Unawareness of HIV Infection Among Men Aged 15–59 Years in 13 Sub-Saharan African Countries: Findings From the Population-Based HIV Impact Assessments, 2015–2019 : JAIDS Journal of Acquired Immune Deficiency Syndromes

Secondary Logo

Journal Logo

Supplement Article

Unawareness of HIV Infection Among Men Aged 15–59 Years in 13 Sub-Saharan African Countries: Findings From the Population-Based HIV Impact Assessments, 2015–2019

West, Christine A. PhD, MPHa; Chang, Gregory C. MPHa,b; W. Currie, Dustin PhD, MPHa; Bray, Rachel MSc; Kinchen, Steve BS ICSa; Behel, Stephanie MPHa; McCullough-Sanden, Rachel MPHb,f; Low, Andrea MD, PhDc,d; Bissek, Anne MDe; Shang, Judith D. PhD, MScf; Ndongmo, Clement B. PhD, MPH, AIMLSf,g; Dokubo, Emily K. MD, MPHf; Balachandra, Shirish MDh; Lobognon, Legre R. MD, MPHh; Dube, Lenhle MPHi; Nuwagaba-Biribonwoha, Harriet MBChB, PhDj; Li, Michelle MPHk; Pasipamire, Munyaradzi MBChB, MSck; Getaneh, Yimam MSCl; Lulseged, Sileshi MD, MMeDm; Eshetu, Frehywot MD, MPHn; Kingwara, Leonard MPHo; Zielinski-Gutierrez, Emily MPH, DrPHp; Tlhomola, Mphotleng BScq; Ramphalla, Puleng MScr; Kalua, Thokozani MBBS, MScs; F. Auld, Andrew MD, PhDt; B. Williams, Daniel MAu; Remera, Eric MScv; Rwibasira, Gallican N. MD, MScv; Mugisha, Veronicah MBChB, DPH, MMed(PH)w,x; Malamba, Samuel S. PhD, MSy; Mushi, Jeremiah MScz; Jalloh, Mohamed F. PhD, MPHaa; Mgomella, George S. MD, CPHaa; Kirungi, Wilford L. MDab; Biraro, Sam MBChB, PhDac; C. Awor, Anna MSad; Barradas, Danielle T. PhDg; Mugurungi, Owen MDae; H. Rogers, John PhD, MPHaf; Bronson, Megan MPHa; M. Bodika, Stephane MDa; Ajiboye, Aderonke MPHa; Gaffga, Nicholas MD, MPH, FAAFPa; Moore, Carole MLS (ASCP)CMa; Patel, Hetal K. MSca; C. Voetsch, Andrew PhDa

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: August 1, 2021 - Volume 87 - Issue - p S97-S106
doi: 10.1097/QAI.0000000000002708
  • Free

Abstract

INTRODUCTION

Inadequate testing and treatment coverage among men living with HIV (MLHIV) in sub-Saharan Africa (SSA) has slowed progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) goal of reaching HIV epidemic control by 2030.1 In particular, men contribute disproportionately to the gap in achieving the global target of 95% of people living with HIV (PLHIV) knowing their status.1,2 As of 2019, there were approximately 9.8 million MLHIV in SSA. Although progress in treatment coverage has increased in the region, reductions in new infections and deaths due to AIDS-related illness have been slower among men than in women.2,3 In 2019, men accounted for a lower proportion (only 38%) of PLHIV compared with women, but men contributed 57% to the burden of AIDS-related deaths.1,2

When compared with women, men test less frequently for HIV, less frequently know their status, less regularly access HIV services, and more commonly present with advanced disease.4–9 MLHIV who are undiagnosed are at risk for poor health outcomes, including coinfection with tuberculosis (TB), other disease comorbidities, and increased AIDS-related mortality.9,10 In 2019, treatment coverage was 12% and viral load suppression was 10% higher among women living with HIV than among MLHIV globally.8 This treatment gap among MLHIV contributes to further transmission and a higher number of new HIV infections among their partners.3,4 Once diagnosed and on treatment, a decreased viral load will result in reduced transmission. The Population-based HIV Impact Assessments (PHIAs) have shown that adult men who knew their HIV status had high rates of antiretroviral therapy use (90.2%) and viral suppression (85.0%).10

Access to and acceptability of testing is the first critical step in ensuring MLHIV are diagnosed and treated. Recent efforts have intensified to find and test high-risk men to initiate them on HIV treatment. The US President's Emergency Plan for AIDS Relief (PEPFAR); the Global Fund to Fight AIDS, TB, and Malaria; and other agencies supporting the HIV response have heavily invested in HIV testing strategies focused on men in SSA.10,11 Typical approaches have included provider-initiated counseling and testing in health facilities and voluntary counseling and testing.12 Partner-initiated and index testing have emerged to reach a high volume and yield of new cases among men.12,13 Self-testing has helped in increasing testing uptake, as part of community-based testing.14,15 In addition, men lack universal entry points for HIV testing compared with women who use reproductive or family health services more readily.4 To address this, other approaches to reach men include differentiated service delivery models, mobile testing sites in places where men work and frequent, and male-centered clinics offering comprehensive outpatient services for all men regardless of HIV status.16,17

