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. 2024 Jan 4;95(1 Suppl):e97–e105. doi: 10.1097/QAI.0000000000003329

Temporal Trends and Determinants of HIV Testing at Antenatal Care in Sub-Saharan Africa: A Pooled Analysis of Population-Based Surveys (2005–2021)

Adrien Allorant a, Paul Muset a, Caroline Hodgins a, Fati Kirakoya-Samadoulougou b, Khumbo Namachapa c, Francisco Mbofana d, Dimitra Panagiotoglou a, Leigh F Johnson e, Jeffrey W Imai-Eaton f,g, Mathieu Maheu-Giroux a,✉
PMCID: PMC10769174  PMID: 38180847

Supplemental Digital Content is Available in the Text.

Key Words: HIV/AIDS, HIV testing, antenatal care, sub-Saharan Africa, Bayesian statistics

Abstract

Background:

In sub-Saharan Africa (SSA), integrating HIV testing into antenatal care (ANC) has been crucial toward reducing mother-to-child transmission of HIV. With the introduction of new testing modalities, we explored temporal trends in HIV testing within and outside of ANC and identified sociodemographic determinants of testing during ANC.

Methods:

We analyzed data from 139 nationally representative household surveys conducted between 2005 and 2021, including more than 2.2 million women aged 15–49 years in 41 SSA countries. We extracted data on women's recent HIV testing history (<24 months), by modality (ie, at ANC versus outside of ANC) and sociodemographic variables (ie, age, socioeconomic status, education level, number of births, urban/rural). We used Bayesian generalized linear mixed models to estimate HIV testing coverage and the proportion of those that tested as part of ANC.

Results:

HIV testing coverage (<24 months) increased substantially between 2005 and 2021 from 8% to 38%, with significant variations between countries and subregions. Two percent of women received an HIV test in the 24 months preceding the survey interview as part of ANC in 2005 and 11% in 2021. Among women who received an HIV test in the 24 months preceding the survey, the probability of testing at ANC was significantly greater for multiparous, adolescent girls, rural women, women in the poorest wealth quintile, and women in West and Central Africa.

Conclusion:

ANC testing remains an important component to achieving high levels of HIV testing coverage and benefits otherwise underserved women, which could prove instrumental to progress toward universal knowledge of HIV status in SSA.

INTRODUCTION

In 2020, an estimated 1.5 million people acquired HIV, of whom 60% resided in sub-Saharan Africa (SSA).1 New HIV infections are disproportionately concentrated among women and girls, with adolescent girls and young women (aged 15–24 years) representing 25% of all new HIV acquisitions.1 The Global AIDS Strategy 2021–2026 aims to end the AIDS epidemic by prioritizing people who are currently left behind in the HIV response.2 This requires attention to barriers to HIV testing, including lack of geographic or financial access to health care, stigma, or attitude toward HIV, which are often driven by social determinants such as gender, age, education, wealth, and location of residence.3–5

HIV testing services (HTS) are the necessary first step to knowing one's HIV status and entering the treatment cascade. These services allow those at ongoing HIV acquisition risk to be linked to appropriate combination prevention interventions, such as preexposure prophylaxis, voluntary medical male circumcision, and condoms, among others.6,7 Expanding HTS through various modalities—voluntary counselling and testing, provider-initiated testing and counselling, home-based testing—increased HIV diagnosis coverage from an estimated 6% of people living with HIV aware of their status in SSA in 2000 to 84% in 2020.8

Integrating HTS into antenatal care services (ANC) has been effective in increasing testing coverage among pregnant and postpartum women.9–11 It is also believed to make HIV testing a commonplace and normalized part of healthcare for women, removing the stigma and financial barriers associated with seeking testing.12 Moreover, this approach can reach most pregnant women because currently, 80%–90% of pregnant women in SSA attend at least one ANC visit,13 and most countries adopted an “opt-out” approach where HIV testing is the default. HIV testing at ANC is particularly crucial for the early diagnosis and access to treatment of pregnant women living with HIV to prevent mother-to-child transmission (MTCT), which accounts for an estimated 9% of new HIV infections globally.1,14 Elimination of MTCT includes goals of more than 95% ANC coverage, more than 95% coverage of HIV testing at ANC, and more than 95% ART coverage of pregnant women living with HIV.15

