Background
We sought to understand how the HIV epidemic is evolving over time by evaluating HIV prevalence and changes in status awareness and antiretroviral therapy (ART) use over 10 years in two high-prevalence, rural regions in East Africa.
Methods
In 2013 and 2023 in rural communities (~5,000 adults/community) in western (W) Kenya and southwestern (SW) Uganda, we conducted universal HIV screening of adult (≥15 years) residents at enrollment in two SEARCH population-level cluster randomized trials (NCT01864603; NCT05768763). Using TMLE and accounting for clustering by community, we estimated age- and sex-specific HIV prevalence, status awareness among persons with HIV, and ART use if living with HIV and aware of status.
Results
In 2013, in 22 communities (12 W-Kenya, 10 SW-Uganda), we ascertained HIV status among 90,467/101,200 (89%) residents. In 2023, among 8 different communities from the same regions (4 W-Kenya, 4 SW-Uganda), we ascertained HIV status among 38,360/42,866 (89%) residents. In W-Kenya, HIV prevalence decreased from 18.7% in 2013 to 12.7% in 2023 (p<0.001). From 2013 to 2023, there were large, significant reductions in HIV prevalence among women aged 15-44 and men aged 20-49 years (Figure), but significant increases among women ≥45. Overall, from 2013 to 2023, HIV status awareness increased from 64% to 90% (p<0.001), and ART use from 81% to 94% (p<0.001), with large, significant increases across all age-sex strata, and greatest gains among men and youth. In contrast, in SW-Uganda, HIV prevalence increased from 6.4% in 2013 to 7.3% in 2023 (p=0.007). There were small, significant reductions in prevalence among women aged 15-29, and men 20-39 (Figure), but prevalence increased among women and men ≥40 years. Overall, from 2013 to 2013, HIV status awareness increased from 57% to 68% (p<0.001), and ART use from 82% to 87% (p=0.002); however, these improvements were not uniform by age and sex in SW-Uganda.
Conclusions
Population-level prevalence data are consistent with a substantial decline in HIV incidence in W-Kenya, particularly among young adults, but not SW-Uganda. Persistently low status awareness, well below the 95% target, over the past 10 years in SW-Uganda may explain this disparity and suggests that efforts to improve status awareness are needed to achieve further reductions in HIV incidence.
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