The objectives of this study were to track progress towards 2020 Fast Track target, which is an interim millstones for the 2030 SDGs of “ending HIV from being a public health threat” [4] across Easter Sub-Saharan Africa countries and to estimate the burden of HIV/AIDS in Ethiopia across ages using GBD 2017 data. There has been slow progress in reducing HIV incidence across the ESSA region since 2010. The goal for reducing HIV/AIDS mortality by 75% by 2020 is within reach in most ESSA countries. Ethiopia, Rwanda and Uganda have achieved the incidence:mortality ratio of less than 0.03, which marks these countries are on track to meet the SDG 2030 target. In Ethiopia the HIV/AIDS mortality rate surpassed the incidence rate contrary to most ESSA countries, which contributed significantly to the reduction in HIV/AIDS prevalence. This is contrary to the UNAIDS’s objective of “ensuring that HIV-positive people live long and healthy lives” and needs serious considerations. At national level understanding the burden of HIV and risk factors are priority areas to control pediatric and adolescent HIV/AIDS [20]. According to the findings, next to heterosexual contact, MTCT is the major contributor to new HIV infection in Ethiopia followed by having a large proportion of HIV positive adults over 50 years who are not virally suppressed. For sustainable epidemic control where Ethiopia is heading, the source of new infections need to be targeted and addressed and there is a need to build strong institutional capacity to track and monitor progress at national and local levels.
To achieve SDG target 3.3, countries are expected to reduce new HIV infection by 75% between 2010 and 2020 [1]. According to the findings, there has been slow progress to achieve the 2020 milestone across the ESSA region. Only Uganda has achieved the 75% target set to reduce HIV incidence by 2020. Ethiopia has reduced the HIV incidence only by 13.3% between 2010 and 2017 and is unlikely to achieve not only the 2020 Fast track target but also its own HSTP plan of reducing adult HIV incidence by 60% between 2010 and 2020 [5, 6]. This is consistent with the HSTP midterm review findings, which highlighted poor progress to achieve the target set for HIV prevention and control and data gaps for progress monitoring [5, 6].
The ESSA region has recorded 73% significant decline in HIV/AIDS related mortality between 2010 and 2017 and is more likely to achieve the Fast Track target by 2020. Ethiopia, Tanzania and Uganda have already achieved the 75% mortality reduction millstone set for 2020 three years earlier. Eritrea, Tanzania and Rwanda are in short of the 75% target unless they have made accelerated progress. In Ethiopia the HIV/AIDS related mortality has shown a declining trend across ages. The under 5 age group followed by the 15–49 age group have recorded the highest decline, while the age group 5–14 recorded the lowest decline. In recent years, the age group 50–69 years has carried the highest burden of the HIV/AIDS related mortality rate. These reflect the reality on the ground that the HIV/AIDS positive people are aging and still most HIV/AIDS prevention, care and treatment services are targeting adults (15–49 years of age) with little attention to older age groups. To realize Ethiopia’s path towards epidemic control, improving access to HIV testing, treatment and care services and retention into the care and treatment program for 50 years and older adults should be considered.
In 2017, the UNAIDS has endorsed the use of incidence:prevalence ratio, a composite measure for tracking countries progress to end the HIV epidemic by 2030 from being a public health threat [1]. Along with Rwanda and Uganda, Ethiopia has already achieved the less than 0.03 epidemic transition benchmark contrary to many ESSA countries, which put Ethiopia on the lead in the HIV/AIDS epidemic control. However, the decreasing prevalence in Ethiopian due to the high rate of mortality is worrisome and needs thorough consideration.
