Moving beyond hotspots of HIV prevalence to geospatial hotspots of UNAIDS 95-95-95 targets in sub-Saharan Africa

Summary

The HIV epidemic in Sub-Saharan Africa displays a varied geographical distribution, with certain regions termed as HIV hotspots due to a higher prevalence of infection. Addressing these hotspots is essential for controlling the epidemic. However, these regions, influenced by historical factors, challenge standard interventions. Legacy effects, or the lasting impact of past events, play a significant role in the persistence of these hotspots. To address this, a shift towards the UNAIDS 95-95-95 targets is proposed. Spatial analysis of HIV viral load and ART coverage can provide a more comprehensive perspective on the epidemic’s dynamics. Studies in Zambia and Zimbabwe, using this approach, revealed disparities in HIV care metrics across regions. By focusing on the UNAIDS 95-95-95 targets, more effective control strategies can be designed, considering both historical and current factors. This approach would offer a solution-oriented strategy, emphasizing tailored interventions based on specific regional needs.

Introduction

The battle against the HIV epidemic in Sub-Saharan Africa (SSA) has long been marked by a challenge as formidable as the virus itself: the heterogeneity in its geographical spread.^1–3 This paper revisits our understanding of the geographical structure of the HIV epidemic in SSA, where localized regions, known as HIV hotspots, exhibit alarmingly high prevalence rates.^4–6 While the identification and response to these hotspots have been cornerstones of recent HIV control initiatives, this approach, though fruitful, has its limitations.^7–9

In this personal view article, we discuss the challenges in addressing these hotspots, highlighting how socio-economic, cultural, and health system factors impact the epidemic. Focusing solely on HIV prevalence risks neglecting key elements like treatment access and healthcare quality. This discussion is crucial for shaping effective HIV interventions in SSA.

In this context, we discuss a more holistic approach aligning with the UNAIDS 95-95-95 targets. These targets aim not just to diagnose HIV infections but also to ensure effective treatment and achieve viral suppression.^10,11 We posit that this approach is not merely a strategic realignment but a necessary evolution in our fight against HIV/AIDS. It acknowledges the changing dynamics of the epidemic and aligns intervention strategies with the current realities of HIV in SSA.

This personal view, therefore, extends the geospatial perspective of HIV prevalence to include a comprehensive analysis of treatment coverage and viral suppression rates across SSA. By doing so, it provides a critical understanding of the epidemic and lays out a roadmap for future interventions. Our conclusions challenge the traditional hotspot approach and pave the way for more effective, tailored strategies that address the unique needs of diverse regions and communities within SSA.

Spatial structure of the HIV epidemic: HIV hotspots

The HIV epidemic in SSA shows a heterogeneous geographical distribution, with some localized regions exhibiting significantly higher prevalence rates.^1,2,6,12 These geographically defined locations exhibiting an exceedingly high HIV prevalence relative to surrounding areas have been defined as HIV prevalence hotspots.³ In detail, a geospatial hotspot is defined as a specific area or region characterized by a significantly higher rate of a particular condition or attribute, such as HIV prevalence, compared to surrounding areas or the general population. These hotspots are identified through geospatial analysis, which uses geographic information system (GIS) technology to map and analyze spatial relationships and patterns.^2,5 HIV prevalence hotspots are identified using a combination of epidemiological data analysis and geospatial mapping techniques. This process involves collecting HIV prevalence data from various sources, such as health surveys and clinical reports, and then using GIS technology to map these data spatially. HIV prevalence data, being routinely collected, offer significant advantages for identifying geospatial hotspots in comparison to other epidemiological measures like incidence, which are more complex and costly to gather.¹³ Prevalence offers a snapshot of the overall burden of disease within a population at a specific point in time, providing immediate insights into the scale of an epidemic and allowing for the quick identification of areas with higher rates of HIV. Then, analysts look for areas where HIV prevalence significantly exceeds the surrounding regions or national averages, taking into account population density and demographic factors. Statistical methods, like spatial autocorrelation metrics, help in confirming the significance of these hotspots.

