Countries with lower HIV prevalence have lower ART coverage

Low- and middle-income countries with adult HIV prevalence less than 5% had significantly lower rates of ART coverage in adults, pregnant women and children than those with higher prevalence. Lower prevalence countries also had a smaller percentage of women attending antenatal (ANC) visits and early infant diagnosis (EID) for infants.

Andrew Hill and colleagues from Liverpool University; Chelsea and Westminster Hospital; Imperial College; University of Oxford; World Health Organisation and UNITAID presented this analysis at CROI 2016.

They used data from the UNAIDS 2014 database that includes country-level information on epidemic size, HIV prevalence, ART coverage, ANC visits and EID. They noted that higher prevalence countries (at least 5%) are prioritised in PEPFAR and Global Fund ART programmes but 50% of HIV positive people live in lower prevalence countries.

Fifty-two low- and middle-income countries with at least 50,000 HIV positive people were included in the analysis: 40 with less than 5% HIV prevalence (total 16 million HIV positive) and 12 at least 5% HIV prevalence (total 16.1 million HIV positive).

The investigators used least squares linear regression to correlate adult HIV prevalence with estimated rates of ART coverage (adults, pregnant women and children), ANC, and EID. They weighted the analysis by epidemic size and controlled for GDP/capita and region (African vs non-African countries).

They found lower prevalence countries to have significantly lower rates of treatment coverage in adults, pregnant women and children, p<0.01 for each comparison. Lower prevalence countries also had a smaller percentage of women attending ANC visits and EID for infants than higher prevalence ones, p<0.01. See Table 1.

Table 1: ART coverage in lower vs higher prevalence countries
Countries	Lower prevalence (<5% HIV+ adults)	Higher prevalence (>5% HIV+ adults)
Number	40	12
HIV epidemic size	16 million	16.1 million
Adult HIV prevalence	1.6%	14.6%
Adults on ART	31.7%	48.3%
Children on ART	22.4%	42.6%
Pregnant women on ART	46.7%	89.1%
Pregnant women with > ANC	55.3%	68.1%
Infants received EID	20.1%	72.3%
Annual HIV death rate	4.5%	2.5%
Annual HIV transmission rate	6.2%	5.4%

Table 1: ART coverage in lower vs higher prevalence countries

Countries

Lower prevalence
(<5% HIV+ adults)

Higher prevalence
(>5% HIV+ adults)

Number

HIV epidemic size

16 million

16.1 million

Adult HIV prevalence

1.6%

14.6%

Adults on ART

31.7%

48.3%

Children on ART

22.4%

42.6%

Pregnant women on ART

46.7%

89.1%

Pregnant women with > ANC

55.3%

68.1%

Infants received EID

20.1%

72.3%

Annual HIV death rate

4.5%

2.5%

Annual HIV transmission rate

6.2%

5.4%

The annual death rate for HIV positive people was 4.5% in the lower prevalence countries compared with 2.5% in the higher prevalence countries. The respective HIV transmission rates were 6.2% and 5.4%.

The investigators acknowledged a subset of lower prevalence countries with high rates of HIV testing and ART coverage eg Thailand, Rwanda, Vietnam and Dominican Republic. But many other lower prevalence countries need to prioritise HIV testing and ART for adults, pregnant women and children eg Russia, China, Nigeria, India and Pakistan, they wrote.