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Monitoring socioeconomic inequalities across HIV knowledge, attitudes, behaviours and prevention: results from cross-sectional surveys in 18 sub-Saharan African countries

Socioeconomic inequalities in the access to and uptake of HIV prevention services constitute important barriers to global prevention targets, especially in sub-Saharan Africa (SSA). We aimed at monitoring these inequalities based on data from population-based surveys conducted in 18 SSA countries between 2010 and 2018.We defined eight HIV indicators aimed at capturing access to and uptake of HIV prevention services among adult participants. Country-specific wealth-related inequalities were measured using the Relative and Slope Index of Inequalities (RII and SII, respectively) and were then pooled using random-effects meta-analyses. We compared inequalities between African regions using the Wilcoxon rank-sum test.The sample consisted of 358,591 participants (66% women). Despite the variability in inequalities between countries and indicators, the meta-analysis revealed significant levels of relative and absolute inequalities in 6 out of 8 HIV indicators. For instance, the richest participants were five times more likely than the poorest to report condom use at last sexual intercourse (RII=5.02; 95% confidence interval, CI: 2.79-9.05), corresponding to an absolute difference of 16 percentage-points (SII=0.16; 95% CI: 0.12-0.20). Similar significant inequalities were observed in HIV-related knowledge, positive attitudes toward people living with HIV, recent HIV testing, participation to prevention of mother-to-child transmission programs and medical male circumcision. Overall, inequalities tended to be larger in West and Central vs. East and Southern African countries.Despite efforts to scale-up HIV-prevention programs, socioeconomic inequalities remain substantial over the continuum of HIV primary and secondary prevention in several SSA countries.