HIV/AIDS surveillance data analysis in Tigray, Ethiopia (2016–2020), with sub-analysis of most-at-risk populations and HIV co-infections (2019–2020)

Abstract

Background

Globally, 37.7 million individuals were living with HIV in 2020, with 1.5 million new infections and over 500,000 deaths. In Ethiopia, approximately 616,105 people were living with HIV in 2021. In Tigray, over 45,000 people were on antiretroviral therapy (ART) in 2020. Despite improved service access and extensive ART delivery, HIV remains a major public health challenge in Tigray, with a 1.4% prevalence rate. This analysis aims to describe HIV burden and service indicators in Tigray (2016–2020), with a sub-analysis of most-at-risk populations and HIV co-infections (2019–2020).

Methods

A retrospective cross-sectional study was conducted using secondary data extracted from the District Health Information System (DHIS-2) for the years 2016–2020. Data for most-at-risk populations (MARPs) and HIV co-infections were available only for 2019–2020. The analysis was performed using Microsoft Excel 2019.

Results

The prevalence of HIV in Tigray was 1.13% (62,657) with variation by persons and places. Females were more affected by HIV, with 1.43% (39,913) cases compared to 0.83% (22,744) in males. The prevalence of HIV ranged from the highest 15,117(4.41%) in Mekelle to the lowest 0.44% (2,756) in the southeastern zone. The prevalence of malnutrition among PLHIV increased from 25.9% (9,617) in 2016 to 56.7% (35,496) in 2020, while the prevalence of nutritional supplementation decreased from 76.2% (7,327) to 6.5% (2,295). The prevalence of HIV among HIV-exposed children increased from 5.43% (43) in 2016 to 9.29% (96) in 2020. In the sub-analysis, among TB patients & Sexually Transmitted Infections (STIs) tested for HIV, 6% (728) of TB and 3.2% (1,223) of STI patients had previously undiagnosed HIV infection.

Conclusion

The findings of this study showed that HIV infection varied by person and place. A higher HIV rate was observed in Women and the Mekelle zone. The trend of HIV testing and ART initiation among pregnant and lactating women varied by service delivery point. An increased trend of HIV infection among HIV-exposed infants, HIV prevalence and malnutrition among PLHIV were also observed. These findings suggest the importance of strengthening community-based HIV testing, PMTCT services, and nutritional support for PLHIV.

Background

Human immunodeficiency virus (HIV) has become and remains a significant public health challenge, especially in developing countries, including Ethiopia [1]. Globally, over 37 million people were living with HIV in 2020, with 1.5 million new HIV infections and over half a million deaths from AIDS-related causes. There were over 10 million people who were not receiving HIV treatment. Among those, over 4 million didn’t know their HIV-positive status, and about 6 million knew their status but couldn’t access treatment [2].

Sub-Saharan Africa (SSA) accounts for the largest proportion of PLHIV, with over 20 million individuals affected in 2019 [3]. Similarly, studies have indicated that SSA countries are the region most influenced by the pandemic of HIV, with nearly 1 out of 25 adults living with HIV [4]. In Ethiopia, the HIV epidemic has passed through different stages, from a localised and concentrated epidemic among most at-risk populations during the initial phase of rapid transmission to the current mixed epidemic, which is sustained in roughly equal measure by new infections from most at-risk groups and the general population [5]. To overcome the burden of HIV, a new global commitment has led to a dramatic increase in the number of PLHIV taking antiretroviral therapy (ART) in recent years, especially in resource-limited countries [4]. Since 2005, Ethiopia has made substantial progress in expanding the accessibility and utilisation of ART [6].

Ethiopia has significantly strengthened its control over the HIV pandemic. Decades of intervention have led to an 81% drop in new infections since 1995 and a 35.5% decrease in overall cases since 2002. However, after this significant improvement in reducing the burden of HIV for decades, the incidence of HIV has increased by 10% since 2008, and newly diagnosed HIV cases increased by 36% in all age groups each year [7]. The recent estimate of more than 13,000 new infections in Ethiopia in 2020 indicates that there has been an ongoing spread of HIV in the population. More than 60% of the new infections are occurring in Amhara, Oromia, SNNP, and Tigray. The burden of new HIV infections in these regions is absolute numbers due to their relatively large population. However, other regions, such as Gambella and Addis Ababa, have a higher HIV incidence. The total number of PLHIV receiving ART increased both nationally and regionally in 2020. In Ethiopia, there were over 745,000 PLHIV on ART [8]. In Tigray, there were about 45,000 PLHIV on ART [9].

