AIDS Reviews.

2018;20

Contents available at PubMed

www.aidsreviews.com PERMANYER AIDS Rev. 2018;20:104-113
www.permanyer.com

 f the publisher.   © Permanyer 2018

HIV/AIDS in Sierra Leone: Characterizing the Hidden
Epidemic
George A. Yendewa1,2*, Eva Poveda3, Sahr A. Yendewa4, Foday Sahr4,5, Miguel E. Quiñones-Mateu1,6,7 and
Robert A. Salata1,2
1
Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; 2Division of Infectious Diseases and HIV Medicine, University
Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; 3Group of Virology and Pathogenesis, Galicia Sur Health Research Institute (IIS Galicia
Sur)-Complexo Hospitalario Universitario de Vigo, SERGAS-UVigo, Spain; 4College of Medicine and Allied Health Sciences, University of Sierra
Leone, Freetown, Sierra Leone; 534 Military Hospital, Republic of Sierra Leone Armed Forces, Freetown, Sierra Leone; 6Department of Pathogenesis,
Case Western Reserve University, Cleveland, Ohio, USA; 7Center for AIDS Research at Case Western University/University Hospitals Cleveland
Medical Center, Cleveland, Ohio, USA

No part of this publication may be reproduced or photocopying without the prior written permission o
Abstract
Sierra Leone is a low-income West African country that has dealt with waves of economic, political, and
public health challenges in its recent past, including a decade-long brutal civil war and the Ebola epi-
demic of 2014-2016. The HIV/AIDS epidemic, which has raged on in the country since 1987, has long been
characterized as stable. The latest UNAIDS report estimates a countrywide HIV prevalence rate of 1.7% in
2016 among adults aged 15-49 years. However, there are indications that the epidemic may be in fact es-
calating and unless arrested urgently, has the potential to deteriorate into a major public health emer-
gency. Although there are high levels of HIV awareness among adults (over 94%), uptake in voluntary HIV
testing has remained low (< 30%), and under one-third (29%) of the country’s 60,000 people living with
HIV/AIDS were on antiretroviral therapy in 2015. This review attempts to address the paucity of scientific
information on the subject by presenting the historical and epidemiological background to the HIV/AIDS
epidemic in Sierra Leone. Other aspects of the HIV/AIDS epidemic in Sierra Leone are examined, including
routine HIV screening and diagnosis, linkage to and retention in HIV care, clinical characteristics and mo-
lecular epidemiology, treatment coverage, and prevention strategies. Finally, we identify four key areas of
challenge that are hampering current efforts attempting to bring the epidemic under control, and perspec-
tive is offered on the way forward. (AIDS Rev. 2018;20:104-113)
Corresponding author: George A. Yendewa, gay7@case.edu

Key words
HIV. Sierra Leone. Antiretroviral therapy. Diagnostics. Resource-limited settings.

Correspondence to:
George A. Yendewa
Division of Infectious Diseases and HIV Medicine
University Hospitals Cleveland Medical Center
11100 Euclid Ave Received in original form: 27/04/2018
Cleveland 44106, Ohio, USA Accepted in final form: 14/05/2018
E-mail: gay7@case.edu doi: 10.24875/AIDSRev.M18000022