Concomitantly, other HIV testing modalities, such as mobile testing or HIV self-testing, have been implemented as alternatives to facility-based testing to increase access.16–19 More recently, efforts to more efficiently reach persons with untreated HIV have motivated the scale-up of mixed-testing modalities, including assisted partner notification or index testing, which tend to have higher new HIV diagnosis yields (ie, higher percentage of positives among people tested).20,21 Combined with declining fertility across SSA in the past decades,22 the emergence of new testing modalities may lead to a decline in the relative importance of ANC as a modality to reach women for HIV testing.23

To achieve UNAIDS’ ambitious diagnostic target of 95% people living with HIV aware of their status, countries' focus and mix of testing approaches need to be adapted to their local epidemics.7 At this critical time for national HIV testing strategies, we analyzed historical and comparative perspective of the role of ANC among women's access to and uptake of HIV testing. Specifically, we synthesized data from 41 SSA countries on recent HIV testing (in the past 24 months), estimated the proportion of these recent tests that were performed during ANC visits, and examined regional, country, and sociodemographic factors associated with HIV testing at ANC.

METHODS

Survey Data

We reviewed nationally representative, population-based, cross-sectional surveys conducted in SSA from 2005 to 2021 that collected information on women's HIV testing histories and HIV testing at ANC. The following data catalogs were searched to complement a previous review of HIV testing8,24: the Global Health Data Exchange, the WHO Multi-Country Studies Data Archive, and the WHO NCD Microdata Repository. The main type of surveys included are the Demographic and Health Surveys (DHS), AIDS Indicator Surveys (AIS), Population-based HIV Impact Assessment (PHIA), Multiple Indicator Cluster Surveys (MICS), and other country-specific surveys (eg, Kenya AIDS Indicator Survey; South African National HIV Prevalence, Incidence, Behaviour, and Communication Survey). DHS/AIS data were extracted using the rdhs package.25

Data Preprocessing and Outcome Definitions

HIV testing coverage was measured as the proportion of women aged 15–49 years who reported a recent HIV test (in the past 24 months) and received its result. We focused on the past 24 months to capture HIV testing at ANC among both pregnant women and those who recently gave birth. Testing in the past 24 months was consistently available from all surveys included. HIV testing at ANC was measured as the proportion of women who reported an HIV test during an ANC visit, among the women who were tested for HIV in the past 24 months. This definition therefore includes women who tested both in ANC settings and outside ANC settings in the past 2 years.

Statistical Analysis

We developed Bayesian logistic mixed-effects models for two outcomes: 1) the proportion of all women (15–49 years) reporting recent HIV testing and 2) the proportion of women tested at ANC among those reporting recent testing. Models included nested random effects by survey, country, and subregion (Eastern, Central, Southern, or Western Africa). Subregion assignments followed the definition of subregions used by the United Nations' Statistics Division.26 To account for survey designs, we replaced observed counts with weighted counts, using survey weights, which were normalized using the Kish effective sample size to account for unequal sampling probabilities.27,28 First-order random walk models were used to capture trends in HIV testing and country random slopes to allow for heterogeneity in country testing trajectories over the study period. Finally, we examined the following sociodemographic determinants of HIV testing: 5-year age group, households' relative wealth quintile (see Figure S2, Supplemental Digital Content, http://links.lww.com/QAI/C156), educational attainment (less than primary education; primary education; secondary education; more than secondary education), geographical strata (urban/rural), and number of births (0–1 births; 2–3; 4–5; 6+ births). Full details on the model specifications and selection are in the Tables S1–S2, Supplemental Digital Content, http://links.lww.com/QAI/C156.

Posterior distributions of all model parameters and hyperparameters were estimated using a Hamiltonian Monte Carlo sampling algorithm with 4 Markov Chains and 4000 iterations each (including 1000 iterations for warm-up), implemented with the statistical package R-Stan version 2.2829 in R. Model convergence was assessed by calculating the potential scale reduction factor30 and the effective sample size for each parameter. Estimates and their associated 95% uncertainty intervals were obtained by drawing 1000 posterior samples for all parameters estimated in the model and calculating their mean, and the 2.5th and 97.5th percentiles. We reported the estimated effect of sociodemographic factors using odds ratio and as average marginal effects, expressed as the average difference in the probability of HIV testing during ANC among women who recently got tested for HIV associated with each covariate, with all other covariates taking on their observed values.31 We performed a sensitivity analysis in which the determinants of HIV testing at ANC were restricted to pregnant and postpartum women only (see Supplementary Results, Supplemental Digital Content, http://links.lww.com/QAI/C156).

