Trends in knowledge of HIV status and efficiency of HIV testing services in Sub-Saharan Africa (2000-2020): a modelling study of survey and HIV testing program data

Abstract

Background: 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.

Enthusiasm for Introducing and Integrating HIV Self-Testing but Doubts About Users: A Baseline Qualitative Analysis of Key Stakeholders' Attitudes and Perceptions in Côte d'Ivoire, Mali and Senegal

“…The corresponding rates were only 68-58-45 in West and Central Africa ( 2 ). The last published data confirmed that the rates of knowledge of HIV status by PLHIV are much lower in the countries of West and Central Africa, than those from Eastern and Southern Africa ( 3 ).…”

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" [36]. 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 ).…”