It is important to acknowledge that prevalence data provides a static snapshot at a specific time and may not capture the levels of ongoing transmission.¹⁴ Despite this limitation, identifying areas HIV hotspot areas through prevalence data has been instrumental in guiding targeted interventions. This data type supports efficient allocation of resources and targeted interventions without the need for extensive, specialized studies required to accurately measure incidence, making it a practical and effective measure for public health planning and response strategies.⁷ For example, Bulstra and colleagues analyzed national survey data across several countries in Eastern and Southern Africa.¹⁵ This study found that high HIV prevalence in young adults was partly explained by an interplay of behavioral, socioeconomic, and environmental factors. Their results emphasize the importance of focusing HIV prevention interventions on areas of high prevalence among young adults to meet the fast-track commitments to end the HIV epidemic by 2030. Another study conducted in Kenya, Malawi, Mozambique, and Tanzania utilized logistic spatial analysis to map HIV prevalence, revealing stark geographical variability within these countries.² They found a heterogeneous distribution of the HIV prevalence in these countries at the subnational level, suggesting that interventions need to be tailored to local contexts to be effective. Similarly, a study conducted by Dwyer-Lindgren and colleagues conducted a comprehensive mapping of HIV prevalence across sub-Saharan Africa between 2000 and 2017, revealing substantial variability at both the country and subnational levels.¹ This study highlighted the differences in HIV prevalence among first and second administrative subdivisions within countries, underscoring the importance of localized interventions.

This geospatial perspective explored in these and similar studies where the support for geospatially targeted intervention strategies and forms the current approach of long-term planning for HIV elimination efforts in SSA.² Several recent program interventions like the UNADS “know your epidemic, know your response” strategy have adopted this geospatial knowledge into their HIV intervention strategies.¹⁶ This approach has been critical for targeted public health efforts to tailor the specific needs of different populations, optimizing the allocation of resources and enhancing the overall effectiveness of the response to the HIV epidemic in SSA.¹⁶

Nonetheless, it is becoming increasingly evident from an expanding compendium of research that such prevalence hotspots, riddled with intricate historical residuals, pose formidable obstacles impeding the efficacy of standard epidemiological interventions.^7–9 Across SSA, the predominant focus has been on direct treatment and prevention, encompassing antiretroviral therapy (ART), condom distribution, and HIV testing initiatives. Yet, there is increasing evidence to suggest that these interventions achieve optimal effectiveness and better resource allocation when supplemented by strategies addressing the underlying drivers of the epidemic. Notably, the drivers of the current spatial structure of the epidemic are not stationary across SSA regions, preventing the design of interventions targeting these specific drivers.^3,17,18 In circumstances where analyses of data from sources like cross-sectional surveys fail to establish a discernible connection between prevailing factors and the HIV prevalence hotspots, it would be critical to contemplate the influence of legacy effects of the early epidemic. Consequently, despite marked transformations in the original contributory factors and the implementation of numerous interventions, regions with a high HIV burden persist as HIV prevalence hotspots due to the legacy effects of the early epidemic. While the contemporary risk factors may have been alleviated or may not manifest a direct association with the HIV hotspot, the influence of the region’s historical HIV prevalence may continue sculpting present infection patterns.

Legacy Hotspots: Formation and Persistence

Legacy effects in HIV hotspots refer to persistent high-prevalence areas shaped by early transmission dynamics. These legacy effects refer to the lasting impact that past events have on the present circumstances.^19,20 Although existing socio-economic, behavioral, and biological variables may not exhibit a consistent association with any given HIV hotspot, the region’s antecedent events and circumstances continue to exert a considerable influence on its current HIV prevalence.¹⁹

