 years were the least likely to know their status (65%, 62–69), but the largest gap in terms of absolute numbers was among men aged 35–49 years, with 701 000 (95% CrI 611 000–788 000) remaining undiagnosed. As knowledge of status increased from 2000 to 2020, the median time to diagnosis decreased from 9·6 years (9·1–10) to 2·6 years (1·8–3·5), HIV testing positivity declined from 9·0% (7·7–10) to 2·8% (2·1–3·9), and the proportion of first-time diagnoses among all positive tests dropped from 89% (77–96) to 42% (30–55). Interpretation On the path towards the next UNAIDS target of 95% diagnostic coverage by 2025, and in a context of declining positivity and yield of first-time diagnoses, disparities in knowledge of status must be addressed. Increasing knowledge of status and treatment coverage among older men could be crucial to reducing HIV incidence among women in sub-Saharan Africa, and by extension, reducing mother-to-child transmission. Funding Steinberg Fund for Interdisciplinary Global Health Research (McGill University); Canadian Institutes of Health Research; Bill & Melinda Gates Foundation; Fonds the recherche du Québec—Santé; UNAIDS; UK Medical Research Council; MRC Centre for Global Infectious Disease Analysis; UK Foreign, Commonwealth & Development Office.

The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals

“…The lack of such identifiers has limited many previous attempts to understand PLHIV movements within health systems and obstructed attempts to provide high-quality person-centered care. In an attempt to answer one such question, a recent analysis of household survey and HIV testing program data across sub-Saharan Africa estimated that “58% of positive tests will have been done on previously diagnosed PLHIV in sub-Saharan Africa in 2020” [ 35 ]. If this trend is further validated, efforts to retain and reengage people who have interrupted treatment will become a higher yield activity than population-wide testing to make new HIV diagnoses.…”

Costs and Scale-Up Costs of Integrating HIV Self-Testing Into Civil Society Organisation-Led Programmes for Key Populations in Côte d'Ivoire, Senegal, and Mali

“…UNAIDS has set targets for 95% of people living with HIV to know their status, 95% of known HIV-positive individuals to be on antiretroviral therapy (ART), and 95% of those on ART to have their viral load suppressed by 2030 (5). Despite significant progress on the proportion of individuals who know their HIV status (increase from 4% in 2000 to 67% in 2020), Western Africa remains far below the first 90 UNAIDS target, with disparities observed between Côte d'Ivoire (76%), Senegal (78%), and Mali (48%) in 2020 (6).…”

Has the relationship between wealth and HIV risk in Sub-Saharan Africa changed over time? A temporal, gendered and hierarchical analysis

“…The widespread roll-out of free anti-retroviral therapy across the continent has both improved survival of especially poorer people with HIV who may not have had prior access, as well as lowered HIV incidence by reducing the national viral load, and thus reducing the likelihood of new acquisition among new cohorts of individuals ( Burger et al, 2020 ; UNAIDS, 2013 ). Additionally, over the last two decades, knowledge about HIV prevention has increased along with HIV testing and condom use, especially among young women and men ( Cohen, 2004 ; Giguère et al, 2021 ; Hlongwa et al, 2019 ; Murphy et al, 2006 ; Okware et al, 2005 ; Singh et al, 2004 ). The achievement of gender parity in education in many African countries ( Adamczyk & Greif, 2011 ; Alsan & Cutler, 2013 ; Murphy, 2003 ; Sia et al, 2020 ) may also have increased women's leverage to demand safe sex in relationships, thereby changing the rate at which women acquire HIV from their male partners ( Jewkes, 2002 ; Pulerwitz et al, 2002 ).…”