David Chipanta

The 2013 World Health Organization (WHO) guidelines for cervical pre-cancer screening recommended screening women aged 30–49 and women living with HI

Introduction: Multidimensional poverty (deprivations in education, health, and living standards) affects people with and without HIV. We compared poverty levels by HIV status in Eastern and Southern Africa and identified indicators driving deprivations. Method: We analysed the 2020–22 Population HIV Impact Assessment data from Eswatini, Lesotho, Malawi, Mozambique, Tanzania, Uganda, and Zimbabwe using the Alkire-Foster method, calculating the multidimensional poverty index (MPI), headcount ratio, and poverty intensity, using the Stata 14.2 mpi command. We classified individuals deprived in 20·0%–33·3% of indicators as vulnerable to poverty, ≥33·3% as poor, and ≥50·0% as severely poor. We estimated the number of people in each poverty category, and decomposed poverty by indicators. Analyses were survey-weighted, disaggregated by sex, residence, and age (15–24 years), and differences by HIV status tested using the Rao–Scott chi-square test (p <0·05). Results: People living with HIV (PLHIV) comprised 7·1% (11·8 million) of the study population (164·9 million). PLHIV were more likely to be vulnerable to poverty, poor, or severely poor than people without HIV. In Eswatini, with the lowest poverty level, PLHIV had higher MPIs (0·248 95% CI [0·239–0·257]) than people without HIV (0·220 [0·215–0·226]). 53·7% [51·8%–55·5%], 99,000, PLHIV were poor compared to 47·5% [46·4%– 48·6%], 266,000, of people without HIV. In Mozambique, with the highest poverty level, the MPIs were similar for people living with and without HIV, but poverty remained higher among PLHIV (70·2% [67·8%– 72·5%], 1·5 million, versus 69·6% [68·6%–70·5%], 10·5 million). The intensity of poverty did not differ across the countries. Education/employment and living standards accounted most for deprivations. Interpretation: Nearly three-quarters of PLHIV in Eastern and Southern Africa experienced multidimensional poverty. Integrating HIV and poverty-reduction efforts, prioritising education, employment, clean energy, water, sanitation, housing, and assets is required. Including HIV indicators in poverty surveys, and research to accelerate joint progress are required. Funding: This study received no external funding Research in context: Evidence before this study: We searched PubMed, Google Scholar, reports by UNAIDS, UNDP, World Bank, and other grey literature, using subject headings and keyword terms ("HIV and poverty", "Differences in poverty between people living with HIV and people not living with HIV", "Multidimensional poverty and HIV", "HIV and sanitation", and "Differences between PLHIV and general population in assets") for English-language publications from January 1, 2005, to September 31, 2025. We reviewed 52 articles published in English (Supplement A1). The studies showed that people living with HIV (PLHIV) face socioeconomic disadvantage, including material deprivation, reduced employment, and limited household assets. The studies find as association between poverty among PLHIV with poorer immunologic and virologic response to antiretroviral therapy, lower adherence, and greater comorbidity. They further show inadequate access to safe drinking water, sanitation, and hygiene, increasing diarrhoeal disease and reducing treatment absorption among PLHIV. Other studies find that people living with HIV are deprived in cooking fuels, leading to upper respiratory infections. Most studies used single indicators of poverty or were restricted to individual settings or countries. Added value of this study: This study, to our knowledge, provides the first multi-country assessment of multidimensional poverty by HIV status in Eastern and Southern Africa. We find across countries, that people living with HIV (PLHIV) were more likely to be vulnerable to poverty, poor, or severely poor than people without HIV. Multidimensional poverty among PLHIV was driven by deprivations in education and employment, and deprivations in living standards such as electricity, clean cooking energy, safe drinking water, sanitation, housing, and household assets. Implications of all the available evidence: Despite major gains in HIV treatment and prevention and in national poverty reduction efforts, PLHIV continue to face socioeconomic and infrastructural disadvantage. These deprivations increase PLHIV’s risk to comorbidities and undermine HIV prevention and treatment services, slowing progress toward the Sustainable Development Goals. Integrating HIV responses with poverty reduction and social protection strategies is essential. Incorporating HIV indicators into national poverty monitoring systems and prioritising investment in education, employment, and essential services can accelerate joint progress towards ending AIDS and reducing poverty, in a context of declining external funding.

