Distribution of advanced HIV disease from three high HIV prevalence settings in Sub-Saharan Africa: a secondary analysis data from three population-based cross-sectional surveys in Eshowe (South Africa), Ndhiwa (Kenya) and Chiradzulu (Malawi)

ABSTRACT

Background: Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality.

Objective: We aimed to quantify population-level estimates of advanced HIV from three high HIV prevalence settings in Sub-Saharan Africa.

Methods: Three cross-sectional surveys were conducted in (Ndhiwa (Kenya): September–November 2012), (Chiradzulu (Malawi): February–May 2013) and (Eshowe (South Africa): July–October 2013). Eligible individuals 15–59 years old who consented were interviewed at home followed by rapid HIV test and CD4 count test if tested HIV-positive. Advanced HIV was defined as CD4 < 200 cells/µl. We used logistic regression to identify patient characteristics associated with advanced HIV.

Results: Among 18,991 (39.2% male) individuals, 4113 (21.7%) tested HIV-positive; 385/3957 (9.7% (95% Confidence Interval [CI]: 8.8–10.7)) had advanced HIV, ranging from 7.8% (95%CI 6.4–9.5) Chiradzulu (Malawi) to 11.8% (95%CI 9.8–14.2) Ndhiwa (Kenya). The proportion of PLHIV with advanced disease was higher among men 15.3% (95% CI 13.2–17.5) than women 7.5% (95%CI 6.6–8.6) p < 0.001. Overall, 62.7% of all individuals with advanced HIV were aware of their HIV status and 40.3% were currently on ART. Overall, 65.6% of individuals not on ART had not previously been diagnosed with HIV, while only 29.6% of those on ART had been on ART for ≥6 months. Individuals with advanced HIV disease were more likely to be men (adjusted Odds Ratio [aOR]; 2.1 (95%CI 1.7–2.6), and more likely not to be on ART (aOR; 1.7 (95%CI 1.3–2.1).

Conclusion: In our study, about 1 in 10 PLHIV had advanced HIV with nearly 40% of them unaware of their HIV status. However, a substantial proportion of patients with advanced HIV were established on ART. Our findings suggest the need for a dual focus on alternative testing strategies to identify PLHIV earlier as well as improving ART retention.

KEYWORDS:

• HIV
• CD4
• ART
• population-level
• Africa

Responsible Editor Stig Wall, Umeå University, Sweden

Responsible Editor Stig Wall, Umeå University, Sweden

Acknowledgments

The following are acknowledged for the success of the study: Study participants, survey field teams and MSF staff, all the individuals who contributed towards the success of the surveys in all three countries and The South African Department of Science and Technology/National Research Foundation (DST-NRF), Centre of Excellence in Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, South Africa for their support.

Author contributions

Menard Chihana: Study design, data analysis and write up and approval of the final manuscript

Helena Huerga: Study design, critical revision of the manuscript and approval of the final manuscript

Gilles Van Cutsem: Critical revision of the manuscript and approval of the final manuscript

Tom Ellman: Critical revision of the manuscript and approval of the final manuscript

Eric Goemaere: Critical revision of the manuscript and approval of the final manuscript

Stephen Wanjala: Critical revision of the manuscript and approval of the final manuscript

Charles Masiku: Critical revision of the manuscript and approval of the final manuscript

Elisabeth Szumilin: Critical revision of the manuscript and approval of the final manuscript

Jean-Francois Etard: Study design, critical revision of the manuscript and approval of the final manuscript

David Maman: Study design, critical revision of the manuscript and approval of the final manuscript

Mary-Ann Davies: Study design, critical revision of the manuscript and approval of the final manuscript

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

All surveys received ethical approval from both the local and international ethics committee. In Kenya, local approval was granted by Kenya Medical Research Institute Ethical Review Committee (KEMRI, protocol number 347), in Malawi it was granted by the National Health Sciences Research Committee (protocol number 1085) and in South Africa by the University of Cape Town Human Research Ethics Committee (HREC) protocol number 461/2012, and the Health Research Committee of the Health Research and Knowledge Management Unit of Kwazulu-Natal Department of Health. International approval was granted for all studies by the Comite´ de Protection des Personnes d’Ile de France (protocol number 12056 for Kenya, 12084 for Malawi and 12091 for South Africa). All study participants in all the three surveys were asked to sign a written consent if they understood the objectives of the study and accepted to be included in the study. For minors younger than 18 years, parental/guardian consent was sought first in Kenya and South Africa but was not required in Malawi where minors aged 14–17 years old are considered able to give their own consent for HIV testing.

Paper context

Despite substantial progress in antiretroviral therapy scale up, a number of people living with HIV continue to experience advanced HIV disease. Most available estimates of advanced HIV are based on clinical cohort data which is prone to selection bias. This may be the first study to quantify advanced HIV at population level. Our results suggest the need for alternative testing strategies to identify people living with HIV earlier, improving retention and virologic suppression on ART.

Additional information

Funding

Not applicable.