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      Recent levels and trends in HIV incidence rates among adolescent girls and young women in ten high-prevalence African countries: a systematic review and meta-analysis

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          Summary

          Background

          The roll-out of antiretroviral therapy (ART) has changed contexts of HIV risk, but the influence on HIV incidence among young women is not clear. We aimed to summarise direct estimates of HIV incidence among adolescent girls and young women since ART and before large investments in targeted prevention for those in sub-Saharan Africa.

          Methods

          We did a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, Global Health, and CINAHL for studies reporting HIV incidence data from serological samples collected among females aged 15–24 years in ten countries (Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe) that were selected for DREAMS investment in 2015. We only included articles published in English. Our main outcome was to summarise recent levels and trends in HIV incidence estimates collected between 2005 and 2015, published or received from study authors, by age and sex, and pooled by region.

          Findings

          51 studies were identified from nine of the ten DREAMS countries; no eligible studies from Lesotho were identified. Directly observed HIV incidence rates were lowest among females aged 13–19 years in Kumi, Uganda (0·38 cases per 100 person-years); and directly observed HIV incidence rates were highest in KwaZulu-Natal, South Africa (7·79 per 100 person-years among females aged 15–19 years, and 8·63 in those aged 20–24 years), among fishing communities in Uganda (12·40 per 100 person-years in females aged 15–19 years and 4·70 in those aged 20–24 years), and among female sex workers aged 18–24 years in South Africa (13·20 per 100 person-years) and Zimbabwe (10·80). In pooled rates from the general population studies, the greatest sex differentials were in the youngest age groups—ie, females aged 15–19 years compared with male peers in both southern African (pooled relative risk 5·94, 95% CI 3·39–10·44) and eastern African countries (3·22, 1·51–6·87), and not significantly different among those aged 25–29 years in either region. Incidence often peaked earlier (during teenage years) among high-risk groups compared with general populations. Since 2005, HIV incidence among adolescent girls and young women declined in Rakai (Uganda) and Manicaland (Zimbabwe), and also declined among female sex workers in Kenya, but not in the highest-risk communities in South Africa and Uganda.

          Interpretation

          Few sources of direct estimates of HIV incidence exist in high-burden countries and trend analyses with disaggregated data for age and sex are rare but indicate recent declines among adolescent girls and young women. In some of the highest-risk settings, however, little evidence exists to suggest ART availability and other efforts slowed transmission by 2016. Despite wide geographical diversity in absolute levels of incidence in adolescent girls and young women, risk relative to males persisted in all settings, with the greatest sex differentials in the youngest age groups. To end new infections among the growing population of adolescents in sub-Saharan Africa, prevention programmes must address gender inequalities driving excessive risk among adolescent girls.

          Funding

          This work was conducted as part of a planning grant funded by the Bill & Melinda Gates Foundation.

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          Most cited references39

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          Safety and Efficacy of a Dapivirine Vaginal Ring for HIV Prevention in Women.

          The incidence of human immunodeficiency virus (HIV) infection remains high among women in sub-Saharan Africa. We evaluated the safety and efficacy of extended use of a vaginal ring containing dapivirine for the prevention of HIV infection in 1959 healthy, sexually active women, 18 to 45 years of age, from seven communities in South Africa and Uganda.
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            HIV decline associated with behavior change in eastern Zimbabwe.

            Few sub-Saharan African countries have witnessed declines in HIV prevalence, and only Uganda has compelling evidence for a decline founded on sexual behavior change. We report a decline in HIV prevalence in eastern Zimbabwe between 1998 and 2003 associated with sexual behavior change in four distinct socioeconomic strata. HIV prevalence fell most steeply at young ages-by 23 and 49%, respectively, among men aged 17 to 29 years and women aged 15 to 24 years-and in more educated groups. Sexually experienced men and women reported reductions in casual sex of 49 and 22%, respectively, whereas recent cohorts reported delayed sexual debut. Selective AIDS-induced mortality contributed to the decline in HIV prevalence.
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              The DREAMS core package of interventions: A comprehensive approach to preventing HIV among adolescent girls and young women

              In sub-Saharan Africa, adolescent girls and young women (AGYW) are 5 to 14 times more likely to be infected with HIV than their male peers. Every day, more than 750 AGYW are infected with HIV. Many factors make girls and young women particularly vulnerable to HIV, including gender-based violence, exclusion from economic opportunities, and a lack of access to secondary school. The President’s Emergency Plan for AIDS Relief (PEPFAR) is dedicating significant resources through the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) partnership to impact the lives of women and girls based on PEPFAR’s mission to help countries achieve epidemic control of HIV/AIDS. The data show that new HIV infections must be reduced in AGYW, or the global community risks losing the extensive progress made towards reaching epidemic control. With support from PEPFAR and private sector partners—the Bill & Melinda Gates Foundation, Gilead Sciences, Girl Effect, Johnson & Johnson and ViiV Healthcare, DREAMS works together with partner governments to deliver a core package of interventions that combines evidence-based approaches that go beyond the health sector, addressing the structural drivers that directly and indirectly increase girls’ HIV risk. Not only is DREAMS an effort to reduce new HIV infections, but it aims to reduce other critical vulnerabilities such as gender-based violence. When girls and young women thrive, the effects are felt throughout their families, communities and countries.
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                Author and article information

                Contributors
                Journal
                Lancet Glob Health
                Lancet Glob Health
                The Lancet. Global Health
                Elsevier Ltd
                2214-109X
                10 October 2019
                November 2019
                10 October 2019
                : 7
                : 11
                : e1521-e1540
                Affiliations
                [a ]Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
                [b ]Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
                [c ]Centre for Rural Health, School of Nursing and Public Health, and KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
                [d ]Africa Health Research Institute, Africa Centre Building, Mtubatuba, South Africa
                Author notes
                [* ]Correspondence to: Dr Isolde Birdthistle, Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK isolde.birdthistle@ 123456lshtm.ac.uk
                Article
                S2214-109X(19)30410-3
                10.1016/S2214-109X(19)30410-3
                7025003
                31607465
                acd2d630-ba6d-47c5-8b67-ad24e72b2b96
                © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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