Subnational mapping of HIV incidence and mortality among individuals aged 15–49 years in sub-Saharan Africa, 2000–18: a modelling study
Benn Sartorius, John D. VanderHeide, Mingyou Yang, Erik A. Goosmann, Julia Hon, Emily Haeuser, Michael A. Cork, Samantha Perkins, Deepa Jahagirdar, Lauren E. Schaeffer, Audrey L. Serfes, Kate E LeGrand, Hedayat Abbastabar, Zeleke Hailemariam Abebo, Akine Eshete Abosetugn, Eman Abu‐Gharbieh, Manfred Accrombessi, Oladimeji Adebayo, Adeyinka Emmanuel Adegbosin, Victor Adekanmbi, Olatunji Adetokunboh, Daniel A Adeyinka, Bright Opoku Ahinkorah, Keivan Ahmadi, Muktar Beshir Ahmed, Yonas Akalu, Oluwaseun Akinyemi, Rufus Akinyemi, Addis Aklilu, Chisom Joyqueenet Akunna, Fares Alahdab, Ziyad Al‐Aly, Noore Alam, Alehegn Aderaw Alamneh, Turki M Alanzi, Biresaw Wassihun Alemu, Robert Kaba Alhassan, Tilahun Ali, Vahid Alipour, Saeed Amini, Robert Ancuceanu, Fereshteh Ansari, Zelalem Alamrew Anteneh, Davood Anvari, Razique Anwer, Seth Christopher Yaw Appiah, Jalal Arabloo, Mulusew Andualem Asemahagn, Mohammad Asghari Jafarabadi, Wondwossen Niguse Asmare, Desta Debalkie Atnafu, Maha Atout, Alok Atreya, Marcel Ausloos, Atalel Fentahun Awedew, Beatriz Paulina Ayala Quintanilla, Martin Amogre Ayanore, Yared Asmare Aynalem, Muluken Altaye Ayza, Samad Azari, Zelalem Nigussie Azene, Zaheer‐Ud‐Din Babar, Atif Amin Baig, Senthilkumar Balakrishnan, Maciej Banach, Till Bärnighausen, Sanjay Basu, Mohsen Bayati, Neeraj Bedi, Tariku Tesfaye Bekuma, Woldesellassie Bezabhe, Akshaya Srikanth Bhagavathula, Pankaj Bhardwaj, Krittika Bhattacharyya, Zulfiqar A Bhutta, Sadia Bibi, Boris Bikbov, Tsegaye Adane Birhan, Zebenay Workneh Bitew, Moses J. Bockarie, Archith Boloor, Oliver J. Brady, Nicola Luigi Bragazzi, Andrey Briko, Н. И. Брико, Sharath Burugina Nagaraja, Zahid A Butt, Rosario Cárdenas, Félix Carvalho, Jaykaran Charan, Souranshu Chatterjee, Soosanna Kumary Chattu, Vijay Kumar Chattu, Mohiuddin Ahsanul Kabir Chowdhury, Dinh‐Toi Chu, Aubrey J. Cook, Natalie Maria Cormier, Richard G. Cowden, Carlos Culquichicón, Baye Dagnew
Abstract
BACKGROUND: High-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. METHODS: In 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. FINDINGS: The 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 rates were accordingly higher. Among second-level administrative units, Guijá District, Gaza Province, Mozambique, had the highest estimated HIV incidence (4661·7 [2544·8-8120·3]) cases per 100 000 people in 2018 and Inhassunge District, Zambezia Province, Mozambique, had the highest estimated HIV mortality rate (1163·0 [679·0-1866·8]) deaths per 100 000 people. Further, the rate of reduction in HIV incidence and mortality from 2000 to 2018, as well as the ratio of new infections to the number of people living with HIV was highly variable. Although most second-level administrative units had declines in the number of new cases (3316 [81·1%] of 4087 units) and number of deaths (3325 [81·4%]), nearly all appeared well short of the targeted 75% reduction in new cases and deaths between 2010 and 2020. INTERPRETATION: Our estimates suggest that most second-level administrative units in sub-Saharan Africa are falling short of the targeted 75% reduction in new cases and deaths by 2020, which is further compounded by substantial within-country variability. These estimates will help decision makers and programme implementers expand access to ART and better target health resources to higher burden subnational areas. FUNDING: Bill & Melinda Gates Foundation.