Spatial-temporal Heterogeneity And Determinants Of HIV Prevalence In The Mano River Union Countries

BackgroundAfrican countries still have the highest burden of HIV infections after forty years of global cooperation in fighting HIV.Even worse,there is still a huge pocket of the caseload in this subregion without knowledge of their HIV status because of low HIV testing uptake.Improving comprehensive correct knowledge(CCK)about HIV/AIDS can translate into a surge in HIV testing uptake,which is expected to suppress the unacceptably high HIV figures.But in Africa,the overall CCK and HIV testing uptake are still far below the threshold set by the Joint United Nations Programme on HIV/AIDS(UNAIDS).And the situation of internal differences in Africa is largely unknown,distracting prevention efforts.The Mano River Union(MRU)countries belonging to Africa are low-income countries with limited resources to conduct national base surveillance on HIV.Data from populationbased surveys done by the Demographic and Health Survey(DHS)and AIDS Indicator Survey(AIS)focus on CCK,HIV testing uptake and epidemiology index from a spatial perspective,integrating sub-regional context to the dynamics of HIV prevalence and pooling prevention resources to priority subarea are often used to study disease trends.Objectives(1)To determine HIV prevalence with respect to CCK and HIV testing uptake at the national and regional levels among the population aged 15-49 years in the MRU according to socioeconomic characteristics.(2)To understand the spatial patterns and distribution of HIV prevalence and women with secondary education or higher among the population at national and subnational levels.(3)To describe HIV hot spots and risk points among adults in the MRU to streamline HIV interventions and provide targeted advice to researchers and policymakers.(4)To predict the combinations of CCK for respondents aged 15-49 years which can lead to an increase in HIV testing uptake with sex-specific needs to improve case finding.MethodsStudy design and contentAn ecological study was performed in the MRU countries utilizing DHS data.We analyzed data from 158,408 respondents who participated in the AIS and DHS from 2005 to 2020 and investigated the response rates by gender and residence.We utilized data for the adult population aged 15 to 49 years to describe the HIV prevalence according to gender in Guinea,Cote d’Ivoire,Liberia and Sierra Leone for 15 years,where at least two DHS were conducted between 2005 and 2020.The data was divided into five-year groups for proper comparison and ease of effective analyses.We leveraged STATcompiler and Spatial Data Repository databases to access data on HIV prevalence,CCK about HIV/AIDS,HIV testing uptake and shape files for spatial analysesSpatial and statistical analysesWe employed ArcGIS software version 10.4 to investigate the patterns of HIV distribution among adults in the general population.We utilized the symbology feature in ArcGIS to construct choropleth maps to describe and compare the spatial distribution of HIV prevalence and the prevalence of adult women with secondary education or higher in the MRU.We utilized Prism 8 software to perform infographics to investigate the trends of CCK and HIV testing uptake according to socioeconomic status at the national and regional level among adults aged 15-49 years in the MRU.We made use Getis Ord Gi*in ArcGIS to determine HIV hot spots at the national and regional levels.Finally,we employed Geodetector to measure the spatial stratified heterogeneity(SSH)of HIV incidence among the population aged 15 to 49 years to determine risk points for HIV infections in the MRU.We examined the country-specific,regional-specific and sex-specific ratios of respondents at the DHS STATcompiler database to profile the CCK and HIV testing uptake and construct infographics utilizing Prism 8 software.We employed a correlation matrix in SPSS software,version 26 to determine the relationship between the mean number of sexual partners in a lifetime and HIV prevalence among adults.We utilized the Spearman Ranked Correlation in SPSS 26 to assess the relationship between women with secondary education or higher and HIV prevalence.We assessed the comprehensive correct knowledge(CCK)about HIV/AIDS and HIV testing uptake utilizing the Least Absolute Shrinkage and Selection Operator(LASSO)regression in R software to predict the combination of CCKs that can scale up the ratio of HIV testing uptake in the sub-region.ResultsAmong the 158,408 respondents,the response rate of participants was higher in the rural residences than in their urban counterparts and women are more likely to participate in demographic surveys than men.HIV prevalence is higher among women than among men in the MRU.Further analysis revealed that women reported a higher rate of HIV testing uptake than men(26.47%/16.79%),and the cities or regions containing the cities had higher proportions of adults reporting HIV testing than their rural peers but far below the threshold of the 90-90-90(90%of the population who know their HIV status,90%of people living with HIV who have access to ART treatments,and 90%of people living with HIV who are virally suppressed)required for reversing the epidemic by 2020.This study also discovered that the regional spatial distribution of HIV prevalence in the MRU is skewed.Our choropleth maps revealed that the patterns of the spatial distribution of HIV prevalence are very similar to the spatial distribution of women with secondary education or higher.From 2005 to 2015,Cote d’Ivoire is the hot spot