To improve testing coverage for men, it is useful to examine testing behaviors among men. Characteristics of men who have never been tested have been previously described. A study using Demographic and Health Survey data from 6 African countries found that although a higher proportion of men than women had never tested for HIV, most men accepted a test when offered.18 Factors associated with never having tested for HIV included never being married, not having children, and lower education, after adjusting for age.18 With resources dedicated to reach young men who have not tested before,10 additional strategies are needed to identify those men who once tested negative but remain at risk for infection and may need more frequent testing. Identifying those who have previously tested by characterizing subgroups of men at risk for infection could improve yield of testing programs. In addition, men who ever tested are generally older and more sexually active; thus, their risk of being positive may be higher than those who never received an HIV test.19

The PHIAs are nationally representative household-based surveys to measure key indicators of progress in controlling the HIV epidemic. With the availability of self-reported testing behavior and HIV biomarker status, which includes laboratory detection of antiretrovirals (ARVs), the PHIAs provide a unique opportunity to examine factors associated with undetected HIV infection among men.

This analysis used pooled PHIA data from 13 countries in SSA to describe men aged 15–59 years who were unaware of their HIV-positive status and to describe risk factors among unaware MLHIV who ever tested. The goal of the findings is to develop targeted interventions to optimize testing strategies to reach MLHIV who are unaware of their HIV-positive status.

METHODS

For the analysis, we pooled PHIA data from Cameroon, Cote d’Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Countries were grouped together using standard UN regional definitions.20 Data collection started for the first survey in October 2015, and completion of fieldwork for the last survey was in March 2019.

Data Collection Procedures

The PHIAs used a 2‐stage cluster sampling design to obtain nationally representative samples of households in each country, stratified by designated geographical zones.21 The design and implementation of the PHIA surveys have been described elsewhere.22,23 Face-to-face interviews were conducted to capture demographic, behavioral, and clinical information, including self-reported knowledge of HIV status and testing history. Individuals were eligible to participate if they slept in the household the night before the interview and were at least 15 years of age. The analysis was restricted to 15–59 years because this age group was shared across all 13 countries.

The surveys included home-based HIV testing and counseling, return of results, community active linkage-to-care where possible, and laboratory-based confirmation of HIV-positive and indeterminate results by each national testing algorithm. In addition to HIV diagnostic testing, most countries provided CD4 and HIV viral load testing. Testing for coinfections such as syphilis and hepatitis B/C varied depending on the country. Participants testing positive at the household received a point-of-care CD4 count in the household, laboratory-based HIV viral load, and were screened for ARV drugs indicative of the first-line and second-line HIV treatment regimens in each country. HIV viral load results were returned to participants through health facilities of their choice. Viral load suppression was defined as <1000 HIV RNA copies per milliliter.

Definition of Variables

Final HIV status classification in the PHIA was determined by the result of the rapid test result at the household, followed by laboratory confirmation. Unawareness and awareness of HIV-positive status was determined based on responses provided in the survey questionnaire, final HIV classification status in the survey, and detection of ARVs. Participants who tested positive for HIV during the survey were considered aware if they reported in the interview being HIV-positive or ARVs were detected in their blood. Participants who tested positive for HIV during the survey were considered unaware if they reported having a negative or unknown HIV status and ARVs were not detected in their blood. The outcomes of interest used in this analysis were unawareness of HIV-positive status and HIV positivity. HIV positivity was defined as receiving an HIV-positive result among HIV-positive unaware and HIV-negative men who ever tested. Ever tested was categorized as those who reported yes to ever testing for HIV.

The wealth category of “upper 60%” included the top 3 wealth quintiles and “lower 40%” included the bottom 2 wealth quintiles, with wealth relative to others in their country. Partner status was defined for sexual partnerships in the past 12 months and includes 4 categories assigned sequentially: no partners in that period; positive if think, told, or tested together as positive for one or more of their partners; unknown status for one or more of their partners; and negative for think, told, or tested together as negative for all of their partners. Hazardous drinking was determined by the Alcohol Use Disorder Identification Test (AUDIT-C) score of 4 or more based on points assigned to 3 alcohol use questions.24 Medical circumcision was defined if the male participant reported being circumcised by a health care provider such as a doctor, nurse, or midwife, and traditional circumcision was defined as being circumcised by a traditional practitioner, religious leader, or relative/friend. Tested in the past 12 months was defined as those participants who reported testing for HIV within 12 months before the interview and receiving results.

Statistical Analysis

Data were weighted to account for sample selection probabilities and to adjust for nonresponse and noncoverage. Normalized weights in Rwanda and Kenya were rescaled to population weights for consistency with the remainder of the countries, by multiplying the weights by a factor of the total estimated population size over the number of interview respondents. All estimates were weighted, and we used Taylor series expansion to obtain robust variance estimators for the complex survey data. Weighted χ2 and t test analyses were conducted to identify associations between unawareness of HIV-positive status and sociodemographic, risk and testing behaviors among HIV-positive men and HIV-negative men who had ever tested.

