Patterns of HIV incidence prior to, during, and after violent conflict in 40 sub-Saharan African nations, 1990-2012: An ecological study

To date, HIV/AIDS has caused nearly 40 million deaths with the overwhelming majority occurring in sub-Saharan Africa. Simultaneously, sub-Saharan Africa has been ravaged by war, with 23 of 40 countries in the region experiencing prolonged conflict since 1990. The aim of this study was to determine the association between HIV incidence and violent conflict within and across 40 sub-Saharan Africa nations between 1990 and 2012. We used generalized linear mixed effect modeling to estimate the effect of a categorical time-period conflict variable (i.e., 5 years prior to conflict, during conflict, 5 years after conflict, and peacetime) on country-level HIV incidence with random intercepts and slopes to account for across and within country variation over time. We then completed a sub-analysis across and within countries that experienced at least one year of conflict to assess the effect of conflict intensity on country-level HIV incidence. All models controlled for level of economic development, number of refugees present in the country, and year. We found that, compared to times of peace, HIV incidence rate increased by 2.1 per 1000 infections per year (P<0.05) in the 5 years prior to conflict. Additionally, we found an inverse association between levels of conflict intensity and country-level HIV incidence. Our study provides data supporting the theory that HIV infection rates increase in the years immediately prior to times of conflict and represents a call for further investigation, stronger data collection, and increased aid to nations at risk of violent conflict to help in the fight against HIV/AIDS in sub-Saharan Africa.