A total of 4539 different strains of HIV were available from the Libyan HIV database. These data were collected for all over the Libyan regions ( West, East. Middle, and South) within ten years period from the start of the armed conflict 2011 till 2020. Of these reported strains 3509 (77.3%) were reported from males and 1030(22.7%) females( M: F ratio 3:1 ). The number of reported cases varied from one year to another during the study period. They were increased from 371 in 2011 to reach 512 in 2020 and the reported incidence rate (IR,) (number of reported cases/population) rose from 6.0:100,000 in 2011 to reach up to 9.0:100,000 in 2020 as shown in Table 1.
The demographic, clinical, and HIV-1 sequences data of the enrolled participants were shown in Table 2. The median age of participants was 37 years [inter-quartile range (IQR) of 26–49 years]. Of 4539 participants involved in the study, 1369 (30.2%) were from the Eastern region, 1685(37.1%) Western region, 937(20.6%) Middle region, and 548(12.1%) Southern region. A total of 3070 ( 67.4%) were reported among resident individuals and 1469 ( 32.4%) from the displaced population. No variation in the number of reported cases within resident individuals. It was found to be 16 % in 2011 and 17.2 % in 2020 while those reported from displaced individuals increased steadily from 2.9% in 2011 to 4.7% (2013-14), 12.6 %, and 7.2 % and then declined to 4.8 % at the end of the conflict period.
The majority of the study participants attributed to IDUs (Injecting Drug users) accounted for 2076 (44.7%). Followed by those with a high-risk sexual behavior 1256( 27.7%) and 1207( 26.6%) with other risk factors. No significant changes were found for transmission risk factors during the investigation period 2011-2020( P> 0.01). The proportion of IDUs cases was reported to be (9.3%) in 2011 and (10.8%) in 2020 and ( 5% to 6.6 %) for sexual contacts and 6.4% and 6.4 for other risk factors.
The overall HIV subtype distribution was A (1084(23.9%), B 2060(45.4%), CRF02_AG 910 (20.1%), and others 485(10.7%). The trends of HIV subtypes were changed overtime during the conflict period. There is a substantial difference in the emergence of each subtype during the ten years. We observed an increase in the proportion of subtype B infections from 8.2% to 10.8% and subtype A from 4.4 % to 6.7%. For CRF02_AG we found a significant decrease over time as it varied from 4.3% to 2.2% during 2011-2020.
The transmission dynamics of HIV Type 1 in the Libyan Population during the armed conflict was illustrated in Figure 1. The country is classified into twenty-two provinces within the four national regions, the West region ( 7 provinces ), Central region (3 provinces), South region (5 provinces ), and East region ( 7 provinces ). According to the geographic data set analysis, the East region was the main exporter accounting on average for 93.5% of the migration events in Libya. The geographic strains movements were mostly observed in this region. The most strongly supported viral migration route was found between Benghazi and Tripoli, Benghazi to Misrata. Other routes connecting Benghazi to Sebha and Western Mountains were frequently reported. Other routes of Genetic flow connected Tripoli to the Western mountain, Misrata to Tripoli, and Misrata to Sebha was also reported.
Table 3 illustrates the different HIV-1 strains that migrated from and to different regions during the armed conflict. A total of 972 type-able strains 504(51.9%) were migrated all over the country. Of these 471 (48.5%) migrated from the Eastern Region including 321(33.0%) recombinant CROF, followed by B 143( 14.7%) and only 7(0.7%)and HIV-1 A. The meddle region received 17 (1.7%) migrated stains ( 9 CROF, 6A 2B), followed by Western Region 9 (0.9%) strains and only 7 ( 0.7%) Southern Region.
Furthermore, 468 (48.1%) strains were migrated to different regions including, 319 (32.8 %) migrated to The western region particularly Tripoli, including B 224(23%) C 82( 8.4%) A13 (1.311%), followed by Meddle region 107( %) A 09(9.0%) B 75(7.7%) C 23(2.4%).Although only 39 ( 4.0%) and only 3 Strains migrated to Eastern and southern regions respectively.
The prevalence of HIV and the distribution of multiple HIV subtypes in different geographic locations during the Libyan conflict were presented in Figure 2. In the first five years period ( 2011-2015 -Figure 2A), the Eastern region showed the highest prevalence of HIV particularly in Benghazi estimated to be> 0.8% followed by Marj, Darna, and Butnan and to less extent Al Wahat and Kufra. In these provinces, CROF was the predominant circulating strain accounted for 60% followed by Strain B with 20%. In the West region, Tripoli reported a HIV prevalence of 6% followed by Nalut 4% others are less than 0.2%. In the Western provinces, HIV-B was the predominant strain which has reached 50% followed by HIV-A and CROF which accounted for 20% each. In Central province, HIV prevalence was reported to be 0.6% in Misrata followed by Sirte and Jufra. HIV –B and CROF were the predominant circulating strains, where they occupied 45 % and 25%respectivelly. In the South region the HIV prevalence was reported to be very low ( <0.4%). The predominant circulating strains in these provinces were B(40%,), A(30%), and to less extent CROF(20%).
In the second period of the conflict ( 2016-2020) Figure 2B. The Western region showed a higher HIV prevalence. The highest prevalence was reported in Tripoli, Zawia, Nuqat Al-Khams, Jafra,Murqub, Nalut, and to less extent Jabl-Al Garbi. In these provinces, the highest-circulating HIV strains were B (40%) CROF (35%), and A (20%). In the Central region the highest prevalence was reported in Misrata( >0.8%) and only < 0.2% in Sirte and Jufra. HIV-strain B accounted for 40% of the circulating strains followed by CROF( 35%) and B (20%). In the Southern provinces, the HIV prevalence reached 0.6% in Sabha and Ghat and 4% in the other three provinces. The most circulating strains occupy the Southern provinces were Strains A&B accounted for 30% each followed by CROF (25%). In the Eastern region HIV prevalence was 0.6% in Benghazi and < 0.2 in the other provinces. Furthermore, the most predominant circulating strains were B (25%), CROF (25%), and A (20%).