We calculated population-weighted estimates of recent HIV testing, recent HIV testing at ANC, and recent HIV testing outside of ANC, at country, subregional, and regional levels, using poststratification by drawing 1000 samples for the parameters' posterior distributions. Poststratifying involved reweighting estimates for each observed country–year–demographic combinations based on the relative size of each demographic combination in the total population of women aged 15–49 years in each country and year,27,32 which was derived from 41 available censuses in 27 countries and 199 population-based surveys in 41 countries. Additional methodological details about poststratification, along with a description of the data sources and processes used to estimate the size of demographic combinations over time and across countries, and comparisons with 5-year age group yearly estimates from the World Population Prospects 2022 Revision,33 can be found in Figures S3–S4, Supplemental Digital Content, http://links.lww.com/QAI/C156.

All analyses were performed using the R software and the rstan library (version 2.28).29 R code reproducing the analysis, full list of data sources, and yearly estimates for all countries are available from https://github.com/pop-health-mod/anc-testing. This study adheres to the Guidelines for Accurate and Transparent Health Estimates Reporting statement, and the checklist can be found in Table S3, Supplemental Digital Content, http://links.lww.com/QAI/C156.

Ethics

All analyses were performed on publicly available and deidentified data. All DHS/AIS survey protocols were reviewed and approved by the Internal Review Board of ICF International in Calverton and by the relevant country authorities regarding other survey instruments used in this study (MICS and PHIA). Ethics approval for secondary data analyses was obtained from the McGill University's Faculty of Medicine Institutional Review Board (A10-E72-17B).

RESULTS

Survey Data

We identified 176 nationally representative population-based surveys conducted in SSA from 2005 to 2021. Of these, we included 139 surveys (82 DHS/AIS, 36 MICS, 13 PHIA, and 8 other) based on data accessibility and inclusion of questions on recent HIV testing (Fig. 1). One hundred twenty-eight of these surveys were included in the analysis of testing at ANC; 11 were excluded because of not having data on HIV testing at ANC. The 139 included surveys came from 41 unique countries and included responses from more than 2.2 million women aged 15–49 years. Of these 41 countries, 36 had multiple surveys and the median survey year was 2013 (see Figure S1, Supplemental Digital Content, http://links.lww.com/QAI/C156).

FIGURE 1.

FIGURE 1.

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Flowchart of considered, included, and excluded nationally representative population-based surveys for the analyses of recent HIV testing and proportion of HIV testing in ANC settings in sub-Saharan Africa (2005–2021).

HIV Testing in the Last 24 months at and Outside of ANC

Across all countries, the proportion of women aged 15–49 years who tested for HIV in the past 24 months (gray curve, Fig. 2, bottom left) increased substantially between 2005 and 2021 from 8% (5%–11%) to 39% (32%–48%). Although these gains resulted from increases in both testing at ANC (red curves) and outside of ANC (blue curves), the contribution of the latter was consistently larger over time: 2% (1%–3%) vs. 6% (5%–6%) in 2005, but 11% (8%–14%) vs. 28% (24%–31%) in 2021. Nationally, although recent HIV testing coverage increased in most countries, disparities between countries increased. Recent testing coverage increased by more than 50%-points in Malawi, Uganda, Zambia, Kenya, Zimbabwe, Lesotho, eSwatini, and South Africa, whereas testing coverage changed minimally in countries such as Mauritania, Mali, Niger, and DRC (gray curve, Fig. 2, right). This heterogeneity in recent testing coverage was mostly driven by substantial national differences in testing coverage outside of ANC (blue curves), which ranged from 67% (52%–75%) in eSwatini and Lesotho to 5% (4%–6%) in Mauritania and Madagascar, in 2021. By contrast, the proportion of women who recently received an HIV test during an ANC visit (red curves) varied less between the countries, extending from 17% (8%–33%) in Uganda and Tanzania to 2% (1%–3%) in Mauritania and Chad, in 2021.

FIGURE 2.

FIGURE 2.

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Recent HIV testing coverage (ie, last 24 months), in ANC settings and outside of ANC, among women aged 15–49 years in sub-Saharan Africa countries, between 2005 and 2021. We present country-mean estimates of the proportion of women who received an HIV test in the past 24 months (gray curves), broken down between testing during an ANC visit (red curves), and outside of an ANC visit (blue curves). Crosses, circles, and triangles represent survey mean estimates of recent HIV testing coverage, recent testing at ANC, and recent testing outside of ANC, respectively. Shaded areas represent 95% uncertainty intervals. Countries in white on the inset map of Africa were not included in the model for the lack of survey data. Countries in Western, Central, Eastern, and Southern Africa are colored in orange, indigo, red, and turquoise, respectively. Centr. Afr. Rep., Central African Republic; Congo, Republic of Congo; DRC, Democratic Republic of Congo; Sao Tome, Sao Tome and Principe.