Although many studies have been conducted on HIV, most of them were analytic studies [10]. Program-related descriptive data analysis was not commonly performed for a long period. Nevertheless, these studies remain essential for monitoring routine service delivery, enabling stakeholders to track operational trends, implement timely interventions, evaluate shifting dynamics, and refine program strategies. Furthermore, community awareness has expanded significantly since the early stage of the HIV pandemic, with most individuals now recognizing the benefits of knowing their HIV status. Despite this increased knowledge, HIV remains a major public health challenge in the Tigray region, which maintains a prevalence rate of 1.4% [11].

The majority of the community members are expected to be aware of their HIV status, and most PLHIV are expected to receive ART [12]. However, a prevalence study on a random sample from the community may be affected by non-response. PLHIV and individuals with risky sexual behaviour may be unwilling to participate in the study, and HIV negative individuals may be willing to participate [13–15]. Hence, these routine ART-related prevalence estimates are expected to provide insights into the burden of HIV in the region.

Therefore, this study provides information on the region’s HIV-related service provision and the minimum regional-level HIV prevalence, which can be used by other scholars to justify their regional-level HIV prevalence estimates, whether it is underestimated or not. It is also important to identify the trend and distribution of HIV across the region. Although such studies should be conducted regularly, regional-level ART-related data have not yet been adequately examined in Tigray. Hence, this study offers valuable insights to support informed decision-making for organisations such as the Tigray Regional Health Bureau (TRHB), nongovernmental organisations (NGOs), and policymakers.

Methods and materials

Study area and period

This study was conducted in Tigray, Ethiopia, where the HIV prevalence was estimated at 1.4% by the end of 2020 [16], . According to the 2007 Ethiopian housing and population census, the estimated population in 2020 was around 6 million. HIV prevalence in urban areas of Tigray was 2.7% [17]. These estimates suggest that HIV has been a public health concern in the region, and HIV related studies are crucial for tracking and informed program amendments at every level of decision-making. This study encompasses seven zones: Western, Central, Southern, Southeastern, Northern, Northeastern, and Mekelle Zone.

Study design

A retrospective cross-sectional descriptive study using routine HIV surveillance data was conducted to describe HIV burden and service indicators in Tigray.

Data inclusion criteria

HIV surveillance data recorded in the DHIS-2 database from 2016 to 2020 were included in the analysis. However, data on Most at-risk Populations (MARPs) and HIV co-infections, including TB-HIV and HIV-STI, were only available for 2019–2020 and were therefore analysed separately without trend analysis.

Data collection

Data were extracted from the District Health Information Software (DHIS-2) with the collaboration of the head of the Health Management Information System (HMIS). DHIS-2 provides tools for integrated disease surveillance and reporting using WHO recommended frameworks [18]. The variables were sex, age, zone, TB-HIV co-infection, STI-HIV co-infection, and nutritional status of the PLHIV on ART.

Data quality control

After extraction from the DHIS-2 database, the data were organized and cleaned using Microsoft Excel 2019. The dataset was checked for completeness, consistency, duplicate entries, and reporting errors before analysis. Records with major inconsistencies or incomplete information were excluded. Data verification was conducted in collaboration with the regional Health Management Information System (HMIS) team to ensure consistency with routine surveillance reports.

Data processing and analysis

Descriptive analysis was used to examine HIV-related morbidity and mortality by person, place, and time. Data were analysed using Microsoft Excel 2019. Reported HIV prevalence estimates were calculated using the regional population as the denominator. Since the study focused on summarising routine surveillance data for program monitoring rather than analysing population-based samples, inferential statistics and confidence intervals were not calculated.

Routine ART reports were used to assess the HIV burden and service indicators. The utility of these programmatic data may have improved following Ethiopia’s 2016 Test and Treat policy [19]. This shift is reflected in EPHIA data, which indicates that among adults aware of their HIV-positive status, a high proportion (97.1%) were enrolled in ART, with similar rates observed across women (96.4%) and men (98.9%) [20]. However, these estimates do not account for undiagnosed individuals or those without access to care and may underestimate the true HIV burden compared to population-based surveys such as EPHIA.

