Place, gender, and uneven progress in pediatric and adolescent HIV across sub-Saharan Africa: a regional meta-analytic assessment (2000--2024)

Abstract

Background: Marked declines in pediatric HIV have been achieved across sub-Saharan Africa, yet progress among adolescents remains uneven and strongly patterned by place. Drawing on place-based perspectives in health geography, we conceptualize Eastern and Southern Africa (ESA) and West and Central Africa (WCA) not merely as epidemiological regions, but as distinct assemblages of health systems, gender norms, and historical investment trajectories shaping HIV risk and care. Using UNICEF-harmonized indicators from 2000 to 2024, we examined how place structures progress toward the 2030 Sustainable Development Goal (SDG 3.3) target. Methods: Country-level estimates were pooled using inverse-variance random-effects meta-analysis with restricted maximum likelihood estimation and Hartung-Knapp adjustment. HIV incidence and AIDS-related mortality were analysed on the log scale, and mother-to-child transmission (MTCT) on the logit scale. Outcomes were pooled by region, age group (0-14; 15-19), sex, and year. We quantified percentage change from 2010 to 2024, the achieved annualized rate of change (ARC), and the required ARC from 2024 to 2030 to achieve a 90% reduction from 2010 levels. Robustness was assessed using prespecified sensitivity analyses. Findings: Between 2010 and 2024, child HIV incidence declined by 72% in ESA and 66% in WCA, while adolescent incidence declined by 54% and 62%, respectively. In 2024, MTCT remained above elimination thresholds in both regions (9.9% in ESA; 17.6% in WCA). Adolescent girls experienced substantially higher HIV incidence than boys, with pooled female-to-male incidence rate ratios of 4.13 (95% CI 3.32-5.13) in ESA and 4.92 (4.04-5.99) in WCA. Despite progress, achieved declines among adolescents (ARC -5.4% per year in ESA; -6.6% per year in WCA) fall well short of the acceleration required to meet 2030 targets. Conclusion: HIV progress among children and adolescents in sub-Saharan Africa is deeply place-dependent. While ESA reflects the benefits of earlier and sustained health system investments, persistent structural and gendered vulnerabilities continue to constrain adolescent outcomes, particularly in WCA. Achieving SDG 3.3 will require place-responsive strategies that integrate gender-sensitive adolescent prevention, differentiated care, and strengthened PMTCT within the specific social, political, and health system contexts shaping risk and access.

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