Spatial patterns of HIV prevalence and Service Use in East Zimbabwe: implications for future targeting of interventions

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Title: Spatial patterns of HIV prevalence and Service Use in East Zimbabwe: implications for future targeting of interventions
Authors: Schaefer, R
Gregson, S
Takaruza, A
Rhead, R
Masoka, T
Schur, N
Anderson, S-J
Nyamukapa, C
Item Type: Journal Article
Abstract: Introduction: Focusing resources for HIV control on geographic areas of greatest need in countries with generalised epidemics has been recommended to increase cost-effectiveness. However, socio-economic inequalities between areas of high and low prevalence could raise equity concerns and have been largely overlooked. We describe spatial patterns in HIV prevalence in east Zimbabwe and test for inequalities in accessibility and uptake of HIV services prior to the introduction of spatially-targeted programmes. Methods: 8092 participants in an open-cohort study were geo-located to 110 locations. HIV prevalence and HIV testing and counselling (HTC) uptake were mapped with ordinary kriging. Clusters of high or low HIV prevalence were detected with Kulldorff statistics, and the socio-economic characteristics and sexual risk behaviours of their populations, and levels of local HIV service availability (measured in travel distance) and uptake were compared. Kulldorff statistics were also determined for HTC, antiretroviral therapy (ART), and voluntary medical male circumcision (VMMC) uptake. Results: One large and one small high HIV prevalence cluster (relative risk [RR]=1.78, 95% confidence interval [CI]=1.53–2.07; RR=2.50, 95% CI=2.08–3.01) and one low-prevalence cluster (RR=0.70, 95% CI=0.60–0.82) were detected. The larger high-prevalence cluster was urban with a wealthier population and more high-risk sexual behaviour than outside the cluster. Despite better access to HIV services, there was lower HTC uptake in the high-prevalence cluster (odds ratio [OR] of HTC in past 3 years: OR=0.80, 95% CI=0.66–0.97). The low-prevalence cluster was predominantly rural with a poorer population and longer travel distances to HIV services; however, uptake of HIV services was not reduced. Conclusions: High-prevalence clusters can be identified to which HIV control resources could be targeted. To date, poorer access to HIV services in the poorer low-prevalence areas has not resulted in lower service uptake, while there is significantly lower uptake of HTC in the high-prevalence cluster where health service access is better. Given the high levels of risky sexual behaviour and lower uptake of HTC services, targeting high-prevalence clusters may be cost-effective in this setting. If spatial targeting is introduced, inequalities in HIV service uptake may be avoided through mobile service provision for lower prevalence areas.
Issue Date: 28-Feb-2017
Date of Acceptance: 1-Feb-2017
ISSN: 1758-2652
Publisher: International AIDS Society
Journal / Book Title: Journal of the International AIDS Society
Volume: 20
Copyright Statement: : © 2017 Schaefer R et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported (CC BY 3.0) License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Sponsor/Funder: Wellcome Trust
Bill & Melinda Gates Foundation
Bill & Melinda Gates Foundation
Funder's Grant Number: 084401/Z/07/Z
Project Number 106
Keywords: Science & Technology
Life Sciences & Biomedicine
Infectious Diseases
Spatial heterogeneity
HIV clustering
targeted interventions
1199 Other Medical And Health Sciences
Publication Status: Published
Article Number: 21409
Appears in Collections:Faculty of Medicine
Epidemiology, Public Health and Primary Care

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