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Background: Malawi has made substantial progress towards the 90/90/90 goals. However, further progress in diagnosing people living with HIV (PLHIV), the first 90, is needed to control the HIV epidemic. Providing testing to undiagnosed PLHIV, particularly in areas with high HIV prevalence, will be critical. Here we identify which PLHIV are at greatest risk of being undiagnosed.
Methods: From November 2015-August 2016, MPHIA recruited a nationally representative sample of 17,127 adults age 15-64. Participants completed an interview and received home-based HIV testing and counseling per national guidelines. We defined participants that tested HIV positive as previously undiagnosed if they reported 1) never previously having an HIV test; or 2) testing negative on their most recent test. We estimated the relative risk of previously undiagnosed HIV by area of residence, age and sex using a multivariate log-binomial regression. All analyses accounted for complex survey design.
Results: MPHIA identified 2,214 HIV-positive adults among whom 578 (26%) were undiagnosed, 1,054 (48%) live in urban areas, 709 (32%) were male, and median age was 37 [Interquartile Range: 30-45]. HIV prevalence was significantly higher in urban areas (14.3%, 95% CI: 13.2-15.4%) vs rural areas (9.7%, 95% CI: 8.9-10.4%).
Previously undiagnosed HIV was higher in urban (30.6%, 95% CI: 27.6-33.6%) vs rural areas (25.9%, 95% CI: 22.9%-28.9%), and significantly higher in men (33.3%, 95% CI: 28.8-37.7%) vs women (23.6%, 95% CI: 21.2-25.9%) and younger (15-24 years: 46.7%, 95% CI: 38.0-55.3%) (25-34 years: 32.1, 95% CI: 27.4-36.9%) vs older age groups (35-64: 21.7, 95% CI: 18.9-24.6%). In multivariate analysis, living in an urban area (RRurban=1.18, 95% CI: 1.01-1.37), being male (RRmale=1.56, 95% CI: 1.34-1.82) and being 15-24 or 25-34 vs 35-64 years old (RR15-24=2.30, 95% CI: 1.86-2.85; RR25-34 =1.58, 95% CI: 1.29-1.94, respectively) were all associated with having previously undiagnosed HIV.
Conclusions: Young, male and urban PLHIV were at increased risk of having undiagnosed HIV in Malawi. These disparities threaten HIV epidemic control as urban areas have higher HIV prevalence and increasing population due to urbanization. To achieve epidemic control, Malawi''s HIV programs should focus on diagnosing HIV in urban areas, particularly among young adults and men.

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