Table 2.
Predicted average relative change in HIV mortality and incidence over 1 year from April 1, 2020, due to a 6-month disruption of specific HIV services for 20%, 50%, and 100% of the population in countries in sub-Saharan Africa
|
Relative increase in HIV mortality |
Relative increase in HIV incidence |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Goals | Optima HIV | HIV Synthesis | Imperial College London Model | EMOD | Goals | Optima HIV | HIV Synthesis | Imperial College London Model | EMOD | ||
| Prevention programmes | |||||||||||
| Suspension of VMMC services | |||||||||||
| 20% disruption | 1·00 (1·00–1·00) | 1·00 (1·00–1·00) | 1·00 (0·99–1·01) | 1·00 (1·00–1·00) | 1·00 (1·00–1·10)* | 1·00 (1·00–1·00) | 1·00 (1·00–1·00) | 1·00 (0·99–1·01) | 1·00 (1·00–1·00) | 1·00 (1·00–1·16)* | |
| 50% disruption | 1·00 (1·00–1·00) | 1·00 (1·00–1·00) | 1·00 (0·97–1·03) | 1·00 (1·00–1·00) | 1·00 (1·00–1·08) | 1·00 (1·00–1·00) | 1·00 (1·00–1·00) | 1·00 (0·97–1·03) | 1·00 (1·00–1·00) | 1·00 (1·00–1·11) | |
| 100% disruption | 1·00 (1·00–1·00) | 1·00 (1·00–1·00) | 1·00 (0·95–1·07) | 1·00 (1·00–1·00) | 1·00 (1·00–1·07)* | 1·01 (1·00–1·01) | 1·00 (1·00–1·00) | 1·00 (0·94–1·07) | 1·00 (1·00–1·00) | 1·00 (1·00–1·12)* | |
| Condom availability interrupted | |||||||||||
| 20% disruption | 1·00 (1·00–1·00) | 1·00 (1·00–1·00) | 1·00 (0·99–1·01) | 1·00 (1·00–1·00) | 1·00 (1·00–1·07)* | 1·07 (1·03–1·12) | 1·02 (1·00–1·04) | 1·01 (0·99–1·05)† | 1·05 (1·05–1·05) | 1·06 (1·00–1·20) | |
| 50% disruption | 1·00 (1·00–1·00) | 1·00 (1·00–1·00) | 1·00 (0·97–1·03) | 1·00 (1·00–1·00) | 1·00 (1·00–1·08)* | 1·19 (1·07–1·30) | 1·06 (1·01–1·10) | 1·03 (0·99–1·13)† | 1·12 (1·12–1·12) | 1·14 (1·01–1·30) | |
| 100% disruption | 1·01 (1·00–1·01) | 1·00 (1·00–1·00) | 1·00 (0·95–1·06) | 1·00 (1·00–1·00) | 1·00 (1·00–1·07) | 1·38 (1·15–1·62) | 1·12 (1·02–1·20) | 1·07 (0·98–1·28)† | 1·25 (1·25–1·25) | 1·28 (1·14–1·48) | |
| Suspension of PMTCT | |||||||||||
| 20% disruption | 1·01 (1·00–1·02) | 1·00 (1·00–1·01) | .. | .. | .. | 1·02 (1·00–1·05) | 1·01 (1·00–1·02) | .. | .. | .. | |
| 50% disruption | 1·03 (1·01–1·06) | 1·01 (1·00–1·02) | .. | .. | .. | 1·05 (1·00–1·11) | 1·02 (1·01–1·03) | .. | .. | .. | |
| 100% disruption | 1·06 (1·02–1·11) | 1·02 (1·01–1·04) | .. | .. | .. | 1·11 (1·00–1·23) | 1·04 (1·01–1·07) | .. | .. | .. | |
| HIV testing | |||||||||||
| Suspension of HIV testing | |||||||||||
| 20% disruption | 1·00 (1·00–1·02) | 1·01 (1·00–1·02) | 1·00 (0·99–1·02)† | .. | 1·00 (1·00–1·18) | 1·00 (1·00–1·01) | 1·00 (1·00–1·01) | 1·00 (0·99–1·02) | .. | 1·00 (1·00–1·14)* | |
| 50% disruption | 1·01 (1·00–1·02) | 1·01 (1·00–1·02) | 1·01 (0·98–1·05)† | .. | 1·00 (1·00–1·18)* | 1·01 (1·00–1·02) | 1·01 (1·00–1·02) | 1·01 (0·98–1·05) | .. | 1·01 (1·00–1·16) | |
| 100% disruption | 1·02 (1·00–1·02) | 1·02 (1·00–1·03) | 1·02 (0·96–1·11)† | .. | 1·00 (1·00–1·16)* | 1·02 (1·00–1·04) | 1·01 (1·00–1·02) | 1·02 (0·96–1·10) | .. | 1·02 (1·00–1·18) | |
| Treatment and care | |||||||||||
| No new ART initiation | |||||||||||
