The burden of the global HIV epidemic is disproportionately
falling on lower-prevalence countries, according to an analysis published in
the Journal of Virus Eradication. The
majority of new HIV infections, cases of mother to child HIV transmission and
AIDS-related deaths now occur in countries with HIV prevalence below 4.5%.
Lower-prevalence countries also had lower rates of antiretroviral therapy (ART)
coverage and early infant diagnosis.

The authors note that international donor
organisations such as PEPFAR (President’s Emergency Plan for AIDS Relief) and
the Global Fund target their resources at countries with the highest HIV
prevalence. Currently, PEPFAR has 13 priority countries. Can targets for the
control of HIV be met if countries with lower prevalence are being neglected?

“The international community has galvanised
large amounts of funding and grassroots action in higher-prevalence countries,
which could be replicated with political will in lower-prevalence countries,” the authors say.

They used information from the UNAIDSinfo
database for 2017 to compare several key indicators of the HIV epidemic
according to whether countries had a high or lower HIV prevalence (above/below
4.5%). Just under half the world’s HIV-positive population live in countries
with a prevalence below this threshold.

Countries in North America, Oceania and Western
Europe were excluded from the analysis. A total of 56 countries, all with HIV
epidemics of 40,000 cases or above, were included. These countries make up 88%
of the global HIV epidemic, 87% of global new infections and 89% of all
AIDS-related deaths.

There were twelve high-prevalence countries
with a total of 16.7 million people living with HIV (PLWH) and 44 lower-prevalence
counties with 15.1 million PLWH. Whereas all the high-prevalence countries were
in sub-Saharan Africa, around only half the lower-prevalence countries were.

There were 4.1 new infections per 100 PLWH in high-prevalence countries, compared
to 5.8 per 100 PLWH in lower-prevalence countries.

ART coverage
was higher in
high- versus lower-prevalence countries (67% vs. 47%). As prevalence decreased,
so too did ART coverage (p = 0.00325).

There were fewer AIDS-related deaths in high- versus lower-prevalence countries (306,100
vs. 530,000).

Coverage of interventions to prevent mother to child transmission
(PMTCT) decreased as national HIV prevalence decreased (p = 0.028). Coverage
was 91% for pregnant women living in higher-prevalence countries, compared to 53%
in lower-prevalence countries.

The rate of mother to child HIV transmission in high- and lower-prevalence
countries was 8% and 17%, respectively. While three of the lower-prevalence countries
did achieve a mother to child transmission rate below 10% (Rwanda, Brazil and
Argentina), nearly half of lower- prevalence countries had a transmission rate
of at least 20%, including Nigeria at 23%. Almost two-thirds (61%) of the
171,000 new childhood infections recorded in 2017 occurred in lower-prevalence

infant diagnosis
(EID) rates
also increased with national prevalence (p = 0.027). Average EID rates in high-
and lower-prevalence countries were 71% and 30%, respectively.

coverage for children
as prevalence increased, averaging at 64% for high-prevalence countries
compared to 29% for lower- prevalence countries. AIDS-related deaths were less frequent in high-prevalence countries
(4% of HIV-positive children) than in lower-prevalence countries (8%).

“There are several strategies used in
higher-prevalence settings that could potentially be applied in
lower-prevalence ones, including healthcare systems decentralization, task
shifting, ART distribution by community health workers and mobile technology,
adherence clubs, support networks and adoption of WHO guidelines to test and
treat,” comment the authors.

Some lower prevalence countries had good
outcomes, with Ethiopia, the Democratic Republic of Congo and Rwanda all
showing that improvements in early infant diagnosis rates and ART coverage are

However they note that lower-prevalence
countries may face particular challenges in reaching key populations. Such
countries often have unique epidemiological, technological and social
challenges to ART delivery.