We fit a log-binomial regression model to identify associations between HIV positivity among HIV-positive unaware and HIV-negative men who ever tested. Covariates included in the adjusted model were based on previous literature, plausible hypotheses, bivariate analyses, and if shared across all countries. The number of sexual partners was not included because of collinearity and was not found to contribute to model fit. We calculated weighted crude and adjusted prevalence ratios examining the potential predictors of interest and accompanying 95% confidence intervals (CIs). The level of significance was set to α = 0.05 in the fitted models. All analyses were conducted in SAS version 9.4 and SAS-callable SUDAAN, version 11.0.3.

Implementation and Ethics

The PHIAs were funded by PEPFAR with technical assistance through the US Centers for Disease Control and Prevention (CDC) under the terms of the cooperative agreement #U2GGH001226. The surveys were implemented by cooperative agreement grantees/federal entities, including country Ministries of Health, ICAP at Columbia University, and the University of California San Francisco. Each survey was approved by human subjects and institutional review boards of each country, cooperative agreement grantees/federal entities implementing the survey, and CDC.

RESULTS

There were 409,855 eligible respondents in the pooled sample from the 13 countries in SSA, of whom 139,220 were men aged 15–59 years. The household response rate was 90.8%, and 123,227 (88.5%) of the eligible men aged 15–59 years were interviewed. Of those interviewed, 114,776 (93.1%) provided a valid blood specimen with a definitive HIV testing result, for an overall response rate of 74.8%. Among those with definitive results, 7430 (4.4%) tested HIV-positive (Fig. 1).

F1
FIGURE 1.:
Flow chart of interview completion and blood sampling among men aged 15–59 years in 13 sub-Saharan countries, 2015–2019*. *All frequencies are unweighted. †Unweighted percentages. ‡Weighted percentages.

HIV prevalence and the proportion of unawareness of HIV-positive status among MLHIV are presented in Table 1. Overall, southern African countries had the highest prevalence, followed by southeastern, eastern, and western African countries. Higher unawareness was found in western African compared with southern, southeastern, and eastern Africa countries, except Tanzania, where 46.8% of men were unaware of their HIV-positive status.

TABLE 1. - HIV Prevalence and Unawareness by Country of HIV-Positive Status Among Men Aged 15–59 Years, in 13 Sub-Saharan Countries, 2015–2019
Region* Country HIV+ HIV+ Unaware
% N LCL UCL % N LCL UCL
Western Cameroon 2017–2018 2.3 11,332 2.0 2.6 49.8 267 45.7 54.0
Cote d'Ivoire 2017–2018 1.6 8580 1.2 2.0 58.7 124 51.6 65.9
Eastern Ethiopia 2017–2018 1.9 7314 1.5 2.3 30.5 146 25.9 35.1
Kenya 2018 3.1 11,185 2.7 3.4 28.5 394 25.2 31.7
Rwanda 2018–2019 2.2 13,277 1.9 2.5 20.2 285 17.4 23.0
Tanzania 2016–2017 3.5 12,271 3.1 3.8 46.8 517 42.3 51.2
Uganda 2016–2017 4.7 11,903 4.3 5.1 33.3 542 29.8 36.8
Southeastern Malawi 2015–2016 8.4 6956 7.8 9.1 28.8 679 25.6 31.9
Zambia 2016 9.3 8142 8.5 10.0 30.3 779 27.0 33.5
Zimbabwe 2015–2016 11.8 8006 11.0 12.7 28.6 1084 25.7 31.5
Southern Eswatini 2016–2017 20.4 4023 18.6 22.1 20.8 871 18.2 23.5
Lesotho 2016–2017 20.8 4762 19.6 22.0 23.4 1019 21.2 25.6
Namibia 2017 9.2 7025 8.4 10.0 21.1 720 17.9 24.3
Total 4.4 114,776 4.2 4.5 33.7 7427 32.5 34.9
LCL: lower confidence limits; UCL: upper confidence limits.
*Countries grouped by region using standard regional definitions: https://unstats.un.org/unsd/methodology/m49/.
Survey year.
All frequencies are unweighted.

Figure 2 shows men's HIV status unawareness regarding their testing behavior. Of the 7430 HIV-positive men, 33.7% were unaware of their HIV-positive status, based on self-report and/or laboratory detection of ARVs. Fourteen percent (n = 390) of HIV-positive men who reported being as unaware of their positive status were reclassified as being aware after ARVs were detected in their blood. Most of the unaware HIV-positive men reported they had ever had an HIV test, 63.0% (n = 1289). Of the unaware men who ever tested, 92.1% (n = 1166) reported they were HIV-negative and 7.9% (n = 123) reported that they never received their results, did not know the results, or results were missing. Of the unaware HIV-positive men who reported being HIV-negative, 60.9% (n = 665) reported testing and receiving their HIV results more than 12 months before the date of the interview. Most unaware HIV-positive men were not virally suppressed (n = 1,860, 91.1%); 47.7% had a CD4 count less than 350 cells/uL (n = 912) and 17.9% (n = 351) had a CD4 count of less than 200 cells/uL (results not shown).

