The number of people forcibly displaced due to conflict is rising rapidly each year. Previous studies have documented associations between mental ill health, HIV risk, and poor engagement with HIV care in conflict-affected populations. Most people forced to migrate are adolescents and young adults, who might already be affected by a high burden of mental ill health due to factors such as high trauma exposure during the developmental period. Adolescent girls (aged 15-19 years) and young men (aged 20-24 years) are highly vulnerable populations for HIV acquisition. Trauma and migration stress can further exacerbate the burden of mental ill health on forcibly displaced adolescents and young adults. Given the high level of vulnerability this population faces, delivery of trauma-informed HIV prevention to this group is crucial, through combined mental health and HIV interventions that are tailored to their unique developmental and socioenvironmental contexts. Trauma-informed HIV prevention is key to controlling and ending the HIV epidemic among adolescents and young adults affected by crises.
Australia has seen a steady decline in HIV notifications since 2013 and has one of the fastest declining rates of HIV transmission in the world. Australia is now in a globally unique position to plan for a near future of virtual elimination of HIV transmission. Through community involvement for every stage of this Delphi consensus process, we ensured the statements drafted reflect the needs of the community and highlight the gaps in the HIV response that will be essential to address if virtual elimination is to be achieved. The targeted strategies developed address how to reduce HIV transmission at every stage and facet of the HIV response (including prevention, testing, treatment, reducing HIV stigma, and enhancing the community-led response and research), resulting in a list of specific and essential priorities for the next stage of Australia's HIV response. Essential to achieving virtual elimination is the need for continued collaboration from community organisations, clinicians, researchers, and funding agencies. As Australia is one of the few countries in the world to be able to plan for HIV elimination in the near future, this Position Paper will be a useful guide for other countries as they plan for their own HIV response.
Background: An individual's HIV risk, and consequently their HIV prevention needs, change over time. In this study we aimed to quantify these changes, examine which life-course events were associated with them, and investigate the extent to which those life-course events were associated with HIV acquisition.
Methods: We used longitudinal data from eight rounds of a general population cohort in Manicaland province, eastern Zimbabwe, on sociodemographic and HIV risk behaviours, as well as HIV serostatus from the first seven rounds. We first visualised how HIV risk behaviours, comprised of having multiple, concurrent, non-regular, or transactional partners, condom non-use, drug use, and visiting bars, changed for individuals over time using Sankey diagrams. We then examined whether logistic regression models incorporating life-course events-namely, changes in marital or employment status, in-migration, or birth of a child-were more strongly associated with changes in HIV risk behaviour than models using only sociodemographic variables. Finally, we compared how well sociodemographic, HIV risk behaviour, and life-course events were associated with the person's risk of HIV acquisition as follows: we used logistic regression to identify which states (divided into sociodemographic, HIV risk behaviour, and life-course events) were most strongly associated with risk of HIV acquisition; based on this we use three models (corresponding to the three divisions) to identify the top 20% of individuals predicted to be at risk of acquiring HIV by each model, and computed what proportion of the actual HIV infection events occurred in that group.
Findings: Between 1998 and 2021, 21 213 individuals were interviewed at least twice, contributing a total of 34 212 participant observations. In this setting, individuals had periods of HIV risk lasting less than 3 years; only 12·3% (102 of 831) of those reporting transactional sex had also reported this in the previous round. We found that life-course events such as changes in marital status, employment status, and in-migrant status were associated with these changes in HIV risk behaviour. Using life-course events, particularly ones related to changes in marital status, 23% and 30% more HIV acquisitions were identified than using HIV risk behaviours or sociodemographic information, respectively.
Interpretation: HIV risk changes dynamically in this population, and life-course events could be a powerful way to understand changes in HIV risk behaviour and risk of HIV acquisition.
Funding: Bill and Melinda Gates Foundation, UK Medical Research Council, and Department for International Development.
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