Our study applied the INSPIRE Framework – the WHO’s 2016 technical package of evidence-based interventions for addressing violence against children – to identify accelerators for youth in Namibia. Accelerators are protective factors that contribute toward achieving multiple SDG targets. Using nationally representative data from the 2019 Namibia Violence Against Children & Youth Survey (n = 5167), three hypothesised accelerators (food security, parental support, and gender-equitable attitudes) were investigated for their impact on 12 adolescent outcomes. Associations between the hypothesised accelerators and outcomes were assessed using multivariable logistic regressions, and adjusted probabilities, differences, and ratios. Among girls, food security, gender-equitable attitudes, and parental support were accelerators, being associated with lower odds for 8, 6, and 2 outcomes, respectively. When all three were present, the combination was significantly associated with 10 out of 12 outcomes, including >75% lower prevalences of child marriage; > 50% lower prevalences of child abuse, sexual violence victimisation, early sexual debut/early pregnancy, and peer violence victimisation; and >25% lower prevalences of intimate partner violence (IPV) victimisation, not being in school or paid work, mental health distress, inconsistent condom use, and age-disparate or transactional sex. Among boys, gender-equitable attitudes was an accelerator and was significantly associated with 7 out of 10 outcomes, including approximately 50% lower prevalences of sexual violence victimisation, child abuse, age-disparate or transactional sex, IPV victimisation, multiple sexual partners, peer violence victimisation, and inconsistent condom use. Adolescents (especially girls) with access to INSPIRE provisions experience lower rates of violence and HIV-related risks. Implementing interventions on these priority protective factors could accelerate progress in achieving the SDGs for adolescents and young people in Namibia.

We assessed socioeconomic inequalities in social protection coverage among the public, men and women living with the human immunodeficiency virus (MLHIV, WLHIV), and adolescent girls and young women (AGYW). We used population-based data from Cameroon, Côte d’Ivoire, Ethiopia, Eswatini, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. We constructed concentration curves (CC) and computed concentration indices (CIX) for each country and population group. A CC represents the cumulative percentage of social protection coverage plotted on the y-axis against the cumulative proportion of the population—ranked by socioeconomic status from the poorest to the richest—on the x-axis. The CIX quantifies the concentration of social protection coverage among the poor or the rich. The sample size ranged from 10,197 in Eswatini to 29,577 in Tanzania. Social protection coverage among the public varied from 5.2% (95% Confidence Interval 4.5%–6.0%) in Ethiopia to 39.9% (37.0%–42.8%) in Eswatini. It ranged from 6.9% (5.7%–8.4%) MLHIV in Zambia to 45.0% (41.2–49.0) among WLHIV in Namibia. Among AGYW, it varied from 4.4% (3.6–5.3) in Ethiopia to 44.6% (40.8–48.5) in Eswatini. Socioeconomic inequalities in social protection coverage favored the poor in 11/13 countries surveyed. It favored the rich in Cameroon and was undefined in Côte d’Ivoire. The CIX in these 11 countries ranged from −0.080 (p = 0.002) among the public in Malawi to −0.372 (p< 0.001) among WLHIV in Zimbabwe. In 8 of these 11 countries, ≥15% of people from the poorest households reported receiving social protection. Only in countries with higher levels of social protection coverage did most people from the poorest households achieve high coverage. Social protection coverage was low and favored the poor. Pro-poor social protection is insufficient to reach the poor. Research is required to reach the poorest households with social protection in Africa.

Persons with disabilities are disadvantaged in accessing sexual and reproductive health services, including condoms. In this study, we investigated whether condom access and use and their associated factors differed between persons with and without disabilities. We used data from adults in households receiving the Government of Zambia social cash transfers (SCT) in four districts of Luapula province. Condom access and use was the outcome. Disability, defined by the Washington Group Short Set Questions on Disability, was the main predictor. We performed logistic regression analyses to determine the associations between condom access and use and disability. In multivariable analyses, we controlled for covariates including age, sex, marital status, poverty status, HIV testing, and receiving the SCT. The sample comprised 1,143 people aged 16–49, with a median age of 21 years (interquartile range 18–28); 57.4% (n = 656) were female, 86.5% (n = 989) accessed and used condoms, and 17.9% (n = 205) were disabled, rating themselves with a 3 or a 4 on a scale of 1 = “not limited” to 4 = “cannot at all” in performing any of the six daily functions (seeing, hearing, walking, cognition, self-care, or communicating). Nearly sixty percent(58.5% (n = 120)) of persons with disabilities were female, 79.5% (n = 163) reported being very poor, 87.8% (n = 180) reported receiving SCT, and 86.3% (n = 177) reported accessing and using condoms. Condom access and use did not differ between persons with and without disabilities (adjusted odds ratio: 1.09; 95% confidence interval [CI]: 0.60–1.98]). We found no differences between persons with and without disabilities in condom access and use. We established that individual-level factors such as age, sex, marital status, and knowledge of being HIV positive might play a more important role in condom access and use than disability. Condom promotion interventions should account for these factors.