F2
FIGURE 2.:
Flow chart of awareness/unawareness status and testing characteristics among HIV-positive men aged 15–59 years, in 13 sub-Saharan countries, 2015–2019*. *All weighted percentages and unweighted frequencies. †Adjusted for ARVs, 390 HIV-positive men self-reported as unaware of their positive status were reclassified as being aware after ARVs were detected in their blood. ‡Missing n = 3 from awareness variable among HIV+ men. §Missing n = 4 from ever tested variable among unaware HIV+ men.

Most unaware HIV-positive men ever tested were aged 25–34 years (36.7%), were in the upper 60% wealth category (62.8%), and employed in the past 12 months (65.8%). Seventy percent of unaware men ever tested reported not using a condom at last sex in the past 12 months, and 37.1% reported one or more sexual partners of unknown status in the past 12 months. More than half (59.8%) of unaware men ever tested engaged in hazardous drinking and were uncircumcised (46.2%). Most men, regardless of awareness status, reported receiving their last HIV test at a health clinic or facility, but more unaware men (13.6% vs. 4.3%) reported their last HIV test at a mobile voluntary counseling and testing site compared with HIV-positive men who were aware of their status. More unaware HIV-positive men than HIV-negative men had a sexually transmitted disease (STD) diagnosis and sexually transmitted infection (STI) symptoms in the past 12 months (Table 2).

TABLE 2. - Distribution of Selected Characteristics Among Ever Tested Unaware/Aware HIV-Positive Men and HIV-Negative Men Aged 15–59 Years, in 13 Sub-Saharan Countries, 2015-2019
Characteristics Unaware HIV+ Men Aware HIV+ Men P* HIV−Negative Men P
Age
Median age (Q1,Q3) 34 (28,42) 41 (34,47) <0.0001 30 (23,38) <0.0001
Age group
 15–24 yrs 11.8 5.6 <0.0001 28.9 <0.0001
 25–34 yrs 36.7 18.3 34.4
 35–44 yrs 30.0 38.0 21.6
 45–59 yrs 21.5 38.1 15.0
Residence
 Urban 39.1 38.6 0.7311 42.0 0.1583
 Rural 60.9 61.4 58.0
Region
 Western Africa 9.9 5.1 <0.0001 12.8 <0.0001
 Eastern Africa 53.2 46.1 69.0
 Southeastern Africa 31.1 39.5 15.9
 Southern Africa 5.8 9.3 2.3
Education
 None 16.8 14.2 0.0405 13.6 0.0042
 Primary 44.2 46.6 40.9
 Post primary 39.0 39.2 45.5
Marital status
 Never married 14.3 10.8 <0.0001 33.3 <0.0001
 Married or living together 71.3 73.7 60.3
 Divorced/separated 12.5 10.8 5.8
 Widowed 1.8 4.7 0.5
Wealth category
 Lowest 40% 37.2 36.0 0.4051 35.6 0.4114
 Upper 60% 62.8 64.0 64.4
Employed in the past 12 months
 Employed 65.8 60.0 0.0002 63.2 0.1772
 Not employed 34.2 40.0 36.8
Sexual partners in past 12 months
 No sexual partners 15.3 19.0 <0.0001 21.0 <0.0001
 One sexual partner 55.7 59.5 56.8
 Two or more sexual partners 29.0 21.4 22.2
Reported partner status in past 12 months
 All negative partners 53.8 23.7 <0.0001 74.7 <0.0001
 At least one positive partner 9.1 62.3 1.6
 At least one unknown partner 37.1 14.0 23.7
Condom use at last sex in past 12 months
 No sex in the past 12 mo 13.7 16.1 <0.0001 13.9 0.6823
 Used condom 16.5 37.7 17.9
 Did not use condom 69.8 46.2 68.2
Paid for sexual intercourse in the past 12 months§
 Paid sex 12.0 9.7 0.1695 8.5 0.0608
 Did not pay for sex 88.0 90.3 91.5
Alcohol use
 Hazardous drinking 59.8 51.9 0.0015 52.4 0.0275
 Nonhazardous drinking 40.2 48.1 47.6
STD diagnosis in the past 12 months#
 STD diagnosis 4.5 6.9 0.0527 2.4 0.0111
 No STD diagnosis 95.5 93.1 97.6
STI symptoms in the past 12 months#
 STI symptoms 20.8 22.2 0.4529 13.9 0.0003
 No STI symptoms 79.2 77.8 86.1
TB diagnosis
 TB diagnosis at TB clinic 4.5 20.1 <0.0001 2.3 <0.0001
 No TB diagnosis at TB clinic 6.8 18.5 4.1
 Not visited a TB clinic 88.7 61.4 93.5
Circumcision
 Medical circumcision 31.5 22.0 <0.0001 42.6 <0.0001
 Traditional circumcision 22.3 18.7 29.0
 Uncircumcised 46.2 59.3 28.4
Tested and received results
 Tested ≤12 mo 36.5 39.8 0.0618 49.4 <0.0001
 Tested >12 mo 63.5 60.2 50.6
Time since the last HIV test
 Median months (Q1,Q3) 18 (7,46) 21 (5,65) <0.0001 12 (4,32) <0.0001
Location of last HIV test
 Health clinic/facility 45.7 58.7 <0.0001 45.5 0.1182
 Hospital outpatient clinic 13.6 13.1 11.1
 VCT facility 12.4 11.8 13.1
 Mobile VCT 13.6 4.3 13.9
 Outreach 5.5 3.9 4.4
 Hospital inpatient wards 3.0 4.2 2.5
 ANC clinic 2.4 0.9 3.9
 At home 1.7 0.8 1.8
 Other 2.1 2.1 3.8
Total N 1289 5271 67,782
*P value from a weighted χ2 and t test to test differences among unaware and aware HIV+ men.
P value from a weighted χ2 and t test to test differences among HIV+ unaware and HIV-negative men.
Ethiopia: small urban area defined as rural and large urban areas defined as urban; Lesotho: periurban and urban are defined as urban.
§Excluding Cameroon, Ethiopia, Kenya, Rwanda, Uganda, and Zimbabwe.
Hazardous drinking was determined by an AUDIT score of 4 or more based on points assigned to 3 alcohol use questions; excluding Cameroon, Cote d'Ivoire, Ethiopia, Kenya, Lesotho, Rwanda, and Uganda.
Penile discharge, painful urination, or ulcer/sore.
#Excluding Cameroon, Cote d'Ivoire, Eswatini, Lesotho, Namibia, Rwanda, and Uganda.

