Article

Declines in HIV prevalence can be associated with changing sexual behaviour in Uganda, urban Kenya, Zimbabwe, and urban Haiti

T B Hallett¹, J Aberle-Grasse², G Bello³, L-M Boulos⁴, M P A Cayemittes⁵, B Cheluget⁶, J Chipeta⁷, R Dorrington⁸, S Dube⁹, A K Ekra¹⁰, J M Garcia-Calleja¹¹, G P Garnett¹, S Greby¹², S Gregson¹³, J T Grove¹⁴, S Hader¹², J Hanson¹², W Hladik¹⁵, S Ismail¹⁶, S Kassim¹⁵, W Kirungi¹⁷, L Kouassi¹⁸, A Mahomva¹⁹, L Marum²⁰, C Maurice¹⁰, M Nolan¹⁴, T Rehle²¹, J Stover²² and N Walker²³

Edited by N Walker, H Ward and R Miller

¹ Imperial College, London, UK
² Centers for Disease Control and Prevention, Global AIDS Program, Malawi
³ Ministry of Health, Community Health Sciences Unit, Malawi
⁴ CERA, Haiti
⁵ Institut Haitien de l’Enfance, Haiti
⁶ National AIDS Control Council, Kenya
⁷ National AIDS Commission, Lilongwe, Malawi
⁸ Centre for Actuarial Research, Cape Town, South Africa
⁹ Department of Infectious Disease Epidemiology, Imperial College, London, UK
¹⁰ Projet RETRO-CI, Abidjan, Cote d’Ivoire
¹¹ World Health Organization, Geneva, Switzerland
¹² US Centers for Disease Control and Prevention, Rwanda, Zimbabwe
¹³ Imperial College London and Biomedical Research and Training Institute, Harare, Zimbabwe
¹⁴ Projet RETRO-CI, Centers for Disease Control and Prevention, Cote d’Ivoire
¹⁵ Centers for Disease Control and Prevention, Atlanta, GA, USA
¹⁶ Centers for Disease Control and Prevention, Ethiopia
¹⁷ Ministry of Health, Kampala, Uganda
¹⁸ National Institute of Statistics, Cote d’Ivoire
¹⁹ Ministry of Health and Child Welfare, Rwanda, Zimbabwe
²⁰ Centers for Disease Control and Prevention, Kenya
²¹ Human Sciences Research Council, Cape Town, South Africa
²² Futures Group, Glastonbury, CT, USA
²³ UNICEF, USA

Correspondence to:
Correspondence to:
T B Hallett
Department of Infectious Disease Epidemiology, Imperial College, Norfolk Place, London W2 1PG, UK; timothy.hallett{at}imperial.ac.uk

Objective: To determine whether observed changes in HIV prevalence in countries with generalised HIV epidemics are associated with changes in sexual risk behaviour.

Methods: A mathematical model was developed to explore the relation between prevalence recorded at antenatal clinics (ANCs) and the pattern of incidence of infection throughout the population. To create a null model a range of assumptions about sexual behaviour, natural history of infection, and sampling biases in ANC populations were explored to determine which factors maximised declines in prevalence in the absence of behaviour change. Modelled prevalence, where possible based on locally collected behavioural data, was compared with the observed prevalence data in urban Haiti, urban Kenya, urban Cote d’Ivoire, Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia.

Results: Recent downturns in prevalence observed in urban Kenya, Zimbabwe, and urban Haiti, like Uganda before them, could only be replicated in the model through reductions in risk associated with changes in behaviour. In contrast, prevalence trends in urban Cote d’Ivoire, Malawi, urban Ethiopia, and Rwanda show no signs of changed sexual behaviour.

Conclusions: Changes in patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban Haiti are quite recent and caution is required because of doubts over the accuracy and representativeness of these estimates. Nonetheless, the observed changes are consistent with behaviour change and not the natural course of the HIV epidemic.

Abbreviations: AIDS, acquired immune deficiency syndrome; ANC, antenatal clinic; HIV, human immunodeficiency virus

Keywords: epidemiology; HIV; prevalence

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