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Abstract
Objectives To describe the epidemiological situation of the HIV/AIDS epidemic and to identify the main drivers for vulnerability in Madagascar.
Design Literature review, qualitative research and situational analysis.
Data sources Search of electronic bibliographic databases, national repositories of documentation from 1998 to 2018. Search keywords included Madagascar, HIV, sexually transmitted infections, men who have sex with men (MSM), sex workers (SWs), transactional sex (TS), injecting drug users (IDUs), vulnerability and sexual behaviour. Qualitative sources were interviews and focus group discussions.
Review methods Studies focused on HIV and/or vulnerability of HIV in Madagascar in general, and key populations (KPs) and HIV/AIDS response were taken into account. National reports from key HIV response actors were included.
Results Madagascar is characterised by a low HIV/AIDS epidemic profile in the general population (GP) (0.3%) combined with a high prevalence of HIV among KPs (SWs, MSM and IDUs).
An increase in HIV prevalence among KP has been observed during recent years. Hospital-based data suggest an increase in HIV prevalence among the GP. The vulnerability traits are inconsistent use of condoms, multipartner relationships and other contextual factors like widespread TS and gender inequality. A high prevalence/incidence of sexually transmitted infections could indicate a high vulnerability to HIV/AIDS. However, there are no reports of HIV prevalence of >1% in antenatal consultation.
Conclusion There is not enough evidence to make a conclusion about the HIV epidemiological situation in Madagascar due to the scarcity of the epidemiological data. However, Madagascar may be closer to a turning point towards a high-prevalence epidemic with severe consequences, particularly when taking into account its socioeconomical fragility and underlying vulnerabilities. More precise epidemiological data and improved HIV/AIDS diagnosis and case management should be a public health priority.
- HIV
- AIDS
- Africa
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Introduction
Madagascar has a low HIV/AIDS epidemic profile, with a 0.3% estimate among the general population (GP) and a high prevalence among key populations1 (KPs). More than a decade ago, some publications highlighted several major risk factors for HIV becoming widespread among the GP.2–4 However, this worst-case scenario has apparently not yet occurred according to the most recent published data.1 The population is estimated at 26.3 million inhabitants, 80% of which live in rural areas.5 The country ranks 161st out of 189 countries in the Human Development Index,6 with worrying health indicator indexes.5
The Malagasy government has made various efforts to improve HIV/AIDS services with non-governmental organisation (NGO) and civil-society-based organisation (CSBO) support: training in HIV/AIDS clinical management and accreditation for an increasing number of health staff and healthcare centres (HCCs), improvement of the health information surveillance system, better coordination of all actors and rolling out systematic community-based testing activities. The ‘test, treat and retain’ strategy is currently in a demonstration phase at some HCCs.
However, data from the 10 basic indicators for the 90–90–90 Joint United Nations Programme on HIV and AIDS (UNAIDS) targets show insufficient achievement. For instance, it is estimated that only 8% (n=2900) of persons living with HIV/AIDS (PLHIVs) have been diagnosed (table 1). Screening community-based campaigns for both GP and KP are carried out by local NGOs and CSBOs, or they take place at primary HCCs but detailed quantitative data are not available. Of note, the current legal framework bans access to free testing for minors, whereas a substantial proportion of the sex worker (SW)/transactional sex (TS) populations are less than 18 years old.
10 basic HIV/AIDS indicators for Madagascar, Joint United Nations Programme on HIV and AIDS, 2018
Given this uncertain situation and the potential consequences of a high-prevalence epidemic in a fragile socioeconomical context, the objectives of this work were to describe the epidemiological situation of the HIV/AIDS epidemic and to identify the main drivers for vulnerability in Madagascar and conduct a situational analysis.
The results may constitute a basis for further research and HIV/AIDS response activity implementation.
Methodology
We carried out a comprehensive literature review using the MEDLINE and CENTRAL databases and the WHO and UNAIDS websites. The keywords were HIV, AIDS, sexually transmitted infections (STI) and sexual reproductive health, and Madagascar. Publications from 1998 to 2018, official publications and reports from the Malagasy Ministry of Public Health, and the Office of the Prime Minister’s national committee for coordinating control over HIV/AIDS (Comité National de Lutte contre le VIH/SIDA) were taken into account. Data about other STI were taken into account as a proxy for vulnerability to HIV.
Quantitative and qualitative data were collected through direct interviews with stakeholders involved in HIV/AIDS control and prevention programmes: public health decision-makers and healthcare providers, as well as representatives from NGOs and CSBOs. We used semistructured questionnaires to conduct focus group discussions (FGDs) to obtain data from KP groups, namely, men who have sex with men (MSM), SWs, injecting drug users (IDUs) and PLHIVs. Questionnaires were designed to explore behavioural risk factors towards acquisition of HIV and STI, general knowledge about HIV prevention and ways of transmission, social and cultural determinants, and potential drivers for HIV transmission.