Prevalence ratios of HIV positivity among ever tested men are presented in Table 3. After adjustment, compared with HIV-negative men aged 15–24 years there was an increased risk of receiving a HIV-positive result and being unaware associated with an age of 25–34 years [adjusted prevalence ratio: 1.84; 95% CI: 1.29 to 2.63], 35–44 years (aPR: 2.07; 95% CI: 1.44 to 2.99), and 45–59 years (aPR: 1.74; 95% CI: 1.18 to 2.56). Compared with HIV-negative men in eastern Africa, living in a sampled country in southeastern Africa (aPR: 2.23; 95% CI: 1.81 to 2.75) and southern Africa (aPR: 3.60; 95% CI: 2.91 to 4.44) was associated with an increased risk. The risk of receiving a HIV-positive result and being unaware was about 2 times as likely in those with no education (aPR: 1.49; 95% CI: 1.09 to 2.05), compared with those with post primary education. Compared with those never married, married men or those living together with a partner (aPR: 2.15; 95% CI: 1.55 to 3.00), divorced/separated (aPR: 3.27; 95% CI: 2.20 to 4.85), and widowed men (aPR: 4.13; 95% CI: 2.09 to 8.18) had a greater likelihood of being HIV-positive and unaware than HIV-negative. Effects for all other sociodemographic covariates (urban versus rural residence, wealth, and employment status) were not significant. Men who had one or more HIV-positive sexual partners (aPR: 5.73; 95% CI: 4.13 to 7.95), or sexual partners with unknown HIV status (aPR: 2.32; 95% CI:1.89 to 2.84), had a higher risk of receiving a HIV-positive result and being unaware compared with HIV-negative men with all HIV-negative sexual partners. Men who had a TB diagnosis were also more likely to be HIV-positive and unaware compared with negative men who had not visited a TB clinic (aPR: 1.67; 95% CI:1.08 to 2.59), as were uncircumcised men compared with HIV-negative men who had undergone medical circumcision (aPR: 1.35; 95% CI:1.04 to 1.74), and men who tested more than 12 months from the interview compared with HIV-negative men who tested within 12 months before the interview (aPR: 1.58; 95% CI: 1.31 to 1.91).