These national time trends suggested diverging subregional trends in recent testing coverage associated with national HIV prevalence: in Eastern and Southern African countries with high HIV prevalence, testing coverage increased steeply, whereas in Western and Central Africa where HIV prevalence is lower, coverage increased much more slowly (see Figure S5, Supplemental Digital Content, http://links.lww.com/QAI/C156). In Eastern and Southern Africa, testing outside of ANC contributed much more to total testing coverage than testing conducted at ANC. By contrast, in Central and Western Africa, a greater proportion of women were tested outside of ANC than at ANC overall, but the difference was smaller compared with the Eastern and Southern African subregions.

Determinants of Recent HIV Testing and of Testing at ANC Among Women Recently Tested

Among women in SSA, age and education were the strongest predictors of recent HIV testing within the past 24 months (Fig. 3A). After adjusting for other covariates, young adult women and those with higher educational levels had higher odds of recent HIV testing. For example, the odds of recent HIV testing were 3.2 times higher among women aged 20–24 years and 3.4 times higher among women aged 25–29 years, compared with adolescent girls and young women aged 15–19 years. On average, across countries and years, the probability of recent HIV testing among women aged 25–29 years was 3.7% greater than for adolescent girls and young women aged 15–19 years (Fig. 4A). In addition, women with higher educational attainment were more likely to have received recent HIV testing. The odds of recent HIV testing were 1.7 times higher among women with primary education, 2.2 times higher among those with secondary education, and 3.3 times higher among those with more than secondary education, compared with women with less than primary education. Across countries and years, the probability of recent HIV testing among women with more than secondary education was 1.9% higher than for those with less than primary education. Other sociodemographics were also associated with recent HIV testing. Women living in rural areas had lower odds of having recently received a HIV test (OR = 0.7 [0.7–0.7]), compared with women living in urban areas, whereas women in higher household relative wealth quintiles and women with more births were more likely to have received an HIV test in the past 24 months, after adjusting for all other factors. However, these statistically significant associations translated to less than 1%-point differences on the probability scale.

FIGURE 3.

FIGURE 3.

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Odds ratio mean estimates and 95% intervals for the logistic regression model predicting recent HIV testing among all women aged 15–49 years in sub-Saharan Africa (A) and for the logistic regression model predicting testing during ANC among women who reported recently being tested for HIV (B), by covariates. Purple circles are used for demographic predictors, red triangle for socioeconomic variables, and blue square for other covariates. The mean estimates are displayed above the circles. Horizontal lines are 95% confidence intervals. For each variable, the reference category is indicated in parenthesis.

FIGURE 4.

FIGURE 4.

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Change in the probability of recent HIV testing among all women aged 15–49 years in sub-Saharan Africa (A) and of testing during ANC among women who reported recently being tested for HIV (B), given a change in the covariates. This figure shows the estimated mean marginal effects of 6 covariates on the probability of HIV testing at ANC on a linear scale, obtained by postestimation simulation from the model. Purple circles are used for demographic predictors, red triangle for socioeconomic variables, and blue square for other covariates. The mean effect estimates are displayed above the circles. Horizontal lines are 95% credible intervals.

Among women recently tested for HIV, the strongest predictor of testing at ANC was the number of births (Fig. 3B). Holding all other covariates constant, women with more births were more likely to have recently been tested at ANC; for instance, across years, the odds of HIV testing at ANC were 3.7 times (3.7–3.8) higher among women with 4–5 births and 5.9 times (5.7–6.1) higher among women with 6+ births, compared with women with less than 2 births. On average, across countries and years, for women with 4–5 births, the probability of HIV testing at ANC among recently tested women was 33.6% (16.8%–41.6%) greater than that for women with less than 2 births (Fig. 4B). Other strong predictors of testing at ANC included age. Among women who recently received a HIV test, adolescent girls and young women were more likely to have received it during an ANC visit, compared with women in all older age groups. Across countries and years, the probability of HIV testing at ANC among recently tested women for women aged 25–29 years was 15.9% (7.1%–23.3%) lower than that for women aged 15–19 years.

