Progress in the HIV response in Uganda: findings from two sequential population-based HIV impact assessment surveys, 2017-21

Abstract

Background: Uganda has experienced a severe HIV epidemic and has endeavoured to implement HIV programmes to confront it. We assessed progress in the Ugandan response by comparing data from two sequential Uganda Population-based HIV Impact Assessments (UPHIAs) conducted in 2017 and 2021.

Methods: The UPHIA was a nationally representative, cross-sectional survey using two-stage, stratified cluster sampling among adults aged 15-64 years (UPHIA 2017) or aged 15 years and older (UPHIA 2021) from all 11 regions of Uganda. Participants from randomly selected households provided demographic information and underwent HIV testing according to national guidelines, with laboratory confirmation of reactive results. We determined HIV-positive status awareness and antiretroviral therapy (ART) use through self-reporting or detection of antiretroviral drugs in blood samples. Viral suppression was defined as HIV-1 RNA of less than 1000 copies per mL. HIV incidence was estimated using a recent infection testing algorithm, and the incidence-to-prevalence ratio was calculated to assess epidemic dynamics, with lower values indicating progress towards epidemic control. We compared key indicators between surveys to evaluate progress towards the 95-95-95 targets and epidemic control. We applied Poisson regression models using survey weights and estimated variances using the Taylor series linearisation approach.

Findings: 29 594 participants were enrolled in UPHIA 2017 and 23 898 participants were enrolled in UPHIA 2021. Overall HIV incidence decreased from 0·40% (95% CI 0·25-0·56) in 2017 to 0·30% (0·18-0·43) in 2021, although this change was not statistically significant (p=0·28). Among adults who tested positive for HIV, awareness of HIV status significantly improved from 72·5% (70·0-74·9) in 2017 to 80·8% (78·0-83·3) in 2021 (p<0·0001). Additionally, the proportion of participants on ART among those aware of their HIV status increased significantly from 90·4% (88·1-92·3) to 96·0% (94·3-97·2, p<0·0001), and the prevalence of viral suppression among those on ART also increased significantly from 83·7% (81·2-85·8) to 92·0% (90·1-93·5, p<0·0001). After adjusting for demographic covariates, adults living with HIV in 2021 were significantly more likely than those in 2017 to know their HIV status (adjusted prevalence ratio 1·09 [95% CI 1·05-1·14], p<0·0001), to be on ART if aware of their status (1·06 [1·03-1·09], p<0·0001), and to be virally suppressed if on ART (1·09 [1·05-1·14], p<0·0001).

Interpretation: Uganda made substantial progress in its HIV response, with substantial improvements in HIV-positive awareness, ART coverage, and viral suppression. However, the absence of a statistically significant decrease in annual incidence or incidence-to-prevalence ratio and the fact that one-quarter of all people with HIV had unsuppressed viral load underscore the need for intensified testing, prevention, and treatment efforts to achieve a definitive epidemic transition.

Funding: The US President's Emergency Plan for AIDS Relief.