Incidence:mortality ratio is another composite measure the UNAIDS has endorsed to estimate resources needed for future HIV/AIDS treatment and care services in a country. Since 2010, this ratio for Ethiopia has been less than 1 contrary to most ESSA countries and at the global level [1]. Although the ratio indicates that the country has fewer new infections than deaths, having high mortality is a reflection of either poor access or poor adherence to treatment and care services. Nonetheless, this finding contradicts what Ethiopia has recorded in the 90-90-90 Fast Track progress. According to EPHIA 2018 findings, Ethiopia has achieved the last two 90 s i.e putting more than 90% of the HIV diagnosed cases on ART and ensuring over 90% of the HIV/AIDS cases who received treatment achieved viral suppression among urban residents [9]. It is known that early initiation of ART and achieving significant viral suppression increases survival probability for patients infected with HIV. Despite these facts, the high mortality estimated in the present study could be attributed to the more than 40% undiagnosed HIV/AIDS cases. According to the 2016 EDHS, about 60% of the population reported that they have never tested for HIV [21]. It is partly due to limited access to HIV testing, treatment and care services, limited access to health care services in some rural and remote areas and low health care utilization (poor health seeking behavior). Hence, at national level Ethiopia has intensified targeted HIV testing, index testing and CBS to address the aforementioned gaps and to identify 90% of the people who are HIV infected (to achieve the first 90).
In Ethiopia the HIV incidence among children under 5 years of age has shown a 77% decline between 2010 and 2017. Hence, the country is more likely to achieve the Zero new infection target set for 2020 but requires accelerate progress [5, 6]. With regard to HIV incidence among adult (15–49 years), the recorded 12% increase by 2017 from the 2010 baseline is against the 60% reduction target the country has set for 2020. This requires to revisit current strategies and initiatives and to come up with innovative approaches to move fast forward [5, 6]. Unlike other similar settings, the HIV incidence rate in Ethiopia was highest among under 5 age group until 2015 compared to the other age groups [1]. This trend indicates the poor attention given to the PMTCT program and poor HIV/AIDS treatment and care services for under 5 children in earlier years. In response to the UNAIDS strategic target “Zero new infection” among children, Ethiopia has introduced “Option B plus” (initiating lifelong HIV treatment for all positive mothers irrespective of immunologic status and CD4 cell count) in 2013, which has brought remarkable progress in reducing MTCT (11–18). However, Option B plus works only for children whose mothers have access to antenatal care and PMTCT services. In Ethiopia, access to antenatal care and PMTCT service is still low, although access is higher in urban compared to rural areas [21]. Recent evidence revealed gaps in achieving the first 90, as it is contingent upon access to health care services where HIV testing is largely taking place. This prompted the government to consider other innovative active HIV case finding and reporting strategies and considers HIV as one of a notifiable disease. For this a case based surveillance (CBS) system integrated with index case testing and recency testing has been launched. These approaches have the potential to increase the number of HIV cases identified and put them on treatment. The next logical move for the country would be to expanding the role of CBS from being a case reporting system to a cohort by incorporating more sentinel events to ensure sustainable epidemic control and monitoring system.
Considering prevalence and DALYs absolute measures, Ethiopia still carried high burden of HIV despite the country being on the lead in the HIV epidemic control. Having high prevalent cases that are not virally suppressed as in the case of 50–69 age group can sustain the production of new infections. According to EPHIA data, in urban settings the 50–64 age group adults have carried the highest HIV prevalence (4.4%) in the country, whereas only 72.2% of the 55–64 years were virally suppressed [9]. Focusing on the declining HIV prevalence and incidence rates as a basis for financing HIV prevention and control activities could have serious consequences in a country having over 650,000 HIV infected people, whereby about 40% them are undiagnosed.
Although, the GBD presents a special opportunity for countries having limited data on vital event registration, the GBD estimation has its own limitation as argued by Kelly and Wilson [22]. In countries like Ethiopia where there is no comprehensive vital registration data, the GBD uses different data sources, where at times some of these data are not updated. HIV being a highly evolving case, relying of years old data may provide misleading information and hence misalign HIV prevention and control efforts including resource allocation. Taking the weakness of the GBD into consideration, this study compares the HIV prevalence estimates with the 2016 EDHS data and found consistency and highlights the validity of the GBD 2017 estimates for program planning and policy formulation.