Socioeconomic covariates were also associated with HIV testing at ANC, although not as strongly as the demographic covariates. Women in higher household wealth quintiles had lower odds of HIV testing at ANC compared with women in the poorest quintile. Among women recently tested, those in the middle wealth quintile had lower odds of HIV testing at ANC than those in the lowest wealth quintile (OR = 0.88; 0.87–0.90). In absolute terms, among women recently tested, those in the middle household wealth quintile had 4.3% (1.7%–5.7%) lower probability than those in the lowest wealth quintile of having a recent ANC test. Similarly, among women who were recently tested, those with higher educational attainment were less likely to have received a recent ANC test, compared with women with no primary education. Holding all else equal, women who attained secondary education had an estimated probability of HIV testing at ANC 6.8%-points (2.5%–9.3%) lower than women with less than a primary education. Finally, we estimated that testing at ANC was on average 4.2% (1.8%–5.5%) more likely among rural women compared with urban women.

Determinants of Recent HIV Testing at ANC Among Pregnant and Postpartum Women

In a sensitivity analysis restricted to pregnant and postpartum women in our sample, we found similar, although weaker, associations among pregnant and postpartum women (see Figure S7, Supplemental Digital Content, http://links.lww.com/QAI/C156): the effects of age, rural residence, household relative wealth quintile, and subregion were closer to the null. The main change was the estimated effect of education: higher educational attainment was associated with higher odds of testing at ANC.

DISCUSSION

Understanding trends and sociodemographic determinants of HIV testing is essential for optimizing national HIV testing strategies and meeting global targets to end AIDS. By pooling data from 139 surveys, this study examined recent HIV testing uptake, and testing at and outside of ANC, among women across SSA countries between 2005 and 2021. Although we found important increases in the proportion of women tested for HIV in the past 24 months, we observed substantial variations between countries and regions because of differences in coverage of testing outside of ANC. Conversely, an estimated 10% of women aged 15–49 years in SSA received an HIV test during an ANC visit each year, with less geographic variations. Sociodemographic factors, such as age, education, and number of births, were strong predictors of recent HIV testing and testing at ANC.

In all four sub-Saharan African regions, recent HIV testing coverage increased substantially between 2005 and 2021. Despite this overall progress, our results highlighted notable subregional differences: recent HIV testing coverage among women has increased at substantially steeper rates in Southern and Eastern Africa compared with Western and Central Africa. Southern and Eastern Africa comprise several of the countries with the heaviest HIV burden in the world, such as South Africa, Kenya, Tanzania, Uganda, Mozambique, Malawi, and Zambia, which have the largest amounts of funding for HIV/AIDS spending.34 Andersen's35 health care utilization model posits that “enabling” factors (eg, health system) and needs are key determinants of service utilization. Our findings can be interpreted in the light of this model: in countries where HTS are widely available and national HIV prevalence is highest (see Figure S6, Supplemental Digital Content, http://links.lww.com/QAI/C156), women are more likely to get tested for HIV regularly. Our results also highlighted lower HIV testing uptake in Western and Central Africa. Although these subregions have lower HIV prevalence, the proportion of people living with HIV aware of their status is also inferior; 84% (76%–97%) in Western and Central Africa compared with 91% (83%–98%) in Eastern and Southern Africa.36

Amidst overall increases in HIV testing mainly driven by the scale up of other testing modalities, a steady 10% of all women aged 15–49 years in SSA received a HIV test during an ANC visit in the past 24 months since 2011. With the substantial decreases in fertility rates over the past decade, a simultaneous decrease in HIV testing in ANC settings could have been expected; our results could be explained by several factors. First, previous studies have shown that ANC attendance has improved in SSA, ensuring high levels of access to HIV testing among pregnant women,37–39 which could offset the effects of decreasing fertility. Furthermore, even in Western and Central Africa where recent HIV testing outside of ANC was low, several countries maintained the level of recent HIV testing coverage at ANC above 10% (eg, Burkina Faso, Cameroon, Central African Republi, Gabon, Togo). This could indicate that, in these countries where population testing coverage is low, investments toward the elimination of MTCT safeguard broad access to HIV testing among women during pregnancy.15,40

Our analysis also revealed that women who were urban, educated, wealthy, multiparous, and older were more likely to have been tested for HIV in the past 24 months. This confirms previous studies that have shown an age-based gap in HIV testing coverage41,42 and identified rurality and lower socioeconomic status as barriers to HIV testing access for women in SSA.5,43 However, regarding determinants of the most recent HIV test being done during an ANC visit, our study suggested that primary users of this testing modality were more likely to be rural women, multiparous, adolescent girls and young women, women with lower educational achievement, and women in the lower household relative wealth quintiles. This could be because of higher fertility in these groups, and further analysis restricting our data set to pregnant and postpartum women was conducted. Although weaker, we found similar statistically significant associations among pregnant and postpartum women, except for education—higher educational attainment was associated with higher odds of testing at ANC (see Figure S7, Supplemental Digital Content, http://links.lww.com/QAI/C156). Our results suggest that among women recently tested for HIV, testing during ANC is a modality that reached women who otherwise lacked access to HTS.

