Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2019 Sep;14(5):354-365.
doi: 10.1097/COH.0000000000000569.

The arc of HIV epidemics in sub-Saharan Africa: new challenges with concentrating epidemics in the era of 90-90-90

Katrina F Ortblad  1 , Jared M Baeten  1   2   3 , Peter Cherutich  4 , Joyce Njeri Wamicwe  4 , Judith N Wasserheit  1   2   3   5
Affiliations
Review

The arc of HIV epidemics in sub-Saharan Africa: new challenges with concentrating epidemics in the era of 90-90-90

Katrina F Ortblad et al. Curr Opin HIV AIDS. 2019 Sep.

Abstract

Purpose of review: The aim of this review is to examine the emerging results from the HIV universal test and treat (UTT) cluster-randomized trials in sub-Saharan Africa, discuss how expanding access to HIV clinical services is likely to reshape the arc of HIV epidemics, and consider implications for HIV prevention and control strategies in the coming decade.

Recent findings: The effect of universal HIV testing followed by immediate antiretroviral treatment (ART) on community-level HIV incidence remains unclear upon completion of five randomized trials. Only two of the four trials that measured HIV incidence found significant reductions in community-level incidence. Even in these trials, HIV incidence remained above levels required for epidemic control (≤1 case per 1000 person-years) despite high levels of ART coverage and viral suppression. These findings may indicate that community-delivered HIV services are not reaching the high-frequency transmitters who sustain HIV epidemics and are likely members of marginalized or hard to engage core groups.

Summary: With expanded access to HIV services in sub-Saharan Africa, HIV epidemics are transitioning from hyperendemic to declining/endemic epidemic phases, characterized increasingly by the reconcentration of HIV in marginalized or hard to engage core groups. To move toward epidemic control, novel HIV service delivery models and technologies are needed to engage those who continue to drive HIV incidence in this new epidemic phase.

PubMed Disclaimer

Conflict of interest statement

Conflicts of interest

The authors of this paper declare no conflicts of interest.

Figures

Figure 1.
Figure 1.. The HIV incidence:prevalence ratio for sub-Saharan Africa, 1990–2017
The ratio of incident to prevalent HIV cases (UNAIDS 2018 estimates) has declined substantially as the number of new cases each year has fallen and the number of persons living with HIV as grown because of global expansion to ART services.
Figure 2.
Figure 2.. Characteristics of HIV epidemic phases and patterns
Epidemics of HIV and other sexually transmitted infections (STIs) move through predictable phases shaped by factors including the biological characteristics of the population, biology and behaviors of the population, and access to prevention and treatment services.
Figure 3.
Figure 3.. Hypothetical non-linear relationship between ART roll-out and population-level effectiveness in reducing new HIV infections
At the population-level the relationship between ART coverage and reductions in HIV incidence appear to not be one-to-one, likely because all individuals living with HIV do not have the same risk of transmitting the virus and the expansion of ART coverage often does not include marginalized groups with high frequency transmission.
Figure 4.
Figure 4.. National HIV surveillance data from the Kenya Ministry of Health, 2000–2018
National HIV incidence has been declining in Kenya over the past two decades as progress on UNAIDS’ 90-90-90 treatment targets and other HIV prevention interventions, such as voluntary medical male circumcision (VMMC) coverage, have increased. Data courtesy of Peter Cherutich, Kenya Ministry of Health.
See this image and copyright information in PMC

References

    1. UNAIDS. Miles to go: closing gaps, breaking barriers, righting injustices. Geneva, Switzerland: UNAIDS; 2018.
    1. Bor J, Herbst AJ, Newell M-L, Bärnighausen T. Increases in adult life expectancy in Rural South Africa: Valuing the Scale-Up of HIV Treatment. Science 2013; 339(6122):961–5. - PMC - PubMed
    1. UNAIDS AIDSinfo; Indicators. [Internet]. [cited 2016 Apr 17]. Available from: http://aidsinfo.unaids.org/
    1. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365(6):493–505. - PMC - PubMed
    1. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 2012; 367(5):399–410. - PMC - PubMed

Publication types

Substances