HIV incidence rates in adolescent girls and young women in sub-Saharan Africa
Authors: Salim S Abdool Karim, Cheryl Baxter
Journal: The Lancet Global Health (2019)

The global acceleration of the AIDS response over the past decade, particularly increased access to antiretrovirals for HIV treatment, has resulted in declining HIV incidence in many regions of the world and a 33% reduction in AIDS-related deaths between 2010 and 2018.1UNAIDSMiles to go: closing gaps, breaking barriers, righting injustices. Joint UN Programme on HIV/AIDS, Geneva2018Google Scholar Despite these gains, a substantial global HIV burden still remains, with 38 million people living with HIV and 1·7 million diagnosed with new HIV infections in 2018.2UNAIDSGlobal epidemic update: communities at the centre.https://www.unaids.org/sites/default/files/media_asset/2019-global-AIDS-update_en.pdfDate: 2019Date accessed: August 28, 2019Google Scholar New HIV infections continue in certain regions and among key populations. Populations that are disproportionately affected by HIV include sex workers, men who have sex with men, transgender individuals, and people who inject drugs. In sub-Saharan Africa, adolescent girls and young women aged 15–24 years are particularly vulnerable. In this region, despite representing just 10% of the population, adolescent girls and young women accounted for 25% of all new HIV infections globally in 2017.1UNAIDSMiles to go: closing gaps, breaking barriers, righting injustices. Joint UN Programme on HIV/AIDS, Geneva2018Google Scholar Of all HIV infections occurring among adolescents in sub-Saharan Africa, 80% are in girls aged 15–19 years. Adolescent girls and young women are also twice as likely to be living with HIV than young men of the same age.2UNAIDSGlobal epidemic update: communities at the centre.https://www.unaids.org/sites/default/files/media_asset/2019-global-AIDS-update_en.pdfDate: 2019Date accessed: August 28, 2019Google Scholar In The Lancet Global Health, Isolde Birdthistle and colleagues present their systematic review and meta-analysis,3Birdthistle I Tanton C Tomita A et al.Recent levels and trends in HIV incidence rates among adolescent girls and young women in ten high-prevalence African countries: a systematic review and meta-analysis.Lancet Glob Health. 2019; 7: e1521-e1540Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar collating available data for HIV incidence in adolescent girls and young women from nine high HIV-burdened African countries between 2005 and 2015; Lesotho was initially included in the study but had no available data. This period corresponds with the substantial scale up of antiretroviral therapy (ART) in Africa and is before the implementation of large projects that specifically targeted HIV prevention for adolescent girls and young women. Although there is evidence of a decline in the absolute levels of HIV incidence among adolescent girls and young women between 2005 and 2015 in Rakai (Uganda), Manicaland (Zimbabwe), and among female sex workers in Kenya, HIV incidence has remained largely unchanged in the highest-burdened communities in South Africa.3Birdthistle I Tanton C Tomita A et al.Recent levels and trends in HIV incidence rates among adolescent girls and young women in ten high-prevalence African countries: a systematic review and meta-analysis.Lancet Glob Health. 2019; 7: e1521-e1540Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar HIV incidence rates have also remained high in certain high-risk groups such as fishing communities in Uganda, where HIV incidence of up to 12·4% are observed among teenage girls aged 15–19 years, and among female sex workers aged 18–24 years in South Africa (HIV incidence of 13·2%) and Zimbabwe (10·8%). Gender disparities in HIV persist; HIV risk is six times higher among young women than among men in southern Africa and three times higher in eastern Africa. The summary estimates of HIV incidence from several published studies, although limited in terms of the studies selected and the inclusion of prevalence-based estimates of incidence, still provides some useful insights. They suggest that the prevailing approach to HIV prevention during this period, which was largely focused on increasing ART coverage and scaling up medical male circumcision, has been insufficient to affect HIV incidence rates in adolescent girls and young women, particularly in high-burdened settings. Given that adolescent girls and young women primarily acquire infections from HIV-positive men aged in their late 20s and early 30s,4de Oliveira T Kharsany AB Graf T et al.Transmission networks and risk of HIV infection in KwaZulu-Natal, South Africa: a community-wide phylogenetic study.Lancet HIV. 2017; 4: e41-e50Summary Full Text Full Text PDF PubMed Scopus (137) Google Scholar who are often unaware that they have HIV and are less likely to be on ART, the minimal decrease in HIV incidence among young women is not surprising. Although relationships with older men might be one of the fundamental drivers of the rapid spread of HIV infection in young women, a complex interplay of biology, gender-power disparities, and socioeconomic and other social triggers, including violence against women, affect vulnerability in women in Africa.5Abdool Karim Q Sibeko S Baxter C Preventing HIV infection in women: a global health imperative.Clin Infect Dis. 2010; 50: 122-129Crossref PubMed Scopus (81) Google Scholar A combination of prevention strategies, including structural, biomedical, and behavioural programmes for both men and adolescent girls and young women are likely to be needed to have an effect on HIV incidence for high-risk populations. In 2014, PEPFAR launched the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) initiative, which aims to meet the prevention needs of adolescent girls and young women through a multipronged approach that includes national campaigns, access to combination prevention, the engagement of men (eg, linkage to HIV testing and counselling, treatment, and voluntary medical male circumcision), integration of HIV services into sexual and reproductive services, provision of pre-exposure prophylaxis, and efforts to keep girls in school.6PEPFARDREAMS innovation challenge fact sheet—DREAMS package: best practices for preventing HIV infection in adolescent girls and young women.https://www.pepfar.gov/documents/organization/247602.pdfDate accessed: August 30, 2019Google Scholar This systematic review and meta-analysis also provides useful baseline HIV incidence rates that could be used to assess whether the DREAMS initiative has met its aims of decreasing HIV incidence among adolescent girls and young women. More studies providing reliable estimates of HIV incidence are needed to establish the effect of prevention interventions, understand HIV epidemic dynamics, and interpret temporal trends in different populations and subgroups. Progress towards achieving the UN's goal of ending AIDS as a public health threat by 2030 will not likely be reached unless a major effort is made to reduce HIV incidence rates in adolescent girls and young women. This group remains a very high global priority. Ongoing accurate measurement of HIV incidence is essential in order to monitor progress towards this global target, an important part of the UN's Sustainable Development Goals. We declare no competing interests. We receive support from the South African Department of Health and the South African Medical Research Council Special Initiative on HIV Prevention (grant 96151 ) and the South African Department of Science and Technology and the National Research Foundation's Centre of Excellence in HIV Prevention (grant 96354 ). Recent levels and trends in HIV incidence rates among adolescent girls and young women in ten high-prevalence African countries: a systematic review and meta-analysisFew sources of direct estimates of HIV incidence exist in high-burden countries and trend analyses with disaggregated data for age and sex are rare but indicate recent declines among adolescent girls and young women. In some of the highest-risk settings, however, little evidence exists to suggest ART availability and other efforts slowed transmission by 2016. Despite wide geographical diversity in absolute levels of incidence in adolescent girls and young women, risk relative to males persisted in all settings, with the greatest sex differentials in the youngest age groups. Full-Text PDF Open Access