HIV care cascades among refugees and host communities in Uganda: findings from two population-based surveys

Uganda's national health system provides integrated health services, including HIV care, to refugees and citizens. However, few data are available comparing HIV outcomes among refugees and the general population. We compared HIV care cascade indicators between the general population and the refugee population using data from two nationally representative surveys.

We analysed data from the Uganda Population-based HIV Impact Assessment (2020-21) and the Uganda Refugee Population-based HIV Impact Assessment (2021). Both surveys used two-stage sampling designs, with the Uganda Refugee Population-based HIV Impact Assessment using an approach specifically adapted for refugee settlements, including stratified cluster sampling among participants (ie, those aged ≥15 years). Key outcomes included HIV prevalence, awareness of HIV-positive status, antiretroviral therapy coverage, and viral load suppression (ie, <1000 copies per mL). Data from the general population in refugee-hosting regions were analysed using inverse probability weighting and Poisson regression models, and variances were estimated using the Taylor series linearisation approach.

Among 13 135 participants (10 430 in the general population and 2705 in the refugee population), HIV prevalence was significantly lower among refugees (1·8%, 95% CI 1·1-3·0) compared with the general population (7·4%, 6·3-8·7; p<0·0001). This difference persisted across sexes, with lower prevalence among both refugee women (1·8% vs 8·0%, p<0·0001) and men (1·7% vs 6·6%, p=0·0023) compared with women and men in the general population. Progress towards the 95-95-95 UNAIDS targets was similar between populations, with refugees reaching 86·8% (95% CI 66·9-95·5), 97·2% (86·8-99·5), and 89·4% (72·3-96·5) across the cascade compared with 82·4% (77·9-86·1), 96·1% (92·6-97·9), and 92·1% (89·0-94·4) in the general population (all p>0·05). In adjusted analyses of the combined general population and refugee population, women showed significantly higher awareness of HIV-positive status compared with men (adjusted prevalence ratio [aPR] 1·13, 95% CI 1·02-1·26; p=0·021). Across both populations, age was significantly associated with status awareness, with higher likelihood of awareness among those aged 30-49 years (aPR 1·34, 95% CI 1·15-1·57) and those aged ≥50 years (1·40, 1·18-1·67) compared with those aged 15-29 years (1 [ref]; p<0·0001). Geographical variation was observed in treatment outcomes across both populations, with South-West Region residents showing significantly higher viral load suppression than those in the West Nile Region (aPR 1·10, 95% CI 1·03-1·18; p=0·0040).

Refugee populations in Uganda had comparable HIV care cascade outcomes to the general population. Although HIV prevalence differed substantially, both groups showed similar progress towards treatment targets. However, gaps persist in HIV-positive status awareness among youth (ie, those aged 15-29 years) in both the general population and the refugee population, and geographical disparities in viral load suppression require attention across both populations. For both refugee-hosting districts and general population areas, strengthened prevention initiatives, youth-focused interventions, sustained financing, and district-level capacity building are crucial to reducing new infections and ensuring equitable outcomes.

The US President's Emergency Plan for AIDS Relief.