HIV Incidence Prior to, during, and after Violent Conflict in 36 Sub-Saharan African Nations, 1990-2012: An Ecological Study

OBJECTIVES: The aim of this study was to determine the association between violent conflict and HIV incidence within and across 36 sub-Saharan Africa countries between 1990 and 2012. METHODS: We used generalized linear mixed effect modeling to estimate the effect of conflict periods on country-level HIV incidence. We specified random intercepts and slopes to account for across and within country variation over time. We also conducted a sub-analysis of countries who experienced 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. RESULTS: We found that, compared to times of peace, the HIV incidence rate increased by 2.1 per 1000 infections per year (95%CI: 0.39, 3.87) in the 5 years prior to conflict. Additionally, we found a decrease of 0.7 new infections per 1000 people per year (95%CI: -1.44, -0.01) in conflicts with 25 to 1000 battle-related deaths and a decrease of 1.5 new infections per 1000 people per year (95%CI:-2.50, -0.52) for conflict with more than 1000 battle-related deaths, compared to conflicts with less than 25 battle-related deaths CONCLUSIONS: Our results demonstrate that HIV infection rates increase in the years immediately prior to times of conflict; however, we did not identify a significant increase during and immediately following periods of violent conflict. Further investigation, including more rigorous data collection, is needed, as is increased aid to nations at risk of violent conflict to help in the fight against HIV/AIDS in sub-Saharan Africa.