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UNAIDS plan would not eliminate HIV in Lesotho, researchers say
The current international plan to rid sub-Saharan Africa of HIV would fail in Lesotho partly due to rural population dispersion, and the same could be true of other countries in the region, researchers said.
Sally Blower, PhD, professor in the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues presented strategies in Science Translational Medicine that they said would more efficiently deliver treatment as prevention (TasP) to patients in remote areas of the country in which about 25% of people have HIV.
“The strategies take into account the characteristic spatial demographics of populations in sub-Saharan Africa, the countrywide spatial diffusion of HIV epidemics and resource constraints,” the researchers wrote.
The UN Program on HIV/AIDS (UNAIDS) and WHO have proposed using TasP as the vehicle for their 90-90-90 strategy, which is to diagnose 90% of people with HIV globally, treat 90% of those diagnosed and achieve viral suppression in 90% of those treated, by 2020. The HIV epidemic in Lesotho has been identified by UNAIDS as “a priority for elimination,” the researchers wrote.
Blower and colleagues created a map showing the estimated dispersion of people with HIV in the country between the ages of 15 and 49 years. They relied on data from the WorldPop project, the 2010 census and HIV testing data from roughly 7,000 people who participated in the 2010 Lesotho Demographic Health Survey. They mapped the estimated density of infection (DOI) — defined as the number of people living with HIV per square kilometer — in communities ranging from small rural towns to big cities. They calculated that there were 223,500 people with HIV, including those not diagnosed, in the country.
The researchers found that about 20% of infected people in the study’s age range live in urban areas. Roughly 27% of Lesotho’s overall population dwells in the country’s 12 urban centers. The DOIs in urban areas range from 100 to 450.
The large majority of people with HIV live in rural areas, the researchers said. Nearly a third reside in settlements with less than six infected people per square kilometer. Low DOIs do not translate to a low HIV prevalence, however — the proportion of those with HIV reach about 20% in rural areas.
Sparse population distribution in areas with limited resources is not unique to Lesotho. The researchers noted previous studies estimating that about 60% of people in sub-Saharan Africa live in rural areas, “where settlements are often widely dispersed and population density is low.”
The researchers said UNAIDS and WHO failed to consider the challenges of special demographics when developing their strategy, and so they sought to minimize the area health workers would have to cover to find and treat patients with HIV by developing a new “geostatistical framework.”
They used an epidemic concentration curve plot to locate communities they said should use TasP if about 70% of people with HIV could be treated — the minimum proportion needed to eliminate the disease, according to UNAIDS.
The researchers found that TasP should be used only in places with a DOI of at least 5. TasP should be distributed to areas in the following order, they said:
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urban communities with a DOI of 100 to 450;
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rural communities with a DOI of 10 to 100; and
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rural communities with a DOI of 5 to 10.
“This strategy would ensure universal coverage in all urban areas in all 10 health care districts and in the largest rural communities in the country,” the researchers wrote.
Blower and colleagues concluded that their mapping strategy can serve multiple purposes.
“Our geostatistical framework can be used to design implementation strategies for other types of interventions for controlling HIV epidemics in sub-Saharan Africa ... It could be used to evaluate their feasibility, as well as improve their efficiency and cost-effectiveness,” they wrote. – by Joe Green
Disclosure: The researchers report no relevant financial disclosures.