Introduction In 2013, the World Health Organization (WHO) issued guidelines for cervical pre-cancer screening. It recommended screening women aged 30–49, and younger women once they tested HIV-positive. Subsequent WHO guidelines recommended screening women living with HIV (WLHIV) starting at age 25. However, the impact of 2013 guidelines and age to start screening on screening has not been studied. Methods We used a regression discontinuity design (RDD) analysis of population-based data to assess the impact of the 2013 WHO guidelines on the screening rates for women according to HIV status and age group in Ethiopia, Malawi, Rwanda, Tanzania, Zambia, and Zimbabwe. The outcome was self-reported ever having been screened for cervical pre-cancer between 2008 and 2018. We compared the screening rates according to HIV status and age group, before and after age 25 years. And before and after 2014, the year countries adopted the 2013 guidelines. We then used a data-driven optimal bandwidth selection procedure to estimate the guidelines’ average treatment effect (ATE), with a local polynomial regression discontinuity and robust bias-corrected confidence intervals. We validated the RDD methodology overall and for women with a significant ATE at the country-level analysis. Results We included 73179 women: 6680 (9.1%) living with HIV, 4328 (5.9%) with unknown HIV status, and 62171 (85.0) with a negative HIV status. 5726 (7.9%) reported having ever been screened; 4022 (6.5%) with unknown HIV status, 525 (12.1%) with a negative HIV status and 1179 (17.7%) living with HIV. Adolescent girls and young women living with HIV (AGYWLHIV) aged 15–24 reported screening less often (917 (13.7%)) than their peers with unknown (1677 (38.8%)) or positive HIV status (27278 (43.9%)) (PConclusion We found no evidence the 2013 WHO guidelines increased or reduced women’s cervical pre- cancer screening. However, AGYWLHIV reported screening less often. Policy makers should lower the age to start screening WLHIV from 25 to 15 to screen more AGYWLHIV. Studies are required to examine the impact of the guidelines on cervical pre-cancer screening in more countries.

Inequality in access to services is a global problem mainly impacting the poorest populations. The role of social protection in reducing inequalities is recognized, but few studies have investigated whether social protection benefits people facing considerable socioeconomic inequalities. We assessed inequalities in receiving social protection among the public, men and women living with human immunodeficiency virus (PLHIV), and adolescent girls and young women (AGYW), using population-based data from 13 African countries. We constructed concentration curves and computed concentration indices (CIX) for each country and population group. We also conducted a desk review of social protection in the studied countries where information was available on the characteristics of social protection programs and their access by the general population, PLHIV, and AGYW. The sample size ranged from 10,197 in Eswatini to 29,577 in Tanzania. Women comprised 60% or more of PLHIV in the surveyed countries. 50%–70% of the respondents were unemployed, except in Cameroon, Kenya, and Uganda, where less than 50% were unemployed. Generally, the proportion of respondents from wealth quintile one (Q1), the poorest 20% of households, was like that from Q2–Q5. The proportion of the general population receiving social protection varied from 5.2% (95% Confidence Interval 4.5%– 6.0%) in Ethiopia to 39.9% (37.0%–42.8%) in Eswatini. Among PLHIV, the proportion receiving social protection varied from 6.9% (5.7%–8.4%) among men living with HIV in Zambia to 45.0% (41.2–49.0) among women living with HIV in Namibia. Among AGYW, the proportion varied from 4.4% (3.6–5.3) in Ethiopia to 44.6% (40.8–48.5) in Eswatini. In general, 15% or less of the respondents from Q1 reported receiving social protection in eight countries (i.e., Cameroon, Côte d’Ivoire, Ethiopia, Kenya, Malawi, Tanzania, Uganda, and Zambia), with 10% or less in three countries (Cameroon, Côte d’Ivoire, and Ethiopia); 15%– 20% in Rwanda, 30% in Zimbabwe, 40% in Lesotho, and more than 50% in Eswatini and Namibia. Among the wealthiest quintiles (Q5), the proportion receiving social protection ranged from 3.6% (2.6%–5.0%) in Ethiopia to 19.7% (16.25–23.8%) in Namibia. Only in countries with higher social protection coverage did the proportion of the poorest wealth quintile households reached also high. Socioeconomic inequalities in receiving social protection favored the poor in 11 out of 13 countries and the rich in Cameroon and were undefined in Côte d’Ivoire. The CIX values for socioeconomic inequalities in receiving social protection in these 11 countries ranged from −0.080 (p=0.002) among the general population in Malawi to −0.372 (p< 0.001) among WLHIV in Zimbabwe. However, in 8 countries (Cameroon, Côte d’Ivoire, Ethiopia, Kenya, Malawi, Tanzania, Uganda, and Zambia) of these 11 countries, 15% or less of the population from the poorest wealth quintile received social protection. In the countries surveyed, access to social protection for the general population, MLHIV and WLHIV, and AGYW was generally low but favored people from poor households. However, pro-poor social protection, although necessary, is not sufficient to ensure that people from the poorest households receive social protection. Further research is required to identify and reach people from the poorest households with social protection in sub-Saharan Africa.