An array of initial conditions has led to an elevated prevalence of HIV that could have been sustained over time, and a community residing in an HIV hotspot might have faced early challenges that influenced its vulnerability to ingoing HIV transmission.²¹ These dynamics may have been molded by many influences, including sociocultural factors, economic conditions, environmental factors, healthcare access and local policies. Following establishment, these prevalence hotspots generally display enduring persistence over time, regardless of modifications in the present risk factors conventionally implicated in the propagation of the HIV epidemic.^4,22 Consequently, the contemporary manifestation of the epidemic in these hotspots represents a complex combination of both historical and current circumstances, with the past exerting a profound, long-lasting influence.²³

To gain a better understanding of legacy hotspots, we summarized the different elements influencing the hotspot emergency in the following conceptual model (Figure 1). The model begins with the HIV infection, infecting the individual, and then interacting with the contextual variables to yield HIV transmission outcomes. Biological and behavioral factors influence individual outcomes along with contextual variables. Meanwhile, the contextual variables interact with individuals by changing legacy and current conditions, including cultural, economic, environmental, healthcare access, heritage, political, and social contexts to influence the distribution of HIV outcomes.^24,25 The HIV outcomes (prevalence, incidence, morbidity and mortality) could also impact contextual variables, for example, changing healthcare access by increasing telehealth services in SSA. In addition, the geographic contextual unit plays a significant role throughout the process. The HIV hotspots are a product of HIV outcomes and the geographic contextual units. The HIV hotspots may change HIV distribution and transmission infections as well. These conditions create a favorable environment for the start and spread of the epidemic, leading to the emergence of a HIV hotspot.^20,26

Figure 1.

Conceptual model of the emergence of HIV hotspots

During the nascent stages of the HIV/AIDS epidemic in SSA, factors such as a lack of disease awareness, cultural norms, limited condom accessibility, and elevated labor migration rates may have played instrumental roles in fueling a swift initial emergence of HIV in certain regions.^27–29 For example, migration patterns linked to male populations been relocated to mining areas in search of employment, might have increased the risk by potentially engaging in multi-partner or transactional sexual activities, thereby acquiring the virus and subsequently transmitting it to their partners upon returning to their respective communities. These circumstances could have been key factors in catalyzing the emergence of HIV hotspots. In a counteractive response, governmental and non-governmental entities may have mobilized comprehensive HIV education drives, enhanced condom accessibility, and initiated diagnostic and therapeutic programs. These interventional efforts could have induced a gradual decline in the prevalence of the risk as mentioned earlier factors over time in these high HIV-burden areas.^1,30,31

Once established, an HIV hotspot tends to display sustained persistence, even in attenuating these initial contributory elements of the original epidemic. Moreover, this longevity can be attributed to numerous reasons. Primarily, HIV is a chronic infection that, without treatment, persists for a lifetime. Thus, individuals who contracted the infection during the early phases of a given hotspot’s formation, continues contributing to the local HIV prevalence. Moreover, HIV prevalence may remain elevated within the hotspot due to the presence of structured transmission networks.^8,32 These networks tend to be generated through relational and interactive dynamics within individuals in the community based on sexual connections that facilitate disease transmission.³³ The perpetuation of high HIV prevalence can be significantly attributed to these established transmission networks, initially formed during the early high prevalence phase. As such, sexual relationship patterns that emerged during the initial phase could persist, acting as channels for ongoing transmission.³³ Consequently, through the passage of time and the maturation phase of the epidemic, these high-burden areas could evolve into legacy hotspots. As a result, despite the potential attenuation of the initial risk factors, HIV prevalence remains high due to the enduring effects of established transmission networks and the legacy of high initial prevalence.^9,34

The Need for Alternative Epidemiological Measures: The UNAIDS 95-95-95 Targets

Addressing these HIV prevalence hotspots effectively necessitates a comprehensive approach that integrates both historical and contemporary factors. This approach involves considering the intricate network of interconnected individuals and the socio-economic, environmental, and healthcare factors that influence HIV transmission over time. Given the complex nature of these hotspots, strategies that solely target current prevalence may not capture the legacy effects crucial to understanding and mitigating the epidemic.