This field work was performed from September to October 2017. A total of 127 collected documents, articles and reports were reviewed, while 65 individuals were involved in either the individual interviews or FGDs. Six stakeholders/key informants were interviewed, as well as three health workers in charge of HIV/AIDS management. Four local NGO/CSBO representatives and two international NGO representatives were interviewed, and three health facilities were visited. Six FGDs were carried out: two with SWs, two with MSM, one with IDU and one with PLHIV. Three visits to KP gathering places were arranged for conducting the informal interviews.
We have used a situational analysis process based on President's Emergency Plan for Aids Relief (PEPFAR) and UNAID’s model, ‘Know your epidemic, know your response’.7 It consists of building an expansive understanding of the HIV/AIDS epidemic in context, including review of available information, exploration of new information and triangulation of varied data sources, to ascertain the epidemiological situation of the HIV/AIDS epidemic and to identify the main drivers for vulnerability in Madagascar and data and response gaps. Data collection was guided by an adaptation of the assessment stage of the WHO’s strategic approach.8
Lastly, we aimed to formulate an explanatory hypothesis based on current situation and considering Malagasy specificities.
Results
Available data about HIV/AIDS infection
According to the national programme estimates, HIV prevalence among the Malagasy GP was around 0.3%, with 39 000 PLHIVs (95% CI 30 000 to 55 000), including 1900 children between 0 and 14 years old. Estimated HIV incidence was 2/1000 per year (95% CI 0.3 to 6.3), and AIDS-related mortality was 4420 persons per year (95% CI 760 to 19 800). In contrast, several studies highlighted a high prevalence/incidence of STI (table 2).2 9–15
Estimated prevalence of STI and HIV in Madagascar
At the Joseph Raseta Befelatanana Hospital (JRBH) in Antananarivo, the largest health centre in the capital city, the HIV/AIDS reference unit is following a cohort of 490 PLHIVs and has shown a sixfold increase in new HIV diagnosis: from 30 in 2010 to 195 in 2018. In addition, during the same period, the proportion of patients diagnosed at a late stage of HIV infection (<200 CD4/mm3) has increased from 1% to 50% (data not published).
In a national-level report, the HIV diagnostic rate for pregnant women was below 0.1% between 2010 and 2014, but HIV screening coverage was estimated at only 20%16 during antenatal consultations (ANCs).
Among people notified with tuberculosis (TB), HIV prevalence rate was estimated at 1.6% in 2012 but had increased to 5.8% in 2016.17 In 2017, a hospital-based study found 12% HIV infection among TB-suspected patients.18 In addition, in the JRBH in Antananarivo, the HIV/AIDS reference unit reported that HIV infection was found in 0.6% of people notified with TB in 2010 but increased to 11.2% in 2016 while also finding that TB was the most frequent AIDS-associated diagnosis during the same year19 (28%).
Estimated prevalence of HIV among SWs rose from 0.3% in 201020 to 1.3% in 201221 and 5.6% in 201622 (table 3). Different rates were observed, ranging from 0% in the industrial city of Antsirabe to 22.7% in the harbour city of Mahajanga (figure 1). The highest prevalence was observed in coastal and touristic cities (Mahajanga and Nosy Be). STI prevalence/incidence among SWs was reported to be extremely high2 9 13 23–25 (table 2).
Estimated HIV infection prevalence in 2012 and 2016 among SWs in the main cities of Madagascar (from BBS studies20 21).
HIV prevalence (%) of KP from published Bio-behavioural studies
A population size study estimated IDU to be around 4000.24 In 2016, a behavioural survey estimated an HIV prevalence of 8.4% among IDUs, with a non-significant (p value>0.05) rise when compared with 2012 (8.1%).26 27
The highest prevalence of HIV observed in Madagascar was reported among MSM (14.8%, 95% CI 6.4% to 23.4%) in behavioural survey reports in 201428 29 (table 3).
Main factors for HIV and STI transmission
A high prevalence of STI found in published studies reflects a lack of condom use among GPs and SWs (table 2).