Background: Persons with disability may have a higher HIV prevalence and be less likely than persons without disability to know their HIV-positive status, access antiretroviral therapy (ART), and suppress their HIV viral load (HIV care cascade). However, studies examining differences between persons with and without disability in HIV prevalence and the HIV care cascade are lacking. Using the Tanzania HIV Impact Survey (THIS) data collected between October 2016 and August 2017, we assessed differences in HIV prevalence and progress towards achieving the 2020 HIV care cascade target between persons with and without disability. Methods: Using the Washington Group Short Set (WG-SS) Questions on Disability, we defined disability as having a functional difficulty in any of the six life domains (seeing, hearing, walking/climbing, remembering/ concentrating, self-care, and communicating). We classified respondents as disabled if they responded having either “Some Difficulty”, “A lot of difficulties” or “Unable to” in any of the WG-SS Questions. We presented the sample characteristics by disability status and analyzed the achievement of the cascade target by disability status, and sex. We used multivariable logistic regressions, and adjusted for age, sex, rural-urban residence, education, and wealth quintile. Results: A total of 31,579 respondents aged 15 years and older had HIV test results. Of these 1,831 tested HIV-positive, corresponding to an estimated HIV prevalence of 4.9% (CI: 4.5 — 5.2%) among the adult population in Tanzania. The median age of respondents who tested HIV-positive was 32 years (with IQR of 21—45 years). HIV prevalence was higher (5.7%, 95% CI: 5.3—7.4%) among persons with disability than persons without disability (4.3%, 95% CI: 4.0 — 4.6%). Before adjustment, compared to women without disability, more women with disability were aware of their HIV-positive status (n = 101, 79.0%, 95% CI: 68.0—87.0% versus n = 703, 63.0%, 95% CI: 59.1—66.7%) and accessed ART more frequently (n = 98, 98.7%, 95% CI: 95.3—99.7% versus n = 661, 94.7%, 95% CI: 92.6—96.3%). After adjusting for socio-demographic characteristics, the odds of having HIV and of accessing ART did not differ between persons with and without disability. However, PLHIV with disability had higher odds of being aware of their HIV-positive status (aOR 1.69, 95% 1.05—2.71) than PLHIV without disability. Men living with HIV and with disability had lower odds (aOR = 0.23, 95% CI: 0.06—0.86) to suppress HIV viral loads than their counterparts without disability. Conclusion: We found no significant differences in the odds of having HIV and of accessing ART between persons with and without disability in Tanzania. While PLHIV and disability, were often aware of their HIV-positive status than their non-disabled counterparts, men living with HIV and with disability may have been disadvantaged in having suppressed HIV viral loads. These differences are correctable with disability-inclusive HIV programming. HIV surveys around the world should include questions on disability to measure potential differences in HIV prevalence and in attaining the 2025 HIV care cascade target between persons with and without disability.