104

Overview of the HIV/AIDS landscape in
Sierra Leone
Sierra Leone is a small, low-income country in West
Africa. It has a total population of 7.4 million people
and a gross domestic product per capita income of
587 United States dollar, with over 60% of its inhabit-
ants living below the poverty line1. Since gaining inde-
pendence from Great Britain in 1961, the country has
grappled with myriad political, economic, and public
health challenges. During the 1990s, Sierra Leone re-
ceived much-unwanted attention on account of a brutal
civil war that decimated the country’s already fragile
health infrastructure, leaving it with some of the worst
indicators of health. The World Health Organization
(WHO) reported that, in 2010, there were only 0.024
physicians per 1000 of the population, one of the low-
est anywhere in the world2. The Sierra Leone Demo-
graphic Health Survey of 2013 (SLDHS 2013) recorded
an average life expectancy of 47 years at birth, infant
mortality rate of 96/1000 live births, under-five mortal-
ity rate of 156/1000 live births, and maternal mortality
rate of 1165/100,000 births3 (Fig. 1).
The recent Ebola epidemic of 2014-2016 has gener-
ated unprecedented interest in various public health
challenges in the country, including the epidemic as-
sociated with HIV/AIDS. The latest Joint United Nations
Programme on HIV and AIDS (UNAIDS) report of 2016
recorded a countrywide HIV prevalence rate of 1.7%,
characterizing Sierra Leone as a low prevalence coun-
try4. However, the true nature and scope of the HIV/
AIDS epidemic in Sierra Leone have not been fully
examined before, and these figures appear to be un-
der-reporting a major and hidden public health prob-
lem. There is a dearth of reliable scientific data on the
epidemiological, clinical, and molecular characteristics
of the HIV/AIDS epidemic in the scientific literature. As
of February 1, 2018, a search in PubMed using the
words “HIV+Sierra Leone” (https://www.ncbi.nlm.nih.
gov/pubmed/?term=HIV+Sierra+Leone) yielded only
88 scientific articles, many of them addressing the
country’s HIV prevalence. All other aspects of HIV
care, including routine screening and diagnosis, initia-
tion of antiretroviral therapy (ART), HIV drug resistance,
linkage to and retention in HIV care, socio-cultural im-
plications of HIV-positive status, access to vital allied
support services (e.g.,  mental health and social sup-
port), and quality of life issues for persons living with
HIV have not been sufficiently studied.
This review summarizes some of the currently avail-
able scientific data on the epidemiological, clinical,
Yendewa, et al.: HIV/AIDS in Sierra Leone
and molecular characteristics of the HIV/AIDS epidemic
in Sierra Leone, current treatment and prevention strat-
egies, and the challenges faced by public health offi-
 f the publisher.   © Permanyer 2018
cials in the uphill fight to surmount the epidemic.
History of the prevalence of HIV/AIDS in
Sierra Leone
The earliest known cases of HIV/AIDS in Sierra Leone
were documented in 1987, consisting of 10 HIV-positive
individuals among commercial sex workers5. Since
then, the countrywide prevalence rate has steadily in-
creased and appears to have peaked at 14.9% during
the civil war years (1990-2001)6-8. Following the civil
war, the Government of Sierra Leone and the United
No part of this publication may be reproduced or photocopying without the prior written permission o
States Centers for Disease Control and Prevention
jointly conducted the first ever countrywide HIV serop-
revalence study in 2002, which recorded a weighted
population HIV prevalence rate of 0.9%9. More recent
countrywide population surveys have consistently re-
ported an apparent plateauing of the HIV prevalence
rate at 1.5-1.7%, representing an estimated total of
67,000 adults and children living with HIV/AIDS in Si-
erra Leone3,4 (Table  1). The majority of HIV-infected
individuals appear to be concentrated in the capital city
of Freetown (2.5% prevalence), in other urban popula-
tions around the country, and in regions of high eco-
nomic activity such as in the diamond mining areas10.
In 2013, the National HIV/AIDS Secretariat (NAS) of
Sierra Leone and UNAIDS conducted a countrywide
population size estimation (PSE) survey, which identi-
fied “key populations” (KP groups) exhibiting high-risk
behaviors or activities that disproportionately increased
their likelihood of being affected by the HIV/AIDS epi-
demic11. The KP groups identified were female sex
workers (FSW) and their partners and clients, long-
distance truck drivers, members of the fishing com-
munity, members of the uniformed armed services, and
migrants. Men who have sex with men (MSM) and injec-
tion drug users (IDU) emerged as relatively new and
major demographic representations for new HIV infec-
tions. The KP groups made up only 4% of the total
population but accounted for 44% of known HIV cases
in the country. In 2015 alone, 1000 new infections were
directly attributable to the KP groups, establishing their
position as the major and perhaps most important driv-
er of the HIV/AIDS epidemic in the country11 (Table 1).
The PSE survey was followed by the HIV Seropreva-
lence study of the KP in 2015, which reported that HