Not only do young women aged years have HIV rates higher than their male peers, they acquire HIV infection years earlier than their male peers. Adapted from [ 12 , 24 ]. The disproportionately high HIV prevalence throughout the region suggest the lack of appropriate interventions to protect young women and to meet their sexual and reproductive health needs as they prepare for adulthood [ 12 ].
In the region, there is a paucity of research in marginalized groups such as men who have sex with men, people who inject drugs and sex workers, however, emerging data suggests that HIV prevalence is significantly higher in these groups than in the general population [ 32 ].
Studies from South Africa and Kenya show that HIV prevalence was almost three fold higher in men who had sex with men than in men who had sex with women only [ 33 , 34 ]. Similarly, HIV incidence rates have also been three to four fold higher at Injecting drug use is a growing concern across the region compounded by reports of high risk sexual behaviors in these individuals.
The absence of harm reduction programs and persistent high risk behaviors has implications for transmission of HIV. Sex work has been the key driver of the epidemic in the region and the burden of HIV remains disproportionately high amongst female sex workers. Even in countries with generalized epidemics, HIV prevalence is at least two fold higher in this group than in the general population and the pooled HIV prevalence among female sex workers in sub-Saharan Africa was Whilst the number of life time sex partners, risky sex acts or behavioral practices impact on HIV acquisition, sex workers within sexual networks play a role in sustaining transmission.
Despite the impact of combination prevention interventions that target high risk marginalized populations, the major challenges in the region are the discriminatory environments and in-country legislation that not only sustain, but fuel the epidemics resulting in extraordinarily high prevalence [ 38 ]. Major challenges exist in maintaining the declining rates of HIV infections. It is imperative that structural, behavioral and biomedical interventions are evidence and rights based, are non-discriminatory and gender transformative [ 38 ].
Furthermore, the programs should aim to decriminalize sex work, men who have sex with men and reduce intimate partner violence [ 39 , 40 ] as these impact on HIV prevention efforts. Ideally, access to comprehensive sexual reproductive health services for HIV prevention should focus on maximizing on coverage of interventions [ 12 ].
Intensifying prevention activities requires a thorough understanding of the HIV epidemic typologies, modes of transmission and populations affected as these inform the extent to which evidence based modalities can be customized and combined to substantially reduce HIV transmission which is critical in continuing the path to altering epidemic trajectory [ 41 - 43 ]. The evolving epidemic has been characterized into several typologies to capture the dominant characteristic at regional and or country level.
However, a key feature of the epidemic is variation in disease burden not only across population and countries but across districts and sub districts. Countries characterized as having low-level epidemics , where adult HIV prevalence has not spread to significant levels in the general population nationally, nor in any sub-population, suggests that sexual networks of risk are diffuse and driven by low levels of partner change or concurrent sexual relationships or that the virus may have been recently introduced.
In such settings, information on the most vulnerable and at risk populations is needed to understand risk behaviors, social sexual networks and factors such as rates of sexually transmitted infections STIs that could potentially impact on the spread of HIV. Many West African countries such as Benin 1. Thus, prevention planning should track the epidemic and entail knowledge of HIV trends.
In concentrated epidemic settings, HIV has spread rapidly in one or more populations but is not well established in the general population. Adult HIV prevalence is high enough in one or more sub-populations, such as men who have sex with men MSM , people who inject drugs PWID or sex workers and their clients who maintain the epidemic in this sub-population, but the virus has not spread in the general population.
In several countries, HIV prevalence is nearly 20 times higher amongst high risk sub-populations such as MSM and sex workers compared to adult HIV prevalence in the general population. In Burundi, HIV prevalence in sex workers is To prevent epidemics expanding to the general population, HIV prevention efforts should focus on understanding the dynamics of HIV transmission, tracking the size and course of the epidemic and prioritizing and intensifying interventions in affected sub-populations.
In generalized epidemic settings , HIV prevalence is well established in pregnant women attending antenatal clinics, indicating that the presence of HIV among the general population is sufficient for sexual networking to drive the epidemic. Multiple partner relationships giving rise to sexual networks intensify HIV transmission and account for majority of infections. Importantly, the behaviors of most at risk populations through longer term multiple concurrent relationships sustain HIV transmission in the general population [ 42 ].
In countries such as Kenya 6. Thus, prevention efforts must focus on broad social movements that contribute to safer sex behaviors and extend to those in the general population with increased vulnerability to HIV, especially young people. In such settings, high levels of HIV related stigma, gender based violence and sexual coercion fuel the spread of HIV in the general population, leading to excessively high prevalence [ 45 , 46 ]. Countries such as Botswana These groups are at an increased risk of infection, yet are less likely to access HIV prevention and treatment services because of the pervasive stigma and discrimination against these groups [ 38 , 46 ].
A more recent concern has been the role of HIV super infection, which occurs when an infected individual is infected again, by another variant. Super infection leads to a spike in viral load and individuals can transmit either variant or a recombinant form to partners [ 47 , 48 ]. Understanding HIV epidemic typologies has been central to the design of prevention programs, however a more in-depth and nuanced understanding of HIV transmission is needed to direct interventions.