TABLE 3. - Crude and Adjusted Prevalence Ratios of HIV Positivity by Selected Characteristics, Among Ever Tested HIV-Positive Unaware and HIV-Negative Men Aged 15–59 Years, in 13 Sub-Saharan Countries, 2015–2019
Characteristics HIV+ unaware* HIV-Negative N cPR LCL UCL aPR LCL UCL
Age group
15–24 yrs 0.6 99.4 20,089 REF REF
25–34 yrs 1.6 98.4 22,323 2.60 1.97 3.43 1.84 1.29 2.63
35–44 yrs 2.1 97.9 15,223 3.36 2.53 4.47 2.07 1.44 2.99
45–59 yrs 2.1 97.8 11,436 3.45 2.58 4.61 1.74 1.18 2.56
Residence
 Urban 1.4 98.6 28,237 REF REF
 Rural 1.6 98.4 42,834 1.27 1.07 1.50 0.99 0.81 1.21
Region
 Western Africa 1.2 98.8 7876 1.00 0.74 1.36 1.15 0.80 1.67
 Eastern Africa 1.2 98.8 37,630 REF REF
 Southeastern Africa 3.0 97.0 13,562 2.49 2.10 2.95 2.23 1.81 2.75
 Southern Africa 3.8 96.2 10,003 3.17 2.67 3.76 3.60 2.91 4.44
Education
 None 2.0 98.0 7084 1.44 1.10 1.87 1.49 1.09 2.05
 Primary 1.7 98.2 27,481 1.26 1.06 1.50 1.13 0.91 1.41
 Post primary 1.4 98.6 33,099 REF REF
Marital status
 Never married 0.7 99.3 24,675 REF REF
 Married or living together 1.8 98.2 40,012 2.71 2.17 3.39 2.15 1.55 3.00
 Divorced/separated 3.2 96.8 3753 4.85 3.55 6.62 3.27 2.20 4.85
 Widowed 4.9 95.1 452 7.34 4.43 12.16 4.13 2.09 8.18
Wealth category
 Lowest 40% 1.6 98.4 26,400 1.07 0.91 1.26 - - -
 Upper 60% 1.5 98.5 42,629 REF
Employed in the past 12 mo
 Employed 1.6 98.4 40,922 1.12 0.95 1.32
 Not employed 1.4 98.6 28,121 REF REF
Status of sexual partners in past 12 mo
 No sexual partners 1.5 98.5 13,966 1.30 0.96 1.76 1.32 0.91 2.36
 All negative partners 1.1 98.9 34,274 REF REF
 One or more positive partners 8.3 91.7 1100 7.44 5.52 10.03 5.73 4.13 7.95
 One or more unknown partners 2.4 97.6 12,569 2.14 1.78 2.58 2.32 1.89 2.84
TB diagnosis
 TB diagnosis at TB clinic 2.9 97.1 1712 3.27 2.21 4.84 1.67 1.08 2.59
 No TB diagnosis at TB clinic 2.5 97.5 3311 2.89 1.96 4.25 1.30 0.93 1.83
 Not visited a TB clinic 1.5 98.5 63,850 REF REF
Circumcision
 Medical circumcision 1.1 98.9 25,391 REF REF
 Traditional circumcision 1.2 98.8 15,116 1.04 0.81 1.34 0.85 0.63 1.16
 Uncircumcised 2.5 97.5 26,431 2.17 1.77 2.65 1.35 1.04 1.74
Tested and received results
 Tested ≤12 mo 1.1 98.9 32,031 REF REF
 Tested >12 mo 1.8 98.2 32,378 1.69 1.63 2.02 1.58 1.31 1.91
*n = 1289.
Bold values are statistically significant at α = 0.05.
Ethiopia: small urban area defined as rural and large urban areas defined as urban; Lesotho: periurban and urban are defined as urban.
aPR, adjusted prevalence ratio; cPR, crude prevalence ratio; LCL, lower confidence limits; UCL, upper confidence limits.

DISCUSSION

We examined unawareness of HIV-positive status among men aged 15–59 years in 13 countries in SSA with a focus on men who had ever tested for HIV. At the population level in the 13 countries, this represents an estimated 3,138,000 MLHIV aged 15–59 years, 948,000 of whom were undiagnosed for HIV. We found most MLHIV unaware of their HIV-positive status were virally unsuppressed, nearly half of whom had a CD4 count less than 350 cells/uL. In addition, a large percentage of HIV-positive unaware men reported testing more than 12 months before the interview. MLHIV who present late to the clinic with a low CD4 count have an increased probability of poor health outcomes and HIV-related mortality.4–7 By knowing their status and commencing treatment, MLHIV will be able to lead longer, healthier lives and prevent further onward transmission of HIV to their sexual partners.

Although recent emphasis in high-burden countries has been on identifying younger men (15–24 years) for testing, this analysis suggests that there is a larger burden of infected and undiagnosed men aged 25 years and older. Studies have found that most HIV-positive men not engaged in HIV prevention and treatment services are older than 35 years, which aligns with the age at the highest prevalence.11,18,25 Our findings of low education level as a risk factor for HIV positivity in unaware men reinforce the need for focused health education strategies targeting men at risk of HIV infection. Other research in the sub-Saharan region has previously described limited health literacy, especially among those with lower education levels among men.11,17,26 Importantly, a review that described barriers of HIV testing uptake in men found most men had knowledge of where to access HIV services but lacked an understanding of ongoing risks of HIV transmission.26 Results suggest the need to improve messaging to underscore that a previously negative test does not necessarily mean a current negative status for those at risk of infection and to thus increase the acceptability and frequency of testing for men in this target group.

HIV testing more than 12 months before the survey was predictive of HIV positivity among men in our study. This provides evidence for the need to increase the frequency and access to HIV testing for men with an ongoing risk of HIV infection and to retest annually or more frequently depending on risk. In addition, these findings of the increased risk of being HIV-positive and unaware among those diagnosed with TB and those uncircumcised demonstrate the need to increase availability of HIV testing at all service delivery points, such as outpatient departments, voluntary medical male circumcision clinics, and as part of screening for TB and sexually transmitted infections. These findings also demonstrate a missed opportunity for HIV testing for the unaware HIV-positive men who accessed health services if these services were sought after onset of infection.

Tailoring available service delivery points with innovative approaches may be effective to reach men who otherwise would be less prone to access facility-based services unless presenting with advanced stage of disease.26 Differentiation delivery of services has included male-friendly services, use of clinics for men to improve confidentiality/privacy, ensure shorter wait times, and provide extended service delivery hours, which have been met with success in increasing testing uptake in some countries.11,13,27–30 The use of community-based mobile HIV testing was commonly reported among HIV-positive unaware men and could be used in combination with other options, such as self-testing, which is being scaled up in certain SSA countries.31 Although few men reported testing at home, scale-up of self-testing occurred after most of the PHIA surveys used for this analysis were conducted.

