Abstract Body

The relationship between the HIV epidemic and urbanicity is complex, and the HIV urban-rural characteristics are not fully understood. Using the data from Population-based HIV Impact Assessment (PHIA) surveys conducted by ministries of health in collaboration with ICAP and CDC (2015-2019), we compared the HIV epidemic characteristics and the progress toward the UNAIDS 90-90-90 targets in urban vs. rural populations.

Consenting adults from randomly selected households in 12 African countries provided demographic data and blood samples for HIV testing. Estimates of awareness (1st 90) and on-treatment status (2nd 90) were based on self-report or antiretroviral (ARV) detection in blood. Viral load suppression (VLS), the 3rd 90, was defined as HIV RNA <1000 copies/ml. We applied multilevel logistic regression models using survey weights. Variances were estimated using survey-weighted Rao-Scott Chi-Square tests with jackknife variance (Figure).

HIV prevalence was significantly higher in urban vs. rural areas in six countries, namely, Cote d’Ivoire, Malawi, Rwanda, Tanzania, Uganda, Zambia. Namibia was the only country where the HIV prevalence was significantly higher in rural than in urban areas. The difference between HIV prevalence in urban and rural areas was not statistically significant In Cameroon, Eswatini, Lesotho, Zimbabwe. In Eswatini, Malawi, and Namibia, the proportion of adults living with HIV (ALWH) aware of their HIV status is higher in the rural areas (88.6% [95%CI 87.2%-90.0%], 78.1% [95% CI 75.3%-80.8%], 88.6% [95% CI 86.5%-90.8%]), compared to urban areas (83.2% [95%CI 80.3%-86.0%], 73.5% [95% CI 70.3%-76.8%], 83.3% [95% CI 79.6%-86.9%]), respectively. In contrast, in Tanzania and Zambia, the proportion of ALWH aware of their HIV status is higher in the urban areas (64.2% [95% CI 60.0%-68.4%], 75.0% [95% CI 72.4%-77.7%]) compared to rural areas (57.6% [95% CI 52.4%-62.7%], 66.2% [95% CI 62.3%-70.2%]). Despite variations in HIV prevalence and knowledge of HIV status between urban and rural areas, we found no significant differences between rural and urban areas in antiretroviral uptake and viral suppression.

The findings from these countries with generalized epidemics should guide where HIV testing services should be prioritized to enhance awareness of HIV+ status, a critical first step in the HIV care and treatment cascade.