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HIV/AIDS in Sierra Leone: Characterizing the Hidden Epidemic George A AIDS Reviews. 2018;20 Contents available at PubMed www.aidsreviews.com PERMANYER AIDS Rev. 2018;20:104-113 www.permanyer.com HIV/AIDS in Sierra Leone: Characterizing the Hidden Epidemic George A. Yendewa1,2*, Eva Poveda3, Sahr A. Yendewa4, Foday Sahr4,5, Miguel E. Quiñones-Mateu1,6,7 and © Permanyer 2018 Robert A. Salata1,2 1Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; 2Division of Infectious Diseases and HIV Medicine, University. Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; 3Group of Virology and Pathogenesis, Galicia Sur Health Research Institute (IIS Galicia Sur)-Complexo Hospitalario Universitario de Vigo, SERGAS-UVigo, Spain; 4College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone; 534 Military Hospital, Republic of Sierra Leone Armed Forces, Freetown, Sierra Leone; 6Department of Pathogenesis, Case Western Reserve University, Cleveland, Ohio, USA; 7Center for AIDS Research at Case Western University/University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA of the publisher Abstract Sierra Leone is a low-income West African country that has dealt with waves of economic, political, and public health challenges in its recent past, including a decade-long brutal civil war and the Ebola epi- demic of 2014-2016. The HIV/AIDS epidemic, which has raged on in the country since 1987, has long been characterized as stable. The latest UNAIDS report estimates a countrywide HIV prevalence rate of 1.7% in 2016 among adults aged 15-49 years. However, there are indications that the epidemic may be in fact es- calating and unless arrested urgently, has the potential to deteriorate into a major public health emer- gency. Although there are high levels of HIV awareness among adults (over 94%), uptake in voluntary HIV testing has remained low (< 30%), and under one-third (29%) of the country’s 60,000 people living with HIV/AIDS were on antiretroviral therapy in 2015. This review attempts to address the paucity of scientific information on the subject by presenting the historical and epidemiological background to the HIV/AIDS epidemic in Sierra Leone. Other aspects of the HIV/AIDS epidemic in Sierra Leone are examined, including routine HIV screening and diagnosis, linkage to and retention in HIV care, clinical characteristics and mo- lecular epidemiology, treatment coverage, and prevention strategies. Finally, we identify four key areas of challenge that are hampering current efforts attempting to bring the epidemic under control, and perspec- tive is offered on the way forward. (AIDS Rev. 2018;20:104-113) Corresponding author: George A. Yendewa, [email protected] Key words HIV. Sierra Leone. Antiretroviral therapy. Diagnostics. Resource-limited settings. Correspondence to: George A. Yendewa Division of Infectious Diseases and HIV Medicine University Hospitals Cleveland Medical Center No part of this publication may be reproduced or photocopying without the prior written permission 11100 Euclid Ave Received in original form: 27/04/2018 Cleveland 44106, Ohio, USA Accepted in final form: 14/05/2018 E-mail: [email protected] DOI: 10.24875/AIDSRev.M18000022 104 Yendewa, et al.: HIV/AIDS in Sierra Leone and molecular characteristics of the HIV/AIDS epidemic verview of the HIV/AIDS landscape in O in Sierra Leone, current treatment and prevention strat- Sierra Leone egies, and the challenges faced by public health offi- cials in the uphill fight to surmount the epidemic. Sierra Leone is a small, low-income country in West Africa. It has a total population of 7.4 million people History of the prevalence of HIV/AIDS in and a gross domestic product per capita income of Sierra Leone 587 United States dollar, with over 60% of its inhabit- ants living below the poverty line1. Since gaining inde- The earliest known cases of HIV/AIDS in Sierra Leone© Permanyer 2018 pendence from Great Britain in 1961, the country has were documented in 1987, consisting of 10 HIV-positive grappled with myriad political, economic, and public . individuals among commercial sex workers5. Since health challenges. During the 1990s, Sierra Leone re- then, the countrywide prevalence rate has steadily in- ceived much-unwanted attention on account of a brutal creased and appears to have peaked at 14.9% during civil war that decimated the country’s already fragile the civil war years (1990-2001)6-8. Following the civil health infrastructure, leaving it with some of the worst war, the Government of Sierra Leone and the United indicators of health. The World Health Organization of the publisher States Centers for Disease Control and Prevention (WHO) reported that, in 2010, there were only 0.024 jointly conducted the first ever countrywide HIV serop- physicians per 1000 of the population, one of the low- est anywhere in the world2. The Sierra Leone Demo- revalence study in 2002, which recorded a weighted 9 graphic Health Survey of 2013 (SLDHS 2013) recorded population HIV prevalence rate of 0.9% . More recent an average life expectancy of 47 years at birth, infant countrywide population surveys have consistently re- mortality rate of 96/1000 live births, under-five mortal- ported an apparent plateauing of the HIV prevalence ity rate of 156/1000 live births, and maternal mortality rate at 1.5-1.7%, representing an estimated total of rate of 1165/100,000 births3 (Fig. 1). 