Acknowledging the efforts and constraints inherent to solely focus on HIV prevalence, it is crucial to transition the assessment of the determinants of HIV hotspots towards alternative epidemiological measures that could offer a more intricate understanding of the current spatial dynamics of the HIV epidemic. One such promising strategy centers on geographical hotspots in alignment with the UNAIDS 95-95-95 targets (Figure 2).³⁵ Established by UNAIDS, the ambitious 95-95-95 targets aim for a dramatic increase in the number of people living with HIV who are diagnosed, treated, and virally suppressed by 2030. The first target (95% diagnosed) emphasizes widespread HIV testing access and reducing stigma to ensure early diagnosis. The second target (95% on treatment) focuses on simplifying treatment initiation, expanding healthcare services, and promoting “Test and Start” strategies for immediate ART access. Though it does not cure HIV, ART can significantly reduce the HIV viral load, and the quantity of HIV in a person’s blood and is a vital indicator of individual health status and the risk of HIV transmission, aiding individuals to live healthier and longer lives and diminishing the risk of transmission.^{36,37 35} Finally, the third target (95% virally suppressed) highlights the importance of adherence support programs, consistent medication access, and viral load monitoring to achieve undetectable viral loads, significantly reducing transmission.^10,11

Figure 2.

A conceptual model including alternative epidemiological measures to identify HIV hotspots

A shift in focus towards these UNAIDS 95-95-95 targets marks the transition from a purely problem-oriented approach towards one that is more solution-oriented.³⁸ In the context of the HIV epidemic, a spatial analysis of HIV testing, ART coverage, and viral load suppression could prove instrumental in the design of effective control strategies, by identifying regions that are falling short of these targets and require intensified efforts.³⁹ However, analyses of the spatial structure of these epidemiological measures require comprehensive population-based data. Surveys such as the Population-based HIV Impact Assessments (PHIA) can serve as an optimal source for such data, providing extensive information on HIV prevalence, testing, ART coverage, viral load suppression among those on treatment, and other crucial HIV-related indicators.⁴⁰ The PHIA Project, initiated in 2014, conducts nationally representative surveys in countries most affected by HIV. These surveys, led by the Ministry of Health in each country with funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) and technical support from ICAP at Columbia University, aim to assess the current state of the HIV epidemic. By offering household-based HIV counseling and testing with immediate return of results and collecting data on access to care and treatment services, PHIA surveys focus on measuring progress toward UNAIDS’ 95-95-95 targets, guiding HIV policy and funding priorities towards epidemic control.

Studies utilizing PHIA data have played a critical role in identifying gaps in the HIV care continuum, particularly at demographic and socioeconomic levels, guiding policy and funding priorities towards epidemic control. For instance, differentiated service delivery (DSD) models, as evaluated in studies like the Link4Health⁴¹ and Engage4Health,⁴² have demonstrated significant improvements in linkage to care and retention in care by simplifying and adapting services to meet client preferences and expectations. These studies underline the importance of client-centered approaches in enhancing the effectiveness of HIV care continuum outcomes and highlight the potential for DSD models to facilitate achieving the 95-95-95 goals by reaching individuals not currently engaged with the health system.⁴³ In another example, the Côte d’Ivoire Population-based HIV Impact Assessment (CIPHIA) survey revealed important insights into the country’s progress towards HIV epidemic control and identified specific gaps in testing services. The survey results indicated advancements in ART uptake and viral load suppression but also highlighted significant gaps, especially among young people and men, in knowledge about HIV and the delivery and uptake of HIV services. Collectively, these studies have emphasized the need for tailored interventions to address the identified gaps and improve HIV services across different age groups, genders, and regions, using differentiated service models across the HIV care continuum.⁴⁴