for HIV prevalence with a Gi_Bin score of 3,Z-Score 3.77 to 3.93 and P<0.01.From 2016 to 2020,one region in Guinea and one region in Sierra Leone are hot spots for HIV prevalence with a Gi Bin score of 2,Z-score of 2.06 and P<0.05.The spatial stratified heterogeneity(SSH)detected significant differences in HIV incidence at the national level strata,with a higher level for Cote d’Ivoire compared to other countries in both adult women and men with q-values of 0.61 and 0.40,respectively.The Geodetector detected higher risk points for HIV incidence in Cote d’Ivoire at the national level and Abidjan at the regional level.Our infographics discovered that the CCKs about HIV/AIDS,HIV testing uptake and HIV prevalence increase with an increase in socioeconomic characteristics among the population aged 15-49 years in the MRU.The capital cities and regions containing the capital cities in urban residences have a higher level of comprehensive correct knowledge about HIV/AIDS(CCK),a higher level of HIV testing uptake and higher HIV prevalence.Conversely,regions in the rural setting have lower comprehensive correct knowledge about HIV/AIDS,lower HIV testing uptake and lower HIV prevalence.HIV prevalence is higher among adults with higher socioeconomic status than those with lower socioeconomic status,and it is true for both adult men and women.There is a percentage increase in CCKs about HIV/AIDS and HIV testing uptake from 2005 to 2020 in all the regions in the MRU,but the figures are far below the threshold 95-95-95(95%of the population who know their HIV status,95%of people living with HIV who have access to ART treatments,95%of people living with HIV who are virally suppressed)set by UNAIDS to end the epidemic by 2030.Our correlation matrix discovered a very weak negative correlation between the mean number of sexual partners in a lifetime and HIV prevalence among adults aged 15-49 years,except for Liberia 2013 DHS which shows a very weak positive linear correlation between the mean number of sexual partners in a lifetime and HIV prevalence.The Spearman Rank Correlation revealed a weak positive linear correlation of 0.32 and a p-value=0.01 between HIV prevalence and women with secondary education.The Least Absolute Shrinkage and Selection Operator(LASSO)predicted that different emphases should be implemented when popularizing the comprehensive correct knowledge about HIV/AIDS to scale up the HIV testing uptake for adult men and women.LASSO also predicted different combinations of CCKs to improve HIV testing uptake in the sub-region.Conclusions(1)The MRU countries are HIV epidemic-prone states.The lower level of education and limited healthcare systems in this sub-region may be one of the reasons responsible for the lower levels of CCK about HIV/AIDS and HIV testing uptake among adults.HIV prevalence is higher among adult men and women with higher socioeconomic status than those with lower socioeconomic status even though adults with higher socioeconomic status have higher CCKs and HIV testing uptake.(2)Cote d’Ivoire is the hot spot for HIV prevalence from 2005 to 2015,as it is confirmed by Geodetector that Cote d’Ivoire has the highest risk for HIV incidence and Abidjan is the risk point for HIV infections in the MRU.(3)Despite the increase in comprehensive correct knowledge about HIV/AIDS and HIV testing uptake in the MRU,the figures are far below the threshold target set by UNAIDS for ending the epidemic in the sub-region.Concomitant relationships or cohabitation is not positively associated with the mean number of sexual partners in a lifetime and HIV prevalence.However,there is a relationship between an increase in socioeconomic status and HIV prevalence.The LASSO model predicted that different emphases should be implemented when popularizing the comprehensive correct knowledge on HIV/AIDS to increase the proportion of adults receiving HIV tests for sex-specific needs.Innovations(1)This study exemplifies the importance to utilize publicly available data to study HIV trends in low-income countries like the MRU counties.The use of the Demographic and Health Survey(DHS)and the AIDS Indicator Survey(AIS)in public health interventions represents a novel reporting strategy in healthcare in which a group of countries in the MRU are employed to fine-tune the fight against epidemics in these communities.(2)This study utilizes variables of CCKs and HIV testing uptake to predict the combinations of CCKs that may increase the voluntary HIV testing uptake in MRU countries for adult women and men aged 15-49 years.We employed Machine Learning to predict the combinations of CCKs that may lead to an increase in HIV testing uptake for better public health forecasting.This is another method in our study that is novel in MRU countries.Predictions for better public health interventions will prepare policymakers,governments and communities for better planning and preparedness.(3)Another innovation in our study is the discovery of the shift in HIV prevalence in MRU countries.HIV prevalence has shifted to be higher among adults with higher socioeconomic status than among adults with lower socioeconomic status.This will bring a change in the HIV interventions in MRU countries targeting adults in the higher socioeconomic classes.(4)Our research has further revealed that there is no association between the mean number of sexual partners in a lifetime and HIV prevalence in MRU countries.This is an important innovation that changes the perception of communities to indicate that concurrency does not represent an increase in HIV prevalence.