| 20% disruption | 1·00 (1·00–1·02) | 1·00 (1·00–1·00) | 1·01 (0·99–1·02)† | 1·01 (1·01–1·01) | 1·00 (1·00–1·12)* | 1·00 (1·00–1·01) | 1·00 (1·00–1·00) | 1·00 (0·99–1·02) | 1·01 (1·01–1·01) | 1·00 (1·00–1·15) | |
| 50% disruption | 1·01 (1·00–1·02) | 1·00 (1·00–1·00) | 1·02 (0·98–1·05)† | 1·03 (1·03–1·03) | 1·00 (1·00–1·13)* | 1·01 (1·00–1·02) | 1·00 (1·00–1·00) | 1·00 (0·97–1·04) | 1·02 (1·02–1·02) | 1·02 (1·00–1·19) | |
| 100% disruption | 1·02 (1·00–1·02) | 1·00 (1·00–1·00) | 1·04 (0·98–1·14)† | 1·06 (1·06–1·06) | 1·00 (1·00–1·13) | 1·02 (1·00–1·04) | 1·00 (1·00–1·00) | 1·01 (0·94–1·08) | 1·04 (1·04–1·04) | 1·03 (1·00–1·24) | |
| Viral load testing, enhanced adherence counselling, and drug regimen switches stopped | |||||||||||
| 20% disruption | 1·01 (1·00–1·04) | 1·01 (1·00–1·02) | 1·00 (0·99–1·02)† | 1·00 (1·00–1·00) | 1·00 (1·00–1·08) | 1·01 (1·00–1·04) | 1·01 (1·00–1·02) | 1·00 (0·99–1·02) | 1·01 (1·01–1·01) | 1·00 (1·00–1·11)* | |
| 50% disruption | 1·03 (1·00–1·10) | 1·04 (1·03–1·05) | 1·01 (0·98–1·05)† | 1·00 (1·00–1·00) | 1·01 (1·00–1·10) | 1·03 (1·00–1·10) | 1·02 (1·01–1·03) | 1·00 (0·96–1·04) | 1·03 (1·03–1·03) | 1·00 (1·00–1·16) | |
| 100% disruption | 1·05 (1·00–1·20) | 1·10 (1·07–1·11) | 1·02 (0·97–1·11)† | 1·00 (1·00–1·00) | 1·03 (1·00–1·14) | 1·05 (1·00–1·21) | 1·05 (1·03–1·07) | 1·00 (0·93–1·08) | 1·07 (1·07–1·07) | 1·00 (1·00–1·14) | |
| Increase in death rate in people with AIDS-defining illnesses due to overstretched health system | |||||||||||
| 20% disruption | 1·01 (1·00–1·02) | .. | 1·02 (1·01–1·04)† | 1·02 (1·02–1·02) | .. | 1·00 (1·00–1·00) | .. | 1·00 (0·99–1·01) | 1·00 (1·00–1·00) | .. | |
| 50% disruption | 1·02 (1·00–1·04) | .. | 1·06 (1·02–1·10)† | 1·06 (1·06–1·06) | .. | 1·00 (1·00–1·00) | .. | 1·00 (0·97–1·03) | 1·00 (1·00–1·00) | .. | |
| 100% disruption | 1·05 (1·01–1·09) | .. | 1·12 (1·05–1·21)† | 1·17 (1·16–1·17) | .. | 1·00 (1·00–1·00) | .. | 0·99 (0·94–1·07) | 0·99 (0·99–0·99) | .. | |
| ART interruption | |||||||||||
| 20% disruption | 1·19 (1·11–1·28) | 1·15 (1·11– 1·17) | 1·29 (1·15–1·46) | 1·25 (1·09–1·47) | 1·34 (1·21–1·50) | 1·06 (1·02–1·11) | 1·04 (1·03–1·04) | 1·02 (1·00–1·07)† | 1·06 (1·06–1·07) | 1·50 (1·29–1·69) | |
| 50% disruption | 1·55 (1·31–1·80) | 1·39 (1·28–1·42) | 1·87 (1·43–2·59) | 1·63 (1·41–2·17) | 1·83 (1·65–2·10) | 1·07 (1·02–1·11) | 1·09 (1·08–1·12) | 1·06 (1·00–1·17)† | 1·16 (1·15–1·18) | 2·26 (1·97–2·51) | |
| 100% disruption | 2·18 (1·63–2·72) | 1·75 (1·54–1·82) | 3·51 (2·05–6·69) | 2·27 (1·44– 3·35) | 2·68 (2·40–3·10) | 1·07 (1·02–1·12) | 1·22 (1·18–1·25) | 1·12 (1·01–1·38)† | 1·32 (1·30–1·36) | 3·49 (3·07–3·93) | |