Result

Descriptive analysis of HIV burden and service indicators (2016–2020)

The findings presented in this section cover data from 2016 to 2020 and show the long-term patterns of HIV burden and related service indicators in Tigray.

Based on the routine ART report in Tigray in 2020, the prevalence of HIV was 1.13% (62,657). Females were more affected by HIV, 1.42% (39,913), compared to 0.83% (22,744) in males. Similarly, females aged 15 years or above were more affected by HIV, 2.2% (38,329) in females compared to 1.25% (21,118) in males (Table 1).

Table 1.

The prevalence of HIV by sex and age based on routine ART data of Tigray, Ethiopia, 2020

Age in Years	Sex	Population	Cases	Prevalence (%)
0_4	Male	397,655	391	0.10
	Female	408,928	400	0.10
5_14	Male	632,596	1235	0.20
	Female	650,528	1184	0.18
>=15	Male	1,695,280	21,118	1.25
	Female	1,743,338	38,329	2.20
Subtotal	Male	2,725,530	22,744	0.83
	Female	2,802,794	39,913	1.42
	Total	5,528,324	62,657	1.13

The prevalence of HIV ranged from the highest 4.41% (15,117) in Mekelle City to the lowest at 0.44% (2,756) in the southeastern zone (Fig. 1).

Fig. 1.

HIV prevalence by zone based on the routine ART report of Tigray, Ethiopia, 2020

Between 2016 and 2020, of the total population (5,528,324) of Tigray, 68.9% (3,811,195) had ever tested for HIV, of whom 0.58% (22,183) were living with HIV. Among females, 98.3% (2,755,918) had tested for HIV, and 0.51% (14,100) of them were living with HIV, while 38.7% (1,055,277) of males had ever tested, from these 0.81% (8,524) were living with HIV.

The prevalence of HIV increased from 0.73% (37,086) in 2016 to 1.13% (62,657) in 2020, while the case fatality rate dropped from 0.5% (185) in 2016 to 0.1% (63) in 2020 (Fig. 2).

Fig. 2.

Trend of HIV prevalence and mortality rate based on the routine ART report of Tigray, Ethiopia, 2016–2020

The prevalence of malnutrition among PLHIV increased by more than twofold from 25.9% (9,617) in 2016 to 56.7% (35,496) in 2020, among PLHIV screened for malnutrition, while nutritional supplementation decreased sharply from 76.2% (7,327) in 2016 to 6.5% (2,295) in 2020 (Fig. 3).

Fig. 3.

The prevalence of malnutrition and nutritional supplementation in PLHIV in Tigray, 2016–2020

The overall testing of HIV in PLWs increased from 73% (149,675) in 2016 to 88.9% (197,003) in 2020. However, testing during Labor and delivery increased from 7.9% (11,883) in 2016 to 13.5% (26,554) in 2020. Similarly, testing at PNC increased from 0.2% (329) in 2016 to 1.2% (2,306) in 2020 (Fig. 4).

Fig. 4.

HIV testing among pregnant and lactating women by time testing in Tigray, Ethiopia, 2016–2020

ART initiation during labour and delivery increased from 12.7% (78) in 2016 to 13.8% (169) in 2020. ART initiation during PNC slightly decreased from 5.4% (33) in 2016 to 4.6% (56) in 2020. ART initiation during ANC remained similar from 81.9% (503) in 2016 to 81.6% (998) in 2020 (Fig. 5).

Fig. 5.

Antiretroviral therapy (ART) initiation in pregnant and lactating women by the timing of initiation in Tigray, Ethiopia, 2016–2020

The prevalence of HIV among PLWs increased from 0.81% (1,206) in 2016 to 0.84% (1,517) in 2019, then it decreased to 0.64% (1,254) in 2020. The prevalence of HIV among HIV-exposed children who get HIV confirmatory tests at 18 months decreased from 5.43% (43) in 2016 to 2.48% (26) in 2019, then it increased to 9.29% (96) in 2020 (Table 2).

Table 2.