The strong association found in partners reported as HIV-positive or of unknown status further strengthens partner testing and contact tracing as effective strategies to identify men who do not know their HIV-positive status.9,11 Given that most unaware men were unsuppressed and reported not using a condom in the past 12 months, their partners are at risk of getting infected. These findings also highlight that men are at risk of acquiring infection by not using a condom while knowing their partner(s) is/are HIV-positive or of unknown status. This underscores the importance of basic prevention measures, including the use of pre-exposure prophylaxis and condoms in HIV-discordant couples.1

Strengths and Limitations

The strength of this analysis is the population representative data across 13 countries with biomarkers linked to demographic and behavioral data. A limitation is that some of the data are based on surveys that started in 2015 and may not reflect the current environment. Our findings use self-report of testing and behavioral factors, which participants may not have disclosed because of social desirability bias. Although ARV testing was used to correct for those on treatment, it is likely that some previously diagnosed participants who were not on treatment did not want to disclose their HIV-positive status, potentially overestimating the true proportion of men's unawareness. Certain variables of interest were not available across all countries and the application of some of these findings may not apply because of contextual/programmatic differences between countries. Caution should also be used when generalizing findings to the western African region as data from only 2 countries were included in this study's regional analysis.

Examining characteristics associated with HIV positivity was shown to be a useful approach and such analyses have been used to develop risk screening tools as part of universal provider-initiated counseling and testing and counseling in facilities across high-burden countries, where the goal is to identify undiagnosed PLHIV and optimize testing yield.32 Once validated, these tools can be adapted by region and selected demographics. However, if the risk screening tools are shown to be an effective method to reach unaware MLHIV earlier and linking them to care in different contexts, then further evaluation of the tools' predictive value is critical.11

CONCLUSION

The results from this large sample suggest that many men in sub-Saharan Africa are likely unaware of their HIV-positive status due to the compounding effects of sociodemographic, behavioral, and clinical influences, albeit with context-specific drivers in each country that are outside the scope of this analysis. Our results found that men who were unaware of their HIV-positive status were at increased risk of poor health outcomes and need earlier engagement of HIV services. When taken together with previous literature, our findings demonstrate that attaining the 95-95-95 UNAIDS goal among MLHIV by 2025 is challenging. Targeted scale-up of both facility-based and community-based approaches will help ensure that MLHIV are health literate, equitably reached, know their status, and are linked to HIV treatment services soon after infection. With the increased availability of standard and new approaches for testing men, more men are being reached for testing, but those at risk still need to test more often. Increased access to and frequency of HIV testing is needed to identify undetected infection in men including in settings where they are accessing services for TB and voluntary medical male circumcision. Our findings also support previous evidence that partner/couples testing and tracing partners' contacts through index testing may help identify HIV-positive men unaware of their status.

