Systematic review on HIV situation, gaps and challenges in Addis Ababa, Ethiopia

Background HIV prevalence in the Addis Ababa is still higher in key and priority populations. Therefore, this systematic review was carried out aiming in determining the prevalence of HIV, mortality rate by HIV/AIDS and predisposing risk factors, identification of hotspot areas, key and priority populations, availability and utilization of services, and challenges and gaps to be addressed for prevention and control of HIV epidemic in Addis Ababa.Methods The documents relevant to address the objectives were collected from online databases Google scholar and PubMed for published works. In addition, unpublished survey and surveillance reports, performance reports and project assessment findings, and mapping results were collected from partner organizations working on HIV/AIDS prevention and control.Results It appears that the prevalence along areas and socio-demographic groups. where address groups of the population. There are many behavioural, biological and socioeconomic factors that predisposed to HIV/AIDS. Weak monitoring of the quality of interventions, limited linkage of positive clients, lost to follow up, financial shortage, limited man power and coordination, data quality and gaps in use of program data or research findings are some of the gaps and challenges. Therefore, prevention and control measures using behavioural, structural and biomedical interventions through filling of gaps and tackle challenges should be strengthened in order to prevent and control HIV/AIDS. key words and phrases in Adds Ababa; resistance in Addis Ababa; HIV behavioural, socioeconomic predisposing factors in Addis Ababa; association of HIV with khat, alcohol and drug use in Addis Ababa; HIV and sexually transmitted infections in Addis Ababa; and of mother to child transmission (PMTCT)


Introduction
According to HIV related estimates and pprojections for Ethiopia [1], there are 610,335 people living with HIV (PLHIV) with estimated adult HIV prevalence being 0.96%. The Ethiopian demographic and health survey (EDHS) 2016 report [2] shows Gambella region (4.8%) and Addis Ababa (3.4%) to have the highest HIV prevalence rates while Somali (<0.1%), and Southern Nations, Nationalities and peoples (SNNP, 0.4%) regional states have the lowest. The adult (1 5 -5 9 ) HIV prevalence in Ethiopia is 0.9%, with varying burden by sex, age, and other demographic characteristics, across sub-regions and population groups. The urban HIV prevalence (2.9%) is seven times higher than the prevalence in rural settings (0.4%), women (1.2%) having twice higher HIV prevalence than men (0.6%) [2].
The Ethiopian population based HIV impact assessment (EPHIA) [3] showed that prevalence of HIV is 3.0% in urban settings [3]. This relatively high prevalence of HIV in Addis Ababa initiated us to look into the magnitude of the HIV prevalence, who and why they are affected, the availability and utilization of services for the most affected groups, and the gaps and challenges to address the problem. Therefore, this systematic review was carried out aiming in determining the prevalence of HIV, and mortality rate by AIDS (1), predisposing risk factors (2), identification of hotspot areas (3), key and priority populations (4), availability and utilization of services, and challenges and gaps to be addressed for prevention and control (5) of HIV epidemic in Addis Ababa.

Methods
The documents relevant to be reviewed to address Addis Ababa

HIV prevalences
Surveys and assessment conducted in Addis Ababa such as EDHS [2,4,5], and EPHIA assessment [3] showed that prevalence of HIV is 4.7%, 5.2%, 3.4% and 3.1%, respectively ( The prevalence is relatively higher in 2014 (5.5%) than the prevalence in 2012 (4.4%). In addition, the prevalence from prevention of mother to child (PMTCT) surveillance report of 2016 (1.8%) is lower than the prevalence from ANC surveillance report of 2014 ( Figure 1).   [11,12,15]. In other studies, the percentage of men who had sex with non-marital, noncohabiting partners is highest in Addis Ababa (26%) compared to national (16%). In Addis Ababa, the highest mean number of lifetime sexual partners reported by men is 5.2; and 72.4% of w o m e n a n d 41.8% men reported using condom during last sexual intercourse with non-regular partner [2].

Biological factors
Discordant couples have the highest risk of acquiring HIV. From the total HIV positive couples in Addis Ababa, 4.3% of them were found to be discordant [2]. The proportion of disclosure of HIV/AIDS diagnosis to HIV-infected children is low. Almost one in ten HIV exposed infants become HIV positive in Ethiopia. Two and four percent of the HIV exposed babies were HIV positive by 6 and 18 months, respectively [16]. There is low utilization of timely early infant diagnosis (EID) services. Being from the rural residence, home delivery, lack of understanding of the efficacy of ART, negative religious influences, and mixed infant feeding practices increased the risk of HIV transmission to children [17,18].  [20]. According to recent estimates, there are about 200,000 FSWs in Ethiopia [23]. The majority of FSWs (57.5 %) are 24 years and younger, and about 14% are 19 years or younger [24]. MARPs study [20] also showed that the size of FSWs in Addis Ababa was estimated to be 10,267.

Socio-economic factors
HIV prevalence in FSWs is four times higher than the general population.
A total of 4,068 IDUs are estimated to be located in Addis Ababa [25].    prophylaxis for FSWs and discordant couples is at piloting stage. More than 10% of the BCC beneficiaries/FSWs had never been tested for HIV [24]. Some parents are refusing to give consent for their children to access HIV testing services (HTS) and ART services [31].
Behavioral, socio-economic and biomedical factors contributed to discontinuation ART. Heavy pill burden, fear of stigma and discrimination, cost and access to transportation, medication side effects, economic problems in the household, long travel due to distance from ART clinics, long waiting times, alcohol drinking, smoking, being with baseline CD4 <200 cells/mm 3 , having mental illness, being bed ridden functional status, and dissatisfaction with healthcare services were risk factors for ART discontinuation. Males were reported to be most affected by discontinuation from being away from home [33,34,35]. More than 6% of HIV positive FSWs who started ART reported discontinuation of treatment for more than seven days in the three months prior to the assessment [24]. With the introduction of appointment spacing, some patients complain of lack of storage space for the sixmonth supply of ARTs, poor storage conditions for their medicines, a n d preference  [3]. In Addis Ababa, the total number of clients on ART were 94,240 a n d 3,616 were newly enrolled during the reporting period. The retention at 12 months was 87% [29, Figure 4]. The Addis Ababa Mortality Surveillance Program using burial surveillance with verbal autopsy method [41] to identify AIDS and other causes of death showed that HIV/AIDS mortality is higher among females (12.1%) as compared to males (9.5%).
Relatively, higher proportion of death due to HIV/AIDS (13.2%) was observed in the age group of 30-49 years [7]. In Addis Ababa from 2007-2010, an overall declining trends of AIDS related mortality was observed. However, starting 2010 onwards it seems stabilized ( Figure 5). Noncompliance to medical instruction and poor adherence fosters emergence of drug resistance. In addition, limited availability of laboratory services such as H I V RNA load and drug resistance testing a n d monitoring due to lack of experience of health professionals, a n d weak infrastructure and health care system contribute to delay in diagnosis of treatment failure [38,39]. The high rate of transmitted and preexisting drug resistance mutations in Ethiopian patients are identified [40]. The finding of HIV-positives with high viral load in some studies [3] alarms the presence of people with high viral load which increases the risk of HIV transmission in the community.
There are gaps and challenges of HIV/AIDS prevention and control in Addis    Number of individuals currently on ART (cumulative), 2006-2011 EFY [29]. EFY= Ethiopian fis Percentage of AIDS death in Addis Ababa from 2007-2011 [41].