HIV prevalence in PLWs and HIV-exposed infants of Tigray, 2016–2020

Variables		Year
	2016	2017	2018	2019	2020
PLWs tested for HIV	149,675	171,754	194,554	180,521	197,003
PLWs positive for HIV	1206	1648	1591	1517	1254
%	0.81	0.96	0.82	0.84	0.64
Antibody test at 18 months	792	1115	1269	1048	1033
HIV positive children	43	49	41	26	96
%	5.43	4.39	3.23	2.48	9.29

PLW, pregnant and lactating women

Sub-analysis of MARPs and HIV co-infections (2019–2020)

The data on MARPs and HIV co-infection presented in this section covers only 2019–2020. These findings offer a snapshot of that specific period and do not show a long-term trend.

Among most-at-risk populations (MARPs), the overall prevalence of HIV in MARPs was 1.57% (3,385). It ranged from the highest, 3.45% (465), among partners of PLHIV to the lowest, 1.12% (35), among prisoners (Table 3).

Table 3.

The prevalence of HIV in MARPS based on the routine ART report of Tigray, Ethiopia, 2019–2020

MARPs	Screened	HIV positive	%
Female commercial Sex workers	28,933	371	1.28
Long-distance drivers	13,376	190	1.42
Mobile/Daily Labourer	59,766	932	1.56
Orphan and vulnerable children	2104	63	2.99
Children of PLHIV	6098	115	1.89
Prisoners	3127	35	1.12
Partners of PLHIV	13,474	465	3.45
Other MARPs	89,335	1214	1.36
All MARPs	216,213	3385	1.57

MARPs (Most At-risk Populations)

In the sub-analysis of HIV co-infections, 6% (728) of tuberculosis (TB) patients had previously undiagnosed HIV infection, 3.2% (1223) of sexually transmitted infection (STI) patients were HIV positive, and 2.4% (1498) of people living with HIV (PLHIV) tested for TB had active TB (Table 4).

Table 4.

TB-HIV, HIV-TB, and HIV-STI co-infections in Tigray, Ethiopia, 2019–2020

Co-infections	Sex	Tested	Positive	%
PLHIV tested for TB	Male	22,744	809	3.6
	Female	39,913	689	1.7
	Total	62,657	1498	2.4
TB patients tested for HIV	Male	6962	417	6.0
	Female	5121	311	6.1
	Total	12,083	728	6.0
STI patients tested for HIV	Male	15,005	379	2.5
	Female	22,945	844	3.7
	Total	37,950	1223	3.2

STI, Sexually Transmitted Infections

Discussion

This study shows that the prevalence of HIV in Tigray is 1.13%, with the highest burden observed among women and in the Mekelle zone. Among TB patients and Sexually Transmitted Infections (STIs) screened for HIV, 6.0% of TB patients and 3.2% of STI patients have previously unrecognised HIV infection. Furthermore, HIV prevalence among infants born to mothers living with HIV showed an increasing trend.

The prevalence of HIV in Tigray was 1.13%, which is comparable to the 1.2% reported in EDHS 2016 [21]. HIV prevalence was higher among females (1.42%) than in males (0.83%), which is also consistent with EDHS 2016 estimates (1.2% female and 0.6% in males) [21]. Previous studies have suggested that biological susceptibility, gender inequalities, and barriers to HIV prevention and treatment services may contribute to the higher HIV burden among women [22, 23].

Geographic variation in HIV prevalence was observed across zones, with the highest prevalence (4.44%) in Mekelle. The higher prevalence observed in Mekelle is consistent with previous reports showing a greater HIV burden in urban settings in Tigray [20]. According to WHO guidelines, a mixed pattern of HIV was observed across populations and geographic areas [24]. Differences in HIV prevalence across factors such as unemployment, low education, unstable housing, and multiple partnerships were reported [25].

The findings show a decline in HIV-related mortality among PLHIV on ART, from 0.5% in 2016 to 0.1% in 2020. This is lower than the earlier report from Tigray, where mortality decreased from 21.5% in 2007–2010 to 11.71% in 2017–2019 [26]. However, these mortality estimates based on routine program data may be affected by underreporting and survivorship bias.

The findings show a decreasing trend in viral suppression rate from 78.8% in 2016 to 64% in 2020. The observed viral suppression rate did not meet the UNAIDS 2020 target of 90% [27]. It is also lower than the 89.6% viral suppression rate reported in EPHIA 2017–2018 [20]. The decline in viral suppression occurred alongside increasing malnutrition and declining nutritional support. Previous studies have reported associations between nutritional status and viral suppression [28].