REFERENCES

1. UNAIDS. Blind Spot: Reaching Out to Men and Boys. Addressing a Blind Spot in the Response to HIV. Geneva, Switzerland: UNAIDS; 2017. Availabel at: https://www.unaids.org/sites/default/files/media_asset/blind_spot_en.pdf.
2. UNAIDS. Global AIDS Update, 2020. Availabel at: https://www.unaids.org/en/resources/documents/2020/unaids-data.
3. UNAIDS. Global AIDS Update, 2018. Availabel at: https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf.
4. Auld AF, Shiraishi RW, Mbofonah F, et al. Lower levels of antiretroviral therapy enrollment among men with HIV compared with women—12 countries, 2002–2013. MMWR. 2015;64:1281–1286. Availabel at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6446a2.htm?s_cid=mm6446a2_w.
5. Johnson LF. Access to antiretroviral treatment in South Africa, 2004–2011. S Afr J HIV Med. 2012;13:6.
6. Osler M, Cornell M, Ford N, et al. Population-wide differentials in HIV service access and outcomes in the Western Cape for men as compared to women, South Africa: 2008 to 2018: a cohort analysis. J Int AIDS Soc. 2020;23:e25530.
7. Sharma M, Barnabas RV, Celum C. Community-based strategies to strengthen men's engagement in the HIV care cascade in sub-Saharan Africa. PLoS Med.. 2017;14:e1002262.
8. UNAIDS. Women Living with HIV Are More Likely to Access HIV Testing and Treatment. Geneva, Switzerland: UNAIDS; 2020. Availabel at: https://www.unaids.org/en/resources/presscentre/featurestories/2020/october/20201005_women-hiv-testing-treatment.
9. Maman D, Farhat JB, Chilima B, et al. Factors associated with HIV status awareness and linkage to care following home based testing in rural Malawi. Trop Med Int Health. 2016;21:1442–1451.
10. PEPFAR. 2019 Annual Report to Congress. U.S. Department of State. Office of the U.S. Global AIDS Coordinator and Health Diplomacy. Availabel at: https://www.state.gov/wpcontent/uploads/2019/09/PEPFAR2019ARC.pdf. Accessed March 26, 2021.
11. Grimsrud A, Ameyan W, Ayieko J, et al. Shifting the narrative: from the missing men to we are missing the men. J Int AIDS Soc. 2020;23:e25526.
12. Drammeh B, Medley A, Dale H, et al. Sex differences in HIV testing—20 PEPFAR-supported sub-Saharan African countries. MMWR. 2019;69:1801–1806.
13. Mwango LK, Stafford KA, Blanco NC, et al. Index, and targeted community-based testing to optimize HIV case finding and ART linkage among men in Zambia. J Int AIDS Soc. 2020;23:e25520.
14. Indravudh PP, Choko AT, Corbett EL. Scaling up HIV self-testing in sub-saharan Africa: a review of technology, policy and evidence. Curr Opin Infect Dis. 2018;31:14–24.
15. Napierala S, Bair EF, Maruc N, et al. Male partner testing and sexual behaviour following provision of multiple HIV self-tests to Kenyan women at higher risk of HIV infection in a cluster randomized trial. J Int AIDS Soc. 2020;23:e25515.
16. Stender SC, Rozario A. Khotla Bophelong Bo Botle: a gathering of men for health. J Int AIDS Soc. 2020;23:e25511.
17. Dovel K, Dworkin SL, Cornell M, et al. Gendered health institutions: examining the organization of health services and men's use of HIV testing in Malawi. J Int AIDS Soc. 2020;23:e25517.
18. Quinn C, Kadengye DT, Johnson CC, et al. Who are the missing men? Characterising the men who never tested for HIV from population-based surveys in six sub-Saharan African countries. J Int AIDS Soc. 2019;22:e25398.
19. Makusha T, Mabaso M, Richter L, et al. Trends in HIV testing and associated factors among men in South Africa; evidence from 2005, 2008 and 2012 national population-based household surveys. Public Health. 2017;143:1–7.
20. UN Department of Economic and Social Affairs, Methodology. Standard Country or Area Codes for Statistical Use. United Nations. Statistics Division. 2020. Available at: https://unstats.un.org/unsd/methodology/m49/.
21. Brown K, Williams DB, Kinchen S, et al. Status of HIV Epidemic control among adolescent girls and young women aged 15-24 years – seven African countries, 2015-2017. MMWR. 2018;67:29–32.
22. Population-based HIV Impact Assessment (PHIA) Data Use Manual. New York, NY: ICAP, PHIA Project; 2021. Available at: https://dms-filesystem.s3.amazonaws.com/uploads/21352ae0cb0eca87931ff495ee92c0b2/01_PHIA%20Data%20Use%20Manual%20v5.4.pdf.
23. Sachathep K, Radin E, Hladik W, et al. Population-based HIV Impact Assessments Survey methods, response, and quality in Zimbabwe, Malawi, and Zambia. J Acquir Immune Defic Syndr. 2021;87(Suppl 1):S5–S15.
24. World Health Organization. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care; 2019. Availabel at: https://www.who.int/publications/i/item/audit-the-alcohol-use-disorders-identification-test-guidelines-for-use-in-primary-health-care. Accessed March 26, 2021.
25. Gottert A, Pulerwiltz J, Heck CJ, et al. Creating HIV risk profiles for men in South Africa: a latent class approach using cross-sectional survey data. J Int AIDS Soc. 2020;23:e25518.
26. Hlongwa M, Mashamba-Thompson T, Makhunga S, et al. Barriers to HIV testing uptake among men in sub-Saharan Africa: a scoping review. Afr J AIDS Res. 2020;19:13–23.
27. Treves-Kagan S, El Ayadi AM, Pettifor A, et al. Gender, HIV Testing, and Stigma: the association of HIV testing behaviors and community-level and individual-level stigma in rural South Africa differ for men and women. AIDS Behav. 2017;21:2579–2588.
28. Sullivan MC, Rosen AO, Allen A, et al. Falling short of the first 90: HIV stigma and HIV testing in the 90-90-90 era. AIDS Behav. 2020;24:357–362.
29. Edwards JK, Arimi P, Ssengooba F, et al. Improving HIV outreach testing yield at cross-border venues in East Africa. AIDS. 2020;34:923–930.
30. Ramphalla P. Men's Clinics Bring Health Services Closer to Men in Lesotho. 2018 Elizabeth Glazer Pediatric AIDS Foundation. Availabel at: https://www.pedaids.org/2018/09/05/mens-clinics-bring-health-services-closer-to-men-in-the-mountainous-kingdom-of-lesotho/. Accessed January 13, 2021.
31. Shapiro AE, van Heerden A, Krows M, et al. An implementation study of oral and blood-based HIV self-testing and linkage to care among men in rural and peri-urban KwaZulu-Natal, South Africa. J Int AIDS Soc. 2020;3:e25514.
32. PEPFAR. PEPFAR 2020 Country Operational Plan Guidance for All PEPFAR Countries. Washington, DC: US President’s Emergency Plan for AIDS Relief; 2020. Availabel at: https://www.state.gov/wp-content/uploads/2020/01/COP20-Guidance_Final-1-15-2020.pdf.
Keywords:

PHIA; HIV household survey; HIV unawareness; HIV positivity; MLHIV; HIV testing

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.