Data are relative changes in estimates, with 95% uncertainty intervals in parentheses. For the Goals model, values are weighted averages of 13 countries in sub-Saharan Africa (South Africa, Malawi, Mozambique, Zimbabwe, eSwatini, Lesotho, Uganda, Kenya, Botswana, Tanzania, Cameroon, Côte d'Ivoire, and Nigeria). We assumed constant condom use rates and PMTCT coverage; historical rates of growth in VMMC; and adult and paediatric ART coverage increasing from 2019 levels to UNAIDS fast-track targets of 81% of all people who live with HIV on ART by 2025 for countries that are below those targets now or 90% if current coverage exceeds 81%.10 The VMMC, testing, and no new ART initiation disruptions affect the growth in the base case. For the increase in AIDS mortality due to overstretched health systems, we assumed that survival would be 2 years shorter with a complete failure of the health system and adjusted the age-specific, sex-specific, and CD4 cell count-specific survival rates accordingly to reflect the 6-month disruption affecting 20%, 50%, or 100% of the population. We assumed no change in sexual behaviour during the service disruption period. All estimates for this model are for adults and children, as relevant. For the Optima HIV model, all values are for all ages and are an average of 12 countries in sub-Saharan Africa (Botswana, Cameroon, Côte d'Ivoire, eSwatini, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, and Zimbabwe). Numbers of circumcisions are held constant over the disruption period because we assumed no new circumcisions would be done due to physical distancing concerns due to the COVID-19 pandemic. For the HIV Synthesis model, deaths and new HIV infections apply to adults only. 95% uncertainty intervals are the 2·5% and 97·5% percentiles of the distribution across setting scenarios and thus reflect uncertainty and intersetting variability. Suspension of PMTCT is not considered separately from interruption of all ART, which has an effect on MTCT. Estimates of disruption of PrEP programmes should be understood in the context that overall only 0·2% of women aged 15–25 years are on PrEP. An effect is seen on MTCT of interruption of ART, with an excess of 2·69 times more babies born with HIV in 1 year as a result of 6 months of disruption in 50% of people. For the Imperial College London model, figures in the table are an average of three countries in sub-Saharan Africa (Malawi, South Africa, and Zimbabwe) and are for adult mortality and new infections only. For survival estimates of individuals who have stopped ART (average monthly mortality risk of 0·24%, lower bound of average monthly mortality risk of 0·10%, and upper bound of 0·44%) more details are in the appendix (pp 17–18). Each scenario is modelled independently of other scenarios. For the EMOD model, to estimate the impact of condom availability interruption, transmission probability per sex act was increased during the disruption interval in proportion to the level of service disruption. Transmission risk factor returns to default values after the disruption period. ART=antiretroviral therapy. EMOD=Epidemiological MODeling software. MTCT=mother-to-child transmission. PMTCT=prevention of mother-to-child transmission. PrEP=pre-exposure prophylaxis. VMMC=voluntary medical male circumcision.
Differences in estimates were non-significant given the stochastic variation.
Data are significantly different from 1 —ie, no stochastic variability.