The study also shows an increasing trend of HIV infection among HIV-exposed children, from 5.43% in 2016 to 9.29% in 2020. These are higher than the 2.1% mother-to-child transmission of HIV (MTCT) prevalence reported in 2019 in Tigray [29]. The increasing trend of HIV among HIV-exposed children occurred alongside an increased ART initiation during labour and delivery from 12.7% in 2016 to 13.8% in 2020, as shown in this study. Studies have reported that HIV infection among HIV-exposed infants may be influenced by maternal HIV status at the time of pregnancy or delivery [30].

The findings show that the prevalence of HIV among TB patients was 6.0%, while TB was detected in 0.12% of PLHIV. These figures are notably lower than the 8.4% and 0.9% rates previously documented in Ethiopia [31]. Furthermore, HIV-STI co-infection prevalence was higher among women (3.68%) than men (2.53%). While these co-infection rates are present in our study area, they remain significantly lower than those found in high-prevalence urban settings, such as Kampala, where co-infection among sexually active youth reached 9.9% [32].

Limitations

While routine DHIS-2 and ART program data provide valuable insights, they have several inherent limitations. Most notably, the estimates rely on individuals already captured within the healthcare system, introducing ART-based prevalence bias, which may underestimate the true HIV burden by missing undiagnosed cases or those not successfully linked to ART services. In addition, using the total regional population as the denominator may affect the accuracy of prevalence estimates. Since aggregated secondary data were used, multivariate analysis was not conducted. The absence of uncertainty measures limited the ability to control for confounding factors, restricting the interpretation to descriptive findings rather than causal inferences.

Data quality is another concern, as DHIS-2 systems are often affected by reporting errors, missing values, and potential double-counting of patients who access services multiple times, affecting data reliability. Furthermore, the lack of detailed information on socio-economic status, behavioural factors, stigma, and treatment adherence, together with a limited two-year dataset for MARPs and HIV co-infections, restricted comprehensive trend analysis. In addition, data beyond 2020 were unavailable due to reporting disruptions following the onset of the Tigray conflict, which affected data continuity in subsequent years.

Conclusion

The findings of this study show that HIV infection in Tigray varies across population groups and geographic areas, with a higher burden observed among women and in the Mekelle zone. An increasing trend in HIV infection among HIV-exposed children and malnutrition among PLHIV was observed, while nutritional support declined. The trend of HIV testing and ART initiation among pregnant and lactating women varied by service delivery point. These findings suggest areas for program attention, including community-based HIV testing, early antenatal care screening, timely linkage to antiretroviral therapy, and nutritional support for PLHIV.

Abbreviations

ANC

Antenatal Care

ART

Antiretroviral Therapy

CDC

Center for Disease Control and Prevention

EDHS

Ethiopian Demographic and Health Survey

EPHIA

Ethiopia Population-based HIV Impact Assessment

FSW

Female Sex Workers

HIV

Human Immunodeficiency Virus

MARPs

Most at Risk Population

MTCT

Mother-To-Child Transmission

OVC

Orphans and Vulnerable Children

PMTCT

Prevention of mother-to-child transmission

PITC

Provider-Initiated Testing and Counselling

PLHIV

People living with HIV

PNC

Post-Natal Care

PLW

Pregnant and Lactating Women

STI

Sexually Transmitted Infections

WHO

World Health Organisation

Author contributions

MF participated in the proposal preparation, data extraction, data analysis, and interpretation. AG participated in the data analysis and interpretation. KT and MY participated in the data interpretation. We declared that all the authors participated in the drafting and approval of the manuscript.

Funding

Funds were not received from any organisations or individuals to conduct this study.

Data availability

The data that support the result are provided in separate pages for each table and figure.

Declarations

Ethical approval

Ethical clearance and approval for this study were granted by the Institutional Review Board of Mekelle University, College of Health Sciences. All research methods were conducted in accordance with relevant institutional guidelines and the ethical principles outlined in the Declaration of Helsinki. Since this study was a regional-level secondary data analysis, a waiver of individual informed consent was obtained due to the use of de-identified data. Permission to access and utilise the records was formally secured from the head of the Tigray Regional Health Bureau (TRHB) and relevant officers. Throughout the study, strict confidentiality was maintained, and no personal identifiers were included during data extraction, analysis, or reporting to ensure participant privacy.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.