Armed Conflicts, HIV Testing, HIV Prevalence, and High-Risk Sexual Behaviors: An Epidemiologic Analysis

Armed conflicts have a wide array of consequences on health and behavior possibly serving a role in the spread of HIV, yet there is limited research on the quantitative association between armed conflicts and HIV. To address this gap in the literature, we evaluated the effect of armed conflicts on HIV testing, HIV prevalence, and high-risk sexual behaviors, using Demographic and Health Surveys data from 11 countries in Sub-Saharan Africa (years 2010 to 2018) and the Armed Conflict Location & Event Data. We hypothesized that armed conflicts, measured using number of conflict days, fatalities, or distance to nearest conflict, would be associated with reduced likelihoods of HIV testing, higher likelihoods of HIV prevalence, and higher occurrences of high-risk sexual behaviors. We developed three specific aims to 1) compare HIV testing, HIV prevalence, HIV knowledge and attitudes, and high-risk sexual behaviors between conflict and non-conflict areas, 2) determine the association between armed conflicts, HIV testing, and HIV prevalence and 3) determine the association between armed conflicts and high-risk sexual behaviors. We utilized a cross-sectional ecologic study, descriptive statistics such as maps, plots and two-sample T tests for the first aim and generalized linear mixed effects models with spatial random effects while adjusting for common confounders for subsequent aims. For these analyses, we used data from 168 administrative regions. Of these, 79 experienced conflict with an average of 87 days spent in conflict and 200 fatalities. In Aim 1, we found significantly lower HIV prevalence, stigma, previous HIV testing, and HIV knowledge in conflict areas. In Aim 2, armed conflicts were significantly associated with lower rates of HIV prevalence but not with previous HIV testing. In Aim 3, number of days and fatalities were significantly associated with increased rates of high-risk sexual behaviors but close proximity to an area of conflict was significantly associated with lower rates of high-risk sexual behaviors. Our findings illustrate that the relationship between armed conflicts and HIV measures is complex and is influenced by conflict duration, intensity, and proximity. Future studies should consider accounting for temporality and utilizing different populations exposed to higher intensity conflicts