67,000 adults and children living with HIV/AIDS in Si- 3,4 The recent Ebola epidemic of 2014-2016 has gener- erra Leone (Table 1). The majority of HIV-infected ated unprecedented interest in various public health individuals appear to be concentrated in the capital city challenges in the country, including the epidemic as- of Freetown (2.5% prevalence), in other urban popula- sociated with HIV/AIDS. The latest Joint United Nations tions around the country, and in regions of high eco- 10 Programme on HIV and AIDS (UNAIDS) report of 2016 nomic activity such as in the diamond mining areas . recorded a countrywide HIV prevalence rate of 1.7%, In 2013, the National HIV/AIDS Secretariat (NAS) of characterizing Sierra Leone as a low prevalence coun- Sierra Leone and UNAIDS conducted a countrywide try4. However, the true nature and scope of the HIV/ population size estimation (PSE) survey, which identi- AIDS epidemic in Sierra Leone have not been fully fied “key populations” (KP groups) exhibiting high-risk examined before, and these figures appear to be un- behaviors or activities that disproportionately increased der-reporting a major and hidden public health prob- their likelihood of being affected by the HIV/AIDS epi- lem. There is a dearth of reliable scientific data on the demic11. The KP groups identified were female sex epidemiological, clinical, and molecular characteristics workers (FSW) and their partners and clients, long- of the HIV/AIDS epidemic in the scientific literature. As distance truck drivers, members of the fishing com- of February 1, 2018, a search in PubMed using the munity, members of the uniformed armed services, and words “HIV+Sierra Leone” (https://www.ncbi.nlm.nih. migrants. Men who have sex with men (MSM) and injec- gov/pubmed/?term=HIV+Sierra+Leone) yielded only tion drug users (IDU) emerged as relatively new and 88 scientific articles, many of them addressing the major demographic representations for new HIV infec- country’s HIV prevalence. All other aspects of HIV tions. The KP groups made up only 4% of the total care, including routine screening and diagnosis, initia- population but accounted for 44% of known HIV cases tion of antiretroviral therapy (ART), HIV drug resistance, in the country. In 2015 alone, 1000 new infections were linkage to and retention in HIV care, socio-cultural im- directly attributable to the KP groups, establishing their plications of HIV-positive status, access to vital allied position as the major and perhaps most important driv- support services (e.g., mental health and social sup- er of the HIV/AIDS epidemic in the country11 (Table 1). port), and quality of life issues for persons living with The PSE survey was followed by the HIV SeroprevaNo part of this publication may be reproduced or photocopying without the prior written permission - HIV have not been sufficiently studied. lence study of the KP in 2015, which reported that HIV This review summarizes some of the currently avail- prevalence rates were highest in the self-identified able scientific data on the epidemiological, clinical, transgender male-to-female category (22.4%), followed 105 AIDS Reviews. 2018;20 © Permanyer 2018 . of the publisher Figure 1. Map and demographic information of Sierra Leone. Data were summarized from the World Bank Report on Sierra Leone1, the World Health Organization Statistics Summary on Sierra Leone2, and the Sierra Leone Health and Demographic Survey3. Gross domestic product; United States dollar. by MSM (14%), IDU (8.5%), and FSW (6.7%)12. Other suppression, which has been shown to improve HIV/ KP groups with high prevalence rates were the trans- AIDS-related morbidity and mortality and interrupt the gender female-to-male category (6.7%), clients of com- HIV transmission cycle across all demographic mercial sex workers (2.9%), and prisoners (2.2%)11. In groups17,18. Towards achieving these goals, UNAIDS a separate study, Djibo et al.13 observed that the HIV announced its ambitious global 90-90-90 strategy in prevalence rate was 3.3% among members of the Si- 2014, which aims for 90% of all HIV-infected people erra Leone Armed Forces. Although not considered a to know their HIV-positive status, 90% of those in- KP group per se, pregnant women are a high-risk fected to be on effective antiretroviral treatment, and group, with an estimated prevalence rate of 3.2% re- 90% of people on treatment to achieve virological sup- corded in 201010. In addition, considerable overlap pression by the year 202019.
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