Recent efforts to reduce sexual transmission of HIV have made progress and strategies from recent evidence based interventions are promising and should incrementally be tested and evaluated in populations at risk for HIV.
To prevent the further spread of HIV, focus on combination strategies and reaching the majority of sex workers, their clients, MSM and other high risk individuals is key to altering epidemic trajectory [ 43 ].
Whilst these have been useful as a national response and scaled up towards attaining universal access to prevention and treatment including care and support for all, these have failed to address social and economic factors and power in relationships. However, country level HIV data masks diverse, complex and heterogeneous epidemics at sub-national, regional and district level.
Furthermore, as new HIV infections continue one or more sub-populations of virus emerge [ 47 , 48 ] resulting in the spread of HIV viral variants. Geospatial mapping is a novel approach that is being used to map HIV infections [ 51 , 55 ] in order to understand geographic variation of the HIV epidemic, its drivers, and for increasing the efficiency of targeted interventions in high HIV burden, resource poor settings. Adding to this novel approach, phylogenetic analyses of HIV-1 viral sequences are increasingly being applied to map HIV transmission links.
The transmission links are important to understand dyadic relationships, and to identify clusters or networks in communities. A combination of HIV phylogenetic analyses with the relevant socio demographic and behavioral data provide powerful knowledge on patterns and dynamics of HIV transmission networks across communities, which could guide HIV prevention and intervention strategies [ 56 - 58 ].
In the village of Mochudi, Botswana, a high proportion of Mochudi unique clusters were identified among sequences suggesting that the HIV epidemic in this community is dominated by locally circulating viral variants [ 56 ]. These data provide empirical evidence to understand the dynamic heterogeneity of HIV which to a significant degree is often masked at a country level [ 49 ]. The HIV prevention field has evolved rapidly over the last five years. Numerous interventions to prevent HIV acquisition are available; however, these have not been implemented and utilized in relation to the magnitude of HIV burden.
Comprehensive and effective public health strategies include programming for behavior change, condom use, HIV testing and knowledge of HIV status, harm reduction efforts for injecting substance use, medical male circumcision and provision of post exposure prophylaxis.
For example condom use is generally highest in commercial sex work and lower and inconsistent in non commercial and regular partnerships [ 61 ]. Studies indicate that the majority of women are generally unable to negotiate consistent male or female condom use which is largely dependent on male partner co-operation. Although increases in male condom distribution and use played a key role in declining HIV incidence during the period [ 62 ], the major challenge has been sustaining consistent condom use [ 63 ] so men can protect themselves and their partners.
Similarly HIV counselling and testing HCT has been tested through several models [ 64 - 68 ] to enhance knowledge of HIV status, access HIV prevention and treatment programs and minimize stigma and discrimination in association with HIV Although these innovative approaches and expansion of services have been fundamental in promoting knowledge of HIV status to access treatment and promoting preventing onward transmission, knowledge of HIV status remains low.
Results from three randomized controlled trials RCTs and modelling data have paved the way for large scale roll-out of voluntary medical male circumcision VMMC as an important intervention by engaging men and reducing heterosexually acquired HIV [ 4 - 6 , 69 ]. These data suggest that for any benefit of VMMC to be realized, coverage must be scaled up. Improving surgical procedures and using novel approaches for recruitment for the safe delivery of high quality VMMC services would contribute to rapidly achieving targets for public health benefit [ 70 - 73 ].
Several RCTs of cervical barrier, diaphragm and non antiretroviral ARV based microbicides when applied vaginally have failed to show any significant benefit in preventing HIV acquisition [ 74 - 80 ]. Randomised clinical trial evidence for preventing sexual transmission of HIV adapted from [ 93 ]. Whilst these trials had no safety concerns, the major drawback was the lack of adherence and therefore the failure to demonstrate the effectiveness of the study products.
In this trial the dapivirine vaginal ring reduced the risk of HIV-1 infection by These results provide renewed hope for women initiated methods, whilst clinical trials on newer ARVs with alternate delivery mechanisms are currently underway and the role of potent broadly neutralizing monoclonal antibodies are being explored as newer HIV prevention interventions [ 24 , 91 ]. These interventions would fill an important gap as HIV prevention options for young women and impact on new HIV infections [ 24 ].
The major challenge of these promising interventions is that they are not yet licensed in sub-Saharan Africa for public sector use. Whilst vaginal microbicides and oral PrEP are urgently needed as behaviors are difficult to modify, effect and sustain, their effectiveness is largely dependent on risk perception, uptake of interventions and adherence to interventions [ 10 ], further complicated by genital inflammation with increased concentrations of HIV target cell recruiting chemokines and a genital inflammatory profile contributing to HIV acquisition [ 92 ].
