Monitoring socioeconomic inequalities across HIV knowledge, attitudes, behaviours and prevention in 18 sub-Saharan African countries

Abstract

ObjectivesSocioeconomic inequalities in the access to and uptake of HIV prevention services constitute important barriers to global prevention targets, especially in sub-Saharan Africa (SSA). We aimed at monitoring these inequalities based on data from population-based surveys conducted in 18 SSA countries between 2010 and 2018.MethodsWe defined eight HIV indicators aimed at capturing access to and uptake of HIV prevention services among adult participants. Country-specific wealth-related inequalities were measured using the Relative and Slope Index of Inequalities (RII and SII, respectively) and were then pooled using random-effects meta-analyses. We compared inequalities between African regions using the Wilcoxon rank-sum test.ResultsThe sample consisted of 358,591 participants (66% women). Despite the variability in inequalities between countries and indicators, the meta-analysis revealed significant levels of relative and absolute inequalities in 6 out of 8 HIV indicators. For instance, the richest participants were five times more likely than the poorest to report condom use at last sexual intercourse (RII=5.02; 95% confidence interval, CI: 2.79-9.05), corresponding to an absolute difference of 16 percentage-points (SII=0.16; 95% CI: 0.12-0.20). Similar significant inequalities were observed in HIV-related knowledge, positive attitudes toward people living with HIV, recent HIV testing, participation to prevention of mother-to-child transmission programs and medical male circumcision. Overall, inequalities tended to be larger in West and Central vs. East and Southern African countries.ConclusionsDespite efforts to scale-up HIV-prevention programs, socioeconomic inequalities remain substantial over the continuum of HIV primary and secondary prevention in several SSA countries.

Understanding the pathways leading to socioeconomic inequalities in HIV testing uptake in 18 sub-Saharan African countries

“…Mediation analysis was conducted in countries where substantial levels of pro-rich inequalities were observed, majority of which were WCA countries which is consistent to other studies [6,26]. This is quite expected since most WCA countries' healthcare delivery is through private sectors and often has inadequate decentralization of HIV services [27].…”

“…We did not use physical distance itself but the perception that distance would be a problem in seeking care and in some countries like Senegal, HIV services reach the populations through both fixed and mobile strategies [37]. Although magnitude is small, reporting no money-related problem tended to have higher PM in WCA countries which have a widespread policy of user fees for health services [26]. In most countries, married women do not usually need spousal consent legally to access sexual and reproductive health facilities [38] which may explain why no spousal/partner permission to seek a doctor mediate less.…”