The findings of this study should be interpreted considering the following limitations. First, we assumed that self-reported HIV testing outcomes are accurate,44 but our estimates could be affected by telescoping bias, which would likely result in a possible overestimation of recent HIV testing uptake.24 However, this should not affect the trends over time or estimates of the proportion of recent testing at and outside of ANC. Second, through poststratification, we combined census and survey data to interpolate the national female population over the study period. It is possible that this procedure introduced oversmoothing of population changes and ultimately of national/regional trends in HIV testing. Third, we modeled the effects of the sociodemographic covariates on HIV testing as constant over time. In exploratory analyses, however, we found minimal temporal changes in the predictors' effect. Despite these limitations, our work has several strengths. First, although previous studies had presented single-country or cross-sectional analyses, we systematically analyzed all available survey data using Bayesian hierarchical models to produce estimates of HIV testing coverage among women in SSA (15 years and older) with associated uncertainty. Second, our study provides estimates of the relative importance of HIV testing during ANC compared with all other modalities, uncovering important trends for national HIV testing programs. Finally, our regression model incorporated sociodemographic predictors emphasizing the crucial importance of HIV testing at ANC for women typically lacking access to health services.

In conclusion, recent HIV testing among women has increased substantially in the past 15 years. Frequent testing and retesting are important to diagnose and (re)engage people living with HIV in the treatment and care continuum. Although various testing modalities have been scaled up, HIV testing at ANC remains a critical and consistent means of testing for women in SSA. The Global AIDS Strategy 2021–2026 highlights the need to reduce inequalities in access to HIV services, particularly among adolescents and young women in high-incidence areas. Our study shows that HIV testing during ANC benefits underserved women, including adolescents, and young women, particularly in regions with low testing uptake. Therefore, in addition to reducing new infections in children, prioritizing MTCT prevention is instrumental to ensure equitable access to HIV testing and prevention services for pregnant women who may otherwise lack access.

Supplementary Material

SUPPLEMENTARY MATERIAL
qai-95-e97-s001.docx (1.6MB, docx)

ACKNOWLEDGMENTS

This research has been supported by the Canadian Institute of Health Research.

Footnotes

A.A. was supported through a Fonds de la recherche du Québec—Santé (FRQS) Post-Doctoral Fellowship. M.M.-G.'s research program is funded by a Canada Research Chair (Tier 2) in Population Health Modeling. P.M. was supported through the Dr. Kenneth Remsen Global Health Award and the Dr. Freda M.Omaswa Travel Award for the Study of Infectious and Tropical Diseases through the McGill Undergraduate Global Health Scholars Program. D.P. is supported by a FRQS Junior 1. J.W.I.-E. was supported by UNAIDS, the Bill and Melinda Gates Foundation (OPP1190661), the National Institute of Allergy and Infectious Disease of the National Institutes of Health under award number R01AI152721, and the MRC Centre for Global Infectious Disease Analysis (reference MR/R015600/1), jointly funded by the UK Medical Research Council (MRC) and the UK Foreign, Commonwealth & Development Office (FCDO), under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the European Union.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jaids.com).

A.A. and P.M. contributed equally.

Contributor Information

Adrien Allorant, Email: adrien.allorant@mail.mcgill.ca.

Paul Muset, Email: Paul.muset@mail.mcgill.ca.

Caroline Hodgins, Email: caroline.hodgins@mail.mcgill.ca.

Fati Kirakoya-Samadoulougou, Email: fati.kirakoya@ulb.be.

Khumbo Namachapa, Email: knamachapa@hivmw.org.

Francisco Mbofana, Email: mbofana12@gmail.com.

Dimitra Panagiotoglou, Email: dimitra.panagiotoglou@mcgill.ca.

Leigh F. Johnson, Email: leigh.johnson@uct.ac.za.

Jeffrey W. Imai-Eaton, Email: jeffrey.eaton@imperial.ac.uk.

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