These findings provide compelling evidence to the importance of viral load as a key predictor of HIV transmission. Furthermore, adding VMMC, behaviour change communication, early ART and preexposure prophylaxis could achieve greater effect in reaching the goals of epidemic control. Although high coverage of early or universal ART with VMMC, behaviour change communication and pre-exposure prophylaxis could achieve greater effect to reach the goal of epidemic control and virtually eliminate HIV transmission [ 9 , 11 ], population-based RCTs are currently ongoing to determine the effectiveness of these regimens in reducing the HIV incidence [ 97 ].
Effective ART first introduced in , led to dramatic reductions in morbidity and mortality [ 20 ]. There has been a parallel increase in the number of pregnant women receiving ART for the prevention of mother to child transmission of HIV and significantly more women and children are receiving ART [ 98 ].
Most countries have progressed with scaling-up ART provision and with a commitment to increase the numbers over the next several years. In South Africa alone over 2. Without land, a person has no way to grow food to eat or to sell to get money. Taking away land impoverishes a person immediately. Education Education costs money. In addition, there is a need for more people to care for the sick.
Girls, then, can care for sick family members or work as maids to earn money for the family. In certain instances, a girl may be married so that her family can collect bridewealth. The long-term effect of forcing girls to quit school is that they grow up without an education. Without an education, it is difficult to obtain a well-paying job. Without a well-paying job, girls become women who must rely on others then to help support them and their children.
Survival Sex Work Survival sex work is the term given to women who sell sex in return for money or food. If they have to feed themselves and their children, it leaves women with few options for work. Condoms Condoms are one of the most popular methods of preventing pregnancy and sexually transmitted diseases. Condoms have a social context too. Because men often have more power in relationships than women, they are usually the ones who decide if a condom can be used during sex. In many places in Africa, men refuse to wear condoms because they think condoms are not needed.
Because there is so much stigma around wearing condoms, men may refuse to wear them. Survival sex workers may not have the power to make men put on a condom if they are in desperate need of food or money.
The stigma is not just a part of sex work, but also extends to serious relationships and marriages. At the suggestion, a husband may have the grounds to divorce her. Women, too, may prefer to avoid using condoms in order to get pregnant. For some women, the community can only consider them adults once they become mothers. They might risk becoming infected in order to have children. During war, many women are raped, which increases their chances of infection. By the end of the war, thousands of women have tested positive for the disease.
What is the U. Social environments, political environments, and economic environments affect what people choose to do. Prevention and treatment programs have to recognize the big picture so that they can work to help stop the epidemic. Go to: Glossary. Where such population characteristics exist, especially in cities, the risk of husband-wife HIV transmission may be significant. Moreover, a high probability of contracting and transmitting the virus may only be exacerbated in societies which expect female virginity at marriage, while nonetheless tolerating prostitution.
Evidence to this effect may be observed in the differing social conventions and infection rates of Kigali and Kinshasa. Men and youth are not as forthcoming with regards to testing, and are disproportionately contributing to testing gaps [ 14 — 16 ]. While interventions have been in place to improve testing rates among these priority populations, confinement due to natural disasters in the Unites States [ 17 ] and violence in Kenya [ 18 , 19 ] have been shown to hinder uptake of HIV testing services.
The current COVID crisis is even more complicated, as there are multifaceted barriers to facility-based HIV testing, including but not limited to a lack of access due to the closure of facilities, shortage of staff due to illness, and reluctance by individuals to attend clinics due to fear of being exposed to SARS-COV 2 at health facilities [ 20 ]. The lockdown measures are in no way a panacea to the pandemic [ 9 ], but are aimed at ameliorating shocks to the health systems of countries due to flood of infected and sick patients needing medical care.
The restrictive measures are, therefore, intended to manage COVID 19 spread and the number of cases requiring treatment at any given time—referred to as flattening the curve—so as to not overstretch health systems.
However, the restrictions come with unintended consequences in terms of HIV testing and care [ 21 ]. Healthcare workers are focused on COVID 19 treatment and care, while the general public are quarantined or scared to seek medical attention for other illnesses due to the threat of acquiring the virus.
The restrictive measures and threat of disease have curtailed access to provider-initiated and community testing. HIVST affords individuals privacy, convenience, and empowering options for care [ 14 , 15 ].
HIVST offers a means to fast track pre-screening and triaging out of those who self-test negative. HIVST can close the testing gap, as it can increase testing coverage and frequency. This allows the health system to focus only on those who require further assistance with respect to counselling, confirmation testing, and ART initiation.
HIVST has the added benefit of reducing the number of health center visits during the period of quarantine and social distancing, in order to curb viral transmission. Multiple studies conducted in the Sub-Saharan Africa region have already revealed high acceptance across individuals of various demographics [ 14 , 23 ].
HIVST can be made available on online drug stores, so that those requiring these services can order and have them delivered and use them in the comfort of their homes. In Eswatini, there has been a growing demand for HIV testing services during the COVID pandemic, as people are interested in knowing their underlying conditions [ 24 ].
Scaling up of a home-based option to HIV testing such as HIVST could prove beneficial and improve health outcomes with little strain to the health system. Publisher's Note. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Malizgani Mhango, Email: moc. Itai Chitungo, Email: moc.
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