Objectives We examined age, residence, education and wealth inequalities and their combinations on cervical precancer screening probabilities for women. We hypothesised that inequalities in screening favoured women who were older, lived in urban areas, were more educated and wealthier. Design Cross-sectional study using Population-Based HIV Impact Assessment data. Setting Ethiopia, Malawi, Rwanda, Tanzania, Zambia and Zimbabwe. Differences in screening rates were analysed using multivariable logistic regressions, controlling for age, residence, education and wealth. Inequalities in screening probability were estimated using marginal effects models. Participants Women aged 25–49 years, reporting screening. Outcome measures Self-reported screening rates, and their inequalities in percentage points, with differences of 20%+ defined as high inequality, 5%–20% as medium, 0%–5% as low. Results The sample size of participants ranged from 5882 in Ethiopia to 9186 in Tanzania. The screening rates were low in the surveyed countries, ranging from 3.5% (95% CI 3.1% to 4.0%) in Rwanda to 17.1% (95% CI 15.8% to 18.5%) and 17.4% (95% CI 16.1% to 18.8%) in Zambia and Zimbabwe. Inequalities in screening rates were low based on covariates. Combining the inequalities led to significant inequalities in screening probabilities between women living in rural areas aged 25–34 years, with a primary education level, from the lowest wealth quintile, and women living in urban areas aged 35–49 years, with the highest education level, from the highest wealth quintile, ranging from 4.4% in Rwanda to 44.6% in Zimbabwe. Conclusions Cervical precancer screening rates were inequitable and low. No country surveyed achieved one-third of the WHO’s target of screening 70% of eligible women by 2030. Combining inequalities led to high inequalities, preventing women who were younger, lived in rural areas, were uneducated, and from the lowest wealth quintile from screening. Governments should include and monitor equity in their cervical precancer screening programmes.

Background Persons with disability may have a higher HIV prevalence and be less likely than persons without disability to know their HIV-positive status, access antiretroviral therapy (ART), and suppress their HIV viral load (HIV testing, treatment, and care cascade, also known as the 90—90—90 and the 95—95—95 targets set to be achieved by 2020 and 2025, respectively). Methods Using the Tanzania HIV Impact Survey (THIS) data collected between October 2016 and August 2017, we assessed differences in HIV prevalence and progress towards achieving the 2020 HIV testing, treatment, and care cascade target between persons with and without disability. We presented the sample characteristics by disability status and analyzed the achievement of the cascade target by disability status, and sex. We used multivariate logistic regressions, and adjusted for age, sex, rural-urban-residence, education, wealth, and region. Results The sample comprised 1,831 people living with HIV (PLHIV) with a median age of 32 years (IQR 21—45). Approximately 11.8% (95% Confidence Interval [CI]: 10.2%—13.6%, n= 212) of PLHIV in Tanzania were disabled. HIV prevalence was higher (6.2%, 95% CI: 5.3%—7.4%) among persons with disability than persons without disability (4.7%, 95% CI: 4.4% — 5.1%); Women with disability were more aware of their HIV-positive status (n = 101, 79.0%, 95% CI: 68.0%—87.0% versus n = 703, 63.0%, 95% CI: 59.1%—66.7%) and accessed ART more frequently (n = 98, 98.7%, 95% CI: 95.3%—99.7% versus n = 661, 94.7%, 95% CI: 92.6%—96.3%) than women without disability. After adjusting for socio-demographic characteristics, the odds of having HIV and of accessing ART were not statistically different between PLHIV with and without disability. However, PLHIV with disability had higher odds of being aware of their HIV-positive status (aOR 1.69, 95% 1.05—2.71) than PLHIV without disability. Men on ART with disability had lower odds (aOR = 0.23, 95% CI: 0.06—0.86) to suppress HIV viral loads than their counterparts without disability. Conclusion We found no differences in HIV prevalence and access to ART between persons with and without disability in Tanzania. Whereas PLHIV disability, women in particular, were advantaged in knowing their HIV-positive status, men on ART with disability may have been disadvantaged in having suppressed HIV viral loads. These differences are correctable by disability-inclusive HIV programming. HIV surveys in multiple countries sampling more persons with disability are required to measure differences in HIV prevalence better and in attaining the 2025 HIV testing and treatment cascade target for both persons with and without disability.