Furthermore, PHIA surveys collect the geographical coordinates of the locations where data were gathered in the country, which were recorded using the global positioning system (GPS) during the household survey. This geospatial information allows the implementation of spatial analysis of the indicators collected in the survey. The implementation of geospatial detection of clusters of each of the UNAIDS targets using this data can uncover vulnerable populations in specific locations with different needs. In detail, a geospatial cluster for the first 95 target is a geographical area where significant numbers of people living with HIV do not know their HIV status, identifying potential areas that have not been reached with HIV testing services, leading to undiagnosed cases. The identification of such hotspots of undiagnosed individuals would be crucial for scaling up testing efforts and ensuring that individuals are aware of their status as a first step towards getting them into care. Likewise, a geospatial cluster for the second target, treatment, is a geographical area where significant numbers of those diagnosed with HIV are not receiving sustained ART. This could indicate challenges such as inadequate access to healthcare services, ART stockouts, stigma, or other barriers preventing people living with HIV from initiating or continuing their treatment in this area. Identifying these geospatial hotspots for the second target allows for targeted interventions to improve ART coverage, such as enhancing healthcare infrastructure, implementing community-based ART distribution, or addressing socio-economic barriers to treatment access. Lastly, a geospatial cluster for the third target, viral suppression, is defined by a geographical area where significant numbers those on ART do not achieve viral suppression. These hotspots might face issues like poor adherence to treatment, suboptimal ART regimens, or lack of access to regular viral load monitoring. Mapping the spatial distribution of viral loads enables public health officials to pinpoint areas where individuals living with HIV may not effectively manage their disease.⁴⁵ A community with high viral loads suggest issues such as inadequate access to health care, lack of adherence to ART, or the presence of treatment-resistant strains of HIV. Therefore, mapping these elements – HIV viral load and ART coverage – can offer a more detailed understanding of the epidemic.⁴⁶ For instance, regions demonstrating a high HIV viral load, but low ART coverage might be prioritized for interventions to enhance access to ART, improve patient adherence to therapy, or address local HIV stigma.

Using this approach we recently have conducted studies that implemented spatial analysis techniques to further explore the HIV epidemic in Zambia and Zimbabwe, in alignment with the UNAIDS “95-95-95” targets.^39,47 Estimated adult HIV prevalence (15–49 years) in Zambia is around 10.8% (2021), which translates to approximately 1.3 million people living with HIV in the country. In Zambia, HIV hotspots have been characterized by factors such as high population mobility, including mining communities and border areas with increased migration, as well as socioeconomic conditions that can limit access to healthcare services.⁴⁸ These areas may also have a legacy of inadequate health infrastructure and societal factors like stigma that hinder effective HIV control efforts.⁴⁹ Recognizing these characteristics, Zambia has implemented targeted control programs focusing on mobile testing and treatment services in mining areas, border health initiatives to address the needs of migrant populations, and community engagement programs aimed at reducing stigma and increasing healthcare access. These targeted strategies are informed by a deep understanding of the local epidemic’s dynamics and are designed to address the specific challenges of HIV hotspots within the country. In addition to these factors, specific sexual networks, such as those associated with transactional sex or men who have sex with men (MSM), can also amplify HIV transmission within hotspots, creating a disproportionate burden on these populations. Likewise, in Zimbabwe, the estimated adult HIV prevalence is around 12.9% (2020), which translates to approximately 1.23 million people living with HIV in the country.⁵⁰ The geographical distribution of HIV in Zimbabwe is influenced by factors such as commercial transport corridors, diamond mining activities, and cross-border mobility, particularly affecting men in specific regions.^46,51 For women, especially in remote and poorer areas, early sexual contact heightens their HIV risk, pointing to the necessity of targeted interventions like pre-exposure prophylaxis (PrEP) for young women in these locales​​.⁵²

Findings from our studies using PHIA data from these two countries reveal substantial disparities in the HIV care continuum metrics across different population sectors and geographical regions within both countries. Progress towards achieving the “95-95-95” targets exhibits significant variation across the country’s distinct regions, with each of the three “95s” demonstrating unique geographical patterns that may be significantly different from the local HIV prevalence. Our research underscores the importance of region-specific interventions to address gaps in the HIV care continuum, as each “95” presented a unique geographical pattern that could be distinct from HIV prevalence. This implies that national-level reporting of the “95-95-95” targets may be insufficient, and different subnational regions within the country might necessitate specific approaches to healthcare enhancement to improve progress towards each HIV treatment goal. Addressing the within-country variations in HIV prevalence, testing coverage, and ART linkage is essential. These countries have been strategizing interventions based on district-specific needs, focusing on improving HIV testing services, enhancing linkage to ART through community-based initiatives, and tackling unique challenges such as mobility among artisanal miners and cross-border issues affecting districts bordering Zambia and Mozambique.⁵³ Implementing the Southern African Development Community (SADC) HIV and AIDS Cross Border Initiative has been part of the strategic approach to provide care and track patients across borders, acknowledging the economic challenges in Zimbabwe that impact HIV control efforts​​.

While this innovative approach bears significant potential, it is not without challenges. The attainment of high-quality data is dependent on the application of rigorous methodologies and substantial resource allocation. The stigma and trepidation associated with HIV testing may impose restrictions on survey participation, impacting the quality and representation of the data. Additionally, the heterogeneity in health infrastructure and contextual determinants such as socioeconomic and cultural factors, both across and within countries, can influence the implementation and efficacy of these programmatic interventions.⁵⁴ Likewise, while PHIA surveys offer valuable insights, their design prioritizes district- or zonal-level analysis, potentially limiting their suitability for fine-grained spatial evaluations. Advanced statistical techniques, such as geostatistical and Bayesian spatial models, can address this limitation. These methodologies incorporate geographical coordinates and spatial dependencies, allowing for adjustments based on the survey’s sampling design and weights. Consequently, these models facilitate the estimation of HIV-related indicators at a more localized level. However, the accuracy of hotspot identification remains susceptible to biases arising from sampling variability. Furthermore, acknowledging the inherent limitations of PHIA data, it is crucial to emphasize the potential value of combining it with other data sources and community-level knowledge. Such a comprehensive approach fosters validation and refinement of geospatial analyses. By integrating epidemiological and socio-cultural context from affected communities, this strategy ensures that hotspot identification transcends mere statistical significance and is grounded in real-world conditions. Ultimately, this comprehensive approach enhances the utility of PHIA data for the development of targeted HIV intervention strategies.

Future Directions of HIV Interventions

Our approach does not dismiss the importance of identifying HIV prevalence hotspots. Instead, it emphasizes the necessity of broadening the indicators necessary for shaping our understanding of the spatial dynamics of the HIV epidemic. By incorporating more complex metrics, such as those outlined by the UNAIDS 95-95-95 targets, we can elucidate a more comprehensive picture of the current status of the HIV epidemic and discern the specific needs of vulnerable communities most heavily affected by the epidemic. These strategies would be paramount for achieving the UNAIDS 95-95-95 targets and for the sustainability of HIV care in a post-UNAIDS targets era.

Concrete policy recommendations for more effectively addressing legacy hotspots and realizing the UNAIDS 95-95-95 targets could involve ramping up community-based testing services, incorporating robust patient tracking systems, and enhancing ART delivery. A more strategic investment in healthcare infrastructure, especially in remote and underserved areas, can improve the access and quality of HIV care.^54,55

Geospatial targeting within the UNAIDS 95-95-95 approach can significantly enhance HIV surveillance and public health efforts. By employing this data-driven method, health authorities can deploy precision public health measures like “Test and Start” strategies more effectively, ensuring that individuals diagnosed with HIV begin antiretroviral therapy immediately.⁵⁶ This approach prioritizes faster viral suppression, leading to improved health outcomes for those living with HIV and dramatically reducing the risk of transmission to others. Widespread testing access, including rapid tests and increased testing locations, is crucial for successful implementation. Therefore, an identification of the geospatial areas with the highest need would facilitate the delivery of this strategy. This not only aids in achieving the 95-95-95 targets but also improves surveillance by providing precise data on intervention impact, guiding future public health decisions.

More specifically, expanding community-based testing is directly linked to the first 95 target, aiming to diagnose 95% of all HIV-positive individuals. This approach is particularly effective in rural and hard-to-reach areas where access to healthcare facilities may be limited. Expanding community-based testing services is crucial, with the deployment of mobile HIV testing units in rural and hard-to-reach areas.⁵⁷ These units, equipped with testing kits and staffed by trained healthcare workers, can offer free, confidential HIV testing in remote villages, improving accessibility and early detection. Policies to reduce stigma and discrimination associated with HIV are also paramount in increasing the willingness of individuals to get tested and seek treatment. This approach would help encourage countries to achieve their UNAIDS 95-95-95 goals and to preserve sustainable HIV care during a post-UNAIDS targets era to ensure that individuals with HIV receive proper care, treatment, and monitoring.

Likewise, to effectively target the first 95 (testing) within identified hotspots, strategies should encompass partner services and contact tracing to influence connections of known HIV-positive individuals, integrating HIV testing with other health services to capitalize on routine care encounters, and initiating workplace HIV testing programs in sectors with heightened mobility or risk. Additionally, educational campaigns and social mobilization efforts can demystify testing and reduce stigma, while data analytics could pinpoint under-tested yet high-prevalence areas for focused intervention. These multifaceted approaches, tailored to the unique dynamics of each hotspot, promise to enhance testing coverage and uptake significantly.

Enhancing ART delivery is another critical aspect (second 95). Introducing home-based ART delivery in these second 95 hotspots, particularly in remote areas, can ensure consistent access to medication. Strategies could involve enhancing linkage to care through immediate ART initiation programs at the point of diagnosis, deploying community health workers to follow up with diagnosed individuals to ensure they start treatment, and implementing mobile clinics in hotspots to provide on-site ART initiation. By partnering with local community health workers to deliver ART medications directly to patients’ homes, barriers to accessing treatment can be significantly reduced. Investment in healthcare infrastructure is also vital. Constructing and equipping local health centers in underserved regions with essential medical equipment and trained medical personnel would not only provide HIV care but also improve general healthcare services. This approach ensures a more holistic health system strengthening.

Technological advancements, such as digital health tools and electronic medical records, support the second and third 95 targets by improving treatment initiation and monitoring viral suppression. For example, telemedicine services can facilitate the initiation of antiretroviral therapy for newly diagnosed individuals by providing remote consultations, thus overcoming geographical and logistical barriers. Likewise, the implementation of robust patient tracking systems is key. The development of digital health records and a smartphone app for healthcare providers would enable efficient tracking of patient visits, ART adherence, and viral load results. This technological integration facilitates timely interventions and follow-ups, ensuring continuity of care. At the same time, artificial intelligence could improve predicting outbreak hotspots or identifying patterns of disease spread, ^58,59 and including more granular data, such as patterns of HIV drug resistance, would amplifying the specificity and effectiveness of targeted interventions.

Other strategies might include personalized medication management plans to cater to individual lifestyles and constraints, offering nutritional support to improve treatment efficacy, leveraging peer mentorship programs where individuals on successful treatment regimens mentor those struggling with adherence, and expanding access to pharmacological interventions like long-acting injectables that reduce the burden of daily pill-taking. Furthermore, integrating mental health services within HIV care can address psychological barriers to viral suppression, ensuring a holistic approach to treatment adherence and health maintenance.

On the societal front, increasing awareness about HIV and promoting inclusivity could encourage more people to get tested and seek treatment, reducing morbidity and transmission rates. Launching educational campaigns and community workshops to reduce stigma associated with HIV is essential. By organizing community events led by local leaders and healthcare professionals, myths can be dispelled, promoting a more inclusive and stigma-free environment.

Likewise, incorporating gender into the specification of the UNAIDS 95-95-95 hotspots might be essential due to the distinct ways HIV affects men and women, influenced by biological, social, and structural factors. Gender-specific interventions can address unique challenges faced by each gender, such as barriers to accessing care, differing social and economic vulnerabilities, and the impact of gender-based violence on HIV risk. Recognizing and responding to these gendered dynamics within hotspots can enhance the effectiveness of HIV programs, ensuring that interventions are appropriately tailored to meet the needs of all individuals, thereby improving health outcomes and advancing towards the 95-95-95 targets more effectively.

Furthermore, collaboration with local NGOs for tailored interventions is necessary to understand and meet the specific needs of different communities. Through surveys and focus groups, unique challenges and preferences can be identified, allowing for the design of customized health interventions that resonate with each community. Incorporating these steps into the existing healthcare systems of SSA requires a concerted effort from governments, NGOs, and local communities. Such a comprehensive approach is critical to not only achieving the UNAIDS targets but also ensuring the sustainability of HIV care in the region. The summarizing panel provided below encapsulates the key strategic recommendations of this section, focusing on geospatial analysis and targeted interventions to meet the UNAIDS 95-95-95 targets effectively.

Summarizing panel

95% of People Know Their HIV Status

• Expand Community-Based Testing: Implement mobile HIV testing units in rural and hard-to-reach areas to improve accessibility and early detection. Employ geospatial analysis to identify these high-need areas for targeted deployment.

• Integrate Testing with Health Services: Combine HIV testing with other routine health services and workplace programs to maximize reach and efficiency, especially in identified hotspots.

• Education and Social Mobilization: Launch educational campaigns and social mobilization efforts to demystify testing and reduce stigma, using data analytics to focus on under-tested areas.

95% of Diagnosed People Receiving ART

• Home-Based ART Delivery: Enhance ART access via home delivery systems, particularly in remote areas pinpointed through geospatial targeting, to ensure continuous treatment availability.

• Infrastructure and On-Site Services: Construct and equip local health centers within identified hotspots to provide on-site ART initiation and care, supported by mobile clinics for immediate linkage to care post-diagnosis.

• Technology and Healthcare Integration: Implement digital health tools and electronic medical records to support ART initiation and monitor adherence, utilizing telemedicine to overcome geographic barriers.

95% of People on ART Achieving Viral Suppression

• Robust Patient Tracking and AI Utilization: Develop comprehensive digital tracking systems to monitor treatment adherence and viral load; use AI to predict and manage outbreak hotspots and optimize interventions.

• Comprehensive Care Approaches: Integrate mental health services and nutritional support into HIV care protocols to enhance treatment adherence and viral suppression outcomes.

• Innovative Treatment Options: Expand access to pharmacological innovations like long-acting injectables to simplify treatment regimens, particularly in geospatially identified regions with adherence challenges.

General Recommendations for Enhancing Intervention Effectiveness

• Gender-Specific Interventions: Tailor interventions to address the unique challenges faced by different genders in hotspot areas, considering social, economic, and biological factors that influence HIV risk and care accessibility.

• Community Collaboration and Customization: Work closely with local NGOs and community groups to design and implement customized interventions that address specific local needs, as identified through geospatial analysis and community feedback.

• Policy Enhancement and Stigma Reduction: Develop policies that facilitate easier access to testing and treatment, reduce HIV-related stigma, and promote inclusivity, ensuring sustainable HIV care beyond the achievement of the 95-95-95 targets.

Conclusions

Our study calls for a detailed understanding of the spatial dynamics of the epidemic, urging health policymakers and practitioners to adopt a dual approach that continues to address the needs of high-prevalence areas while expanding focus to include broader treatment and prevention strategies. This approach is not merely a response to the limitations of current strategies but a proactive step towards sustainable, long-term control of the HIV epidemic in SSA. Moreover, we would like to highlight the critical role of robust data systems, community engagement, and the need to address stigma and healthcare accessibility as integral parts of this strategy. The adaptability of the 95-95-95 targets to diverse regional contexts in SSA offers a flexible framework for developing tailored interventions, ensuring that no community is left behind in our collective quest for HIV control. As we look to the future, this holistic approach bears the potential to refine the tailoring of our interventions, reducing cost and ultimately advancing us closer to controlling and eliminating the HIV epidemic in SSA.