Primary prevention measures are inconsistently used among the GP. Having multiple sex partners seems to be a frequent practice among this group. In 2005, it was found in a rural area that only 6.5% of 401 men aged 15–49 used a condom during their last sexual intercourse, and 45.6% reported to have had multiple sexual partners during the previous 3 months.30 In 2007, among 320 university students from Antananarivo, consistent use of condom was reported by 5.7% of respondents.31 In 2013, among a sample of 1000 young men, 30% had reported sexual intercourse with multiple partners during the previous 12 months.32
Adolescent girls and young women (AGYW) of 15–24 years share the traits of high vulnerability to HIV transmission that are observed in high-burden countries.33 In the poorest social groups, some seek sexual partners among older men.34 Indeed, AGYW who have had first sexual intercourse before the age of 15 years were 40%,35 and inconsistent use of condoms has been described among them.36–39 Moreover, TS, defined as occasional sexual intercourse in exchange for any material or non-material benefit other than money, is rather frequent. In 2008, TS has been reported for 5.9% of 1078 AGYW during the past 12 months before the interview.36 In 2012, 31% of AGYW in a behavioural study declared having had a TS experience.40 Gender inequality has also been associated with HIV diffusion,41 but few studies have focused on this issue in Madagascar, although they have pointed out difficult access to sexual and reproductive health services,42 as well as a high prevalence of gender-based violence.43 44 High pregnancy rates45 and inconsistent use of condoms45 46 were described among SWs.
Almost 80% of MSM reported to have had transactional anal sex during the previous year in 2014.28 Over three out of four (76.3%) MSM report having had more than one sexual partner per year, and 57.2% of having used a condom during their last anal intercourse.28 A high prevalence of syphilis infection was also reported (6.2%, 95% CI 2.7% to 10.0%).28 29
Qualitative analysis of HIV vulnerability in Madagascar
Malagasy women seem to be particularly at risk as they present all cultural, social and financial factors related to vulnerability to HIV47: low schooling rates, food insecurity, poor access to family planning and reproductive health, and frequent STI.
Qualitative information indicates that SW and TS populations (all age groups) increased in Madagascar following the 2009–2013 economic crisis. A characteristic of Madagascar is the rarity of brothels, as sex work is practised individually and in public settings, which makes them hard to reach. The widespread practice of TS may take place with complex motivations that go beyond the simple exchange of sex for goods or income. For instance, TS may be motivated by the desire to achieve a higher social status or simple ‘survival sex’.32 48–50 An increase in mining activities and population mobility is associated with an increased demand for SWs in some regions, which could be also potential determinants of increasing risk for HIV transmission and STI, but precise data are missing.
There are no published studies in indexed journals about IDU in Madagascar. Qualitative research carried out during our work suggests that IDUs are a relatively recent and increasing phenomena in Madagascar, tend to be young (under 25), living in urban areas, and of middle or high economic status for Madagascar status, but remain a hard to reach population. As of today, syringe exchange activities and opioid substitution therapy are illegal but were carried out by some CSBOs with passive tolerance of local authorities. In 2016, it was estimated that only 19.5% of IDUs had access to syringe exchange programs.26
MSM tend to be a hidden population because of fear of stigmatisation. This lead many MSM to live a double life and to get married and act as bisexual. This situation may facilitate the transmission of HIV as a bridge to GP women.
Besides the high degree suffered by KP, stigmatisation of PLHIV have been reported when attending healthcare centres.51
Access to care for PLHIV
Seventy-four HCCs in 114 districts offer care to PLHIV. According to the 90–90–90 UNAIDS target estimations, 7% of PLHIVs are currently receiving antiretroviral therapy (ART), with 92% adherence to treatment. At the JRBH reference unit, HIV plasma viral load was below 1000 copies/mL for 82.4% of the 295 patients of the PLHIV cohort.52 Results from an unpublished pilot study carried out in the cities Antananarivo, Mahajanga and Morondava between 2015 and 2018 found that among 962 PLHIVs undergoing ART, 26.7% had >1000 copies/mL. Virological success at 6 and 12 months of ART were 682/860 (79.3 %) and 610/760 (80%), respectively (personal communication, M Raberahona 2019). Elsewhere in the country, very few additional data are available on viral loads or CD4 count coverage and results, since these laboratory analyses are not performed for most of the PLHIV receiving ART.
Discussion
The main finding of this review of available data is that the real extent of HIV epidemics in Madagascar could not be ascertained. The available information is scarce, piecemeal and frequently out of date.
The contrast between the low prevalence among the GP and the high-prevalence risk factors remains an unresolved question. There is no evidence that HIV is circulating at high rates among the GP population as there is no report of HIV prevalence in ANC of >1% prevalence. The scarcity and low quality of the HIV prevalence data might form part of the explanation.53 To date, only a single study published in 200512 has found a relatively high prevalence of HIV (2.5%) among the GP, but only 80 participants were tested. Moreover, data from Spectrum model should be interpreted with caution, as they might underestimate the number of PLHIVs.
However, there is a high level of vulnerabilities known to promote the transition to a high prevalence of HIV/AIDS in the country, and some alarming points have been raised. First, the low estimated number (8%) of PLHIVs who are diagnosed means that most of them are unaware of their status. Undiagnosed PLHIVs might contribute to the ongoing HIV epidemic in the GP.54 Second, as shown in table 3, a much higher percentage of HIV new diagnoses has been identified among SWs since 2010, especially in coastal areas (figure 1). These populations, together with TS among the GP, could represent an important driver for HIV transmission, as already reported in sub-Saharan Africa.55 In spite of the fact that the prevalence studies among SW were based on responding driven sampling and may be biased in a certain extent, it is striking to observe that the increase in HIV prevalence has been consistently reported in almost all surveyed sites during three consecutive surveys (see table 3). During the interviews, it was also pointed out that the numbers of SWs and TS cases increased in Madagascar following the 2009–2013 crisis, which might have led to an increase in HIV vulnerability. Third, the increased prevalence of HIV among TB patients could reflect an increase in the HIV epidemic.
Besides sex work, there is a high prevalence of risky behaviours in AGYW, which can be a neglected driver of HIV transmission among the GP through TS.56 57 MSM should also be considered as a potential specific driver of HIV transmission, as the prevalence in this group is already at around 15%, while bisexual relationships, concomitant STI, sex work and IDU seem to be frequent. IDU had a substantial contribution to HIV/AIDS burden in countries experiencing a general epidemic,58 and although the data are still scarce, and could contribute to HIV transmission in Madagascar. Furthermore, national and international sexual tourism may act as an additional risk factor for HIV transmission. At last, the reported stigmatisation of KPs when attending HCCs may discourage them from being tested, counselled and treated.59
Excluding an information gap, the question is why data do not show a higher prevalence of HIV in Madagascar. Some factors could be raised to explain the slow spread of the HIV epidemic among the GP in Madagascar. First, few years after independence was declared in 1960, a Marxist socialist regime led to moderate international isolation, which could have slowed down the introduction and progression of HIV/AIDS in the country, together with the natural geographical isolation. In addition, to date, Madagascar has a relatively small population with a difficult mobility network in a wide country, and this may have prevented the spread of HIV. The role of male circumcision, which is a widespread practice in Madagascar to slow down HIV transmission, remains unknown as it was not studied.
This study has several limitations. First, most of the studies have small sample sizes, different designs and targeted populations, and are not representative of country population. Respondent Driven Sampling used in each round of biobehavioural surveys among KP were not conducted on the same sites for each round, so comparisons should be made carefully. Data coming from specialised HIV clinic in a capital city are not representative of the general situation. Second, data coming from modelling studies should be interpreted with caution. Third, some studies are quite old and have limited representativeness for a current picture. Another limitation is the lack of comprehensive quantitative and qualitative data representative from all the regions in Madagascar.
Our work highlights that new comprehensive and reliable qualitative and quantitative data are needed to understand the HIV/AIDS dynamics in Madagascar. True cross-disciplinary and sustainable efforts are needed to collect evidence through prevalence studies on the GP and KP with a number of new diagnoses, late diagnosis rate, prevalence among pregnant women and number of virally supressed PLHIVs. The situation may be approached by studying prevalence, local microepidemics or mixed epidemic, as suggested in figure 1.
Allocating resources to the hotspots highlighted in figure 1 could be a cost-effective approach for KPs. AGYW could be targeted for a wide access to sexual and reproductive programmes. Re-enforcing HIV tests during ANC could be used as a surveillance method and would help to improve the prophylaxis of mother-to-child transmission. More specifically, syringe exchange and opioid substitution programmes will constitute an important opportunity for IDU population for prevention, counselling, testing and access to care. Continuous efforts should be made to communicate about HIV and STI transmission risk, increase counselling and diagnosis capabilities, improve access to care and adherence to HIV continuum of care. This should include the fight against stigma that may discourage attendance to health centres.
HIV/AIDS is naturally resilient to transitioning towards a highly prevalent epidemic, but once the point of no return has been passed (the tipping point), this resilience is reversed.59 Therefore, financial and organisational efforts should continue to fill the remaining gaps in knowledge to avoid such transition.
Key messages
There is no evidence that a high-prevalence epidemic is ongoing in Madagascar.
Due to the scarcity of data, this could not be excluded.
A high vulnerability to STI, including HIV, could be ascertained in Madagascar.
Additional epidemiological studies to determine the true extent of the HIV/AIDS epidemic in Madagascar are urgently needed.
Abstract translation
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.References
Footnotes
Handling editor Gwenda Hughes
Contributors All authors have contributed at last to the critical reading of the article, revision and contribution of additional information included in the article.
Funding This evaluation was carried out during the feasibility assessment of a community-based HIV/AIDS observatory project. This project is managed by the non-governmental organisation Médecins du Monde (France) and is funded by Expertise France (EF) (initiative 5%, reference number 16SANIN208). FDM, HZO, XV, CM, MR and ER were funded by EF.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval This study obtained the approval of the ethics committee of the Ministry of Public Health of Madagascar (number 088/MSANP/CERBM).
Provenance and peer review Not commissioned; externally peer reviewed.