Risk scores for predicting HIV incidence among adult heterosexual populations in sub-Saharan Africa: a systematic review and meta-analysis
File(s)
Accepted version
Supporting information
Author(s)
Type
Journal Article
Abstract
Introduction: Several HIV risk scores have been developed to identify individuals for prioritised HIV prevention in sub-Saharan Africa. We systematically reviewed HIV risk scores to: (i) identify factors that consistently predicted incident HIV infection, (ii) review inclusion of community-level HIV risk in predictive models, and (iii) examine predictive
performance.
Methods: We searched nine databases from inception until February 15, 2021 for studies developing and/or validating HIV risk scores among the heterosexual adult population in sub-Saharan Africa. Studies not prospectively observing seroconversion or recruiting only key populations were excluded. Record screening, data extraction, and critical appraisal
were conducted in duplicate. We used random-effects meta-analysis to summarise hazard ratios and the area under the receiver-operating characteristic curve (AUC-ROC).
Results: From 1563 initial search records, we identified 14 risk scores in 13 studies. Seven studies were among sexually active women using contraceptives enrolled in randomised-controlled trials, three among adolescent girls and young women (AGYW), and three among cohorts enrolling both men and women. Consistently identified HIV prognostic 51
factors among women were younger age (pooled adjusted hazard ratio: 1.62 [95% 52 Confidence Interval: 1.17, 2.23], compared to above-25), single/not cohabiting with primary partners (2.33 [1.73, 3.13]) and having sexually transmitted infections (STIs) at baseline (HSV-2: 1.67 [1.34, 2.09]; curable STIs: 1.45 [1.17; 1.79]). Among AGYW only STIs were consistently associated with higher incidence, but studies were limited (n=3). Community-level HIV prevalence or unsuppressed viral load strongly predicted incidence but were only considered in three of 11 multi-site studies. The AUC-ROC ranged from 0.56 to 0.79 on the model development sets. Only the VOICE score was externally validated by multiple studies, with pooled AUC-ROC 0.626 [0.588, 0.663] (I2: 64.02%).
Conclusions: Younger age, non-cohabiting, and recent STIs were consistently identified as predicting future HIV infection. Both community HIV burden and individual factors should be considered to quantify HIV risk. However, HIV risk scores had only low-to-moderate discriminatory ability and uncertain generalisability, limiting their programmatic utility. Further evidence on the relative value of specific risk factors, studies populations not restricted to ‘at-risk’ individuals, and data outside South Africa will improve the evidence
base for risk differentiation in HIV prevention programmes.
performance.
Methods: We searched nine databases from inception until February 15, 2021 for studies developing and/or validating HIV risk scores among the heterosexual adult population in sub-Saharan Africa. Studies not prospectively observing seroconversion or recruiting only key populations were excluded. Record screening, data extraction, and critical appraisal
were conducted in duplicate. We used random-effects meta-analysis to summarise hazard ratios and the area under the receiver-operating characteristic curve (AUC-ROC).
Results: From 1563 initial search records, we identified 14 risk scores in 13 studies. Seven studies were among sexually active women using contraceptives enrolled in randomised-controlled trials, three among adolescent girls and young women (AGYW), and three among cohorts enrolling both men and women. Consistently identified HIV prognostic 51
factors among women were younger age (pooled adjusted hazard ratio: 1.62 [95% 52 Confidence Interval: 1.17, 2.23], compared to above-25), single/not cohabiting with primary partners (2.33 [1.73, 3.13]) and having sexually transmitted infections (STIs) at baseline (HSV-2: 1.67 [1.34, 2.09]; curable STIs: 1.45 [1.17; 1.79]). Among AGYW only STIs were consistently associated with higher incidence, but studies were limited (n=3). Community-level HIV prevalence or unsuppressed viral load strongly predicted incidence but were only considered in three of 11 multi-site studies. The AUC-ROC ranged from 0.56 to 0.79 on the model development sets. Only the VOICE score was externally validated by multiple studies, with pooled AUC-ROC 0.626 [0.588, 0.663] (I2: 64.02%).
Conclusions: Younger age, non-cohabiting, and recent STIs were consistently identified as predicting future HIV infection. Both community HIV burden and individual factors should be considered to quantify HIV risk. However, HIV risk scores had only low-to-moderate discriminatory ability and uncertain generalisability, limiting their programmatic utility. Further evidence on the relative value of specific risk factors, studies populations not restricted to ‘at-risk’ individuals, and data outside South Africa will improve the evidence
base for risk differentiation in HIV prevention programmes.
Date Acceptance
2021-12-06
Citation
Journal of the International AIDS Society, 25 (1)
ISSN
1758-2652
Publisher
International AIDS Society
Journal / Book Title
Journal of the International AIDS Society
Volume
25
Issue
1
Copyright Statement
© 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.
License URL
Sponsor
UNAIDS
Bill & Melinda Gates Foundation
Medical Research Council (MRC)
Bill & Melinda Gates Foundation
UNAIDS
Bill & Melinda Gates Foundation
Identifier
https://onlinelibrary.wiley.com/doi/10.1002/jia2.25861
Grant Number
2017/778519
INV-006733
MR/R015600/1
EPPHZM5513/Imperial
2019/974072
GR424146
Subjects
HIV incidence
adolescent girls and young women
risk factors for HIV incidence
risk scores
sub-Saharan Africa
1103 Clinical Sciences
1117 Public Health and Health Services
1199 Other Medical and Health Sciences
Publication Status
Published