HIV-Prevalence in South Africa by settlement type: A repeat population-based cross-sectional analysis of men and women

PLOS ONE RESEARCH ARTICLE HIV-Prevalence in South Africa by settlement type: A repeat population-based crosssectional analysis of men and women Andrew Gibbs ID1,2*, Tarylee Reddy3, Kristin Dunkle1, Rachel Jewkes1,4,5 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa, 2 Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa, 3 Biostatistics Unit, South African Medical Research Council, Durban, South Africa, 4 Office of the Executive Scientist, South African Medical Research Council, Pretoria, South Africa, 5 School of Public Health, University of Witwatersrand, Johannesburg, South Africa * Abstract OPEN ACCESS Citation: Gibbs A, Reddy T, Dunkle K, Jewkes R (2020) HIV-Prevalence in South Africa by settlement type: A repeat population-based crosssectional analysis of men and women. PLoS ONE 15(3): e0230105. https://doi.org/10.1371/journal. pone.0230105 Editor: Angel Blanch, University of Lleida, SPAIN Received: July 29, 2019 Accepted: February 21, 2020 Published: March 17, 2020 Copyright: © 2020 Gibbs et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are available via unrestricted access off the HSRC website: 2002 dataset: http://dx.doi.org/doi:10. 14749/1400830395 2005 dataset: http://dx.doi. org/doi:10.14749/1400830455 2008 dataset: http://dx.doi.org/doi:10.14749/1441969417 2012 dataset: http://dx.doi.org/doi:10.14749/ 1485430466 Funding: This study was funded by the South African Medical Research Council (SAMRC). To assess i) whether there is an independent association between HIV-prevalence and settlement types (urban formal, urban informal, rural formal, rural informal), and, ii) whether this changes over time, in South Africa. We draw on four (2002; 2005; 2008; 2012) cross-sectional South African household surveys. Data is analysed by sex (male/female), and for women by age categories (15–49; and 15–24; 25–49) at all-time points, for men in 2012 data is analysed by age categories (15–24; 25–49). By settlement type and sex/age combinations, we descriptively assess the association between socio-demographic and HIV-risk factors; HIV-prevalence; and trends in HIV-prevalence by time. Relative risk ratios assess unadjusted and adjusted risk for HIV-prevalence by settlement type. All estimates are weighted, and account for survey design. In all survey years, and combinations of sex/age categorisations, HIV-prevalence is highest in urban informal settlements. For men (15–49) an increasing HIV-prevalence over time in rural informal settlements was seen (p = 0.001). For women (15–49) HIVprevalence increases over time for urban informal, rural informal, rural formal, and women (15–24) decreases in urban formal and urban informal, and women (25–49) increases urban informal and rural informal settlements. In analyses adjusting for potential socio-demographic and risk factors, compared to urban formal settlements, urban informal settlements had consistently higher relative risk of HIV for women, in all age categorisations, for instance in 2012 this was RR1.89 (1.50, 2.40) for all women (15–49), for 15–24 (RR1.79, 1.17–2.73), and women 25–49 (RR1.91, 1.47–2.48). For men, in the overall age categorization, urban informal settlements had a higher relative risk for HIV in all years. In 2012, when this was disaggregated by age, for men 15–24 rural informal (IRR2.69, 1.28–5.67), and rural formal (RR3.59, 1.49–8.64), and for men 25–49 it was urban informal settlements with the highest (RR1.68, 1.11–2.54). In 2012, rural informal settlements also had higher adjusted relative risk for HIVprevalence for men (15–49) and women (15–49; 15–24; 25–49). In South Africa, HIV-prevalence is patterned geographically, with urban informal settlements having a particularly high burden. Geographical targeting of responses is critical for the HIV-response. Competing interests: The authors have declared that no competing interests exist. PLOS ONE | https://doi.org/10.1371/journal.pone.0230105 March 17, 2020 1 / 20 PLOS ONE HIV-Prevalence by settlement type in South Africa Introduction HIV-incidence and HIV-prevalence is spatially distributed globally, nationally, and subnationally. The spatial patterning of HIV across settings reflects inequalities in access to resources, healthcare services, and power differentials, particularly along lines of poverty, sexuality, gender and race [1–3]. Across Africa (excluding South Africa) a limited body of work has looked at this by settlement type. In Kenya, HIV-prevalence was assessed comparing urban slums, with urban-non slum settlements, with the HIV-prevalence 12% and 5% respectively [4]. While in Namibia’s capital city, Windhoek, hotspot mapping identified particularly high HIV-incidence in informal settlement areas [5]. Understanding the spatial patterning of HIVprevalence globally, and nationally, is critical to ensure limited resources are targeted most effectively, particularly as donor funding is declining [6]. In South Africa, a number of studies have explored the spatial patterning of HIV. Studies have, for instance, sought to highlight HIV ‘hot-spots’. For example, Tanser et al [7] found wide variation in HIV-prevalence (from 6–39%) in a rural demographic health surveillance area in KwaZulu-Natal, with clustering of HIV in homesteads [8], nearer national roads [7], and by transport corridors [9]. Amongst women screened for enrollment in clinical trials, also in KwaZulu-Natal, but in more urban settings, HIV-prevalence clustered in ‘hot spots’ with HIV-prevalence in those ranging from 56.0% to 39.0%; with distinguishing factors including being in peri-urban communities (typically including informal settlements), and reporting more lifetime sexual partners [10]. Finally, one nationally representative youth (15–24) survey, found that HIV-prevalence was pattern by rural/urban status, with higher HIV-prevalence in urban settings, and was highest for young women in urban informal settlements (but not men) [11]. In addition, in South Africa, there have been five nationally representative population based studies of HIV-prevalence and incidence, in 2002, 2005, 2008, 2012, and 2017 [12–16]. In each of these data on settlement type is collected and analysed in the main report. The 2017 data is not yet publicly available, and in the report that has been produced, settlement types have been coded differently to previous studies, combing urban informal and urban formal to create one category of ‘urban’. All four previous (2002; 2005; 2008; 2012) nationally representative studies analysed data by urban formal, urban informal, rural formal and rural informal, (...truncated)