Call for action: addressing the alarming surge of HIV in Madagascar

A 2020 analysis by Raberahona et al on the status of HIV in Madagascar already suggested that the country may be on the verge of a high-prevalence epidemic, with a concerning rise in sexually transmitted infections (STIs) in the general population, elevated HIV rates among sex workers and an increase in cases newly diagnosed with late-stage disease.2 The study also underscores weaknesses in the epidemiological surveillance of HIV. Hospital cohort data show a rise in newly diagnosed HIV cases during admission, increasing from 0% to 25.4% between 2010 and 2016, and patients diagnosed in stage 3 and/or 4 rose from 6.6% to 38.9%.4 An increase in extrapulmonary tuberculosis (TB) cases, mainly lymphadenopathy, revealed by TB surveillance data, raises further concern. The majority (82%–92%) has never undergone an HIV test, and only 3% of women are aware of their serological status.7 A cross-sectional study on STI prevention among university students indicates over one in three engage in high-risk sexual behaviour.8 Madagascar’s artisanal mining sector, exceeding one million in 2014, poses additional transmission risks with its young population, frequent migration, transactional sex driven by local economic factors and limited healthcare access within a highly informal sector, further amplifying risks and vulnerabilities.9 According to the World Bank, eight of 10 people in Madagascar live in monetary poverty (with a daily consumption below USD 2.15 per person).10 With 1.9 medical doctors and 2.9 nurses and midwives per 10 000 in 2019, Madagascar’s health worker density is particularly low.11 A recent modelling study, considering these contextual factors, forecasts a transition to a generalised HIV epidemic with a prevalence rate of 9%–24% in the general population within the next decade unless testing and treatment efforts are escalated.12 In Madagascar’s population of 28.9 million, UNAIDS estimates 70 000 HIV cases in 2022, with 18% of cases receiving antiretroviral treatment.1 The country recently expanded its national HIV strategy to move beyond key populations, including vulnerable groups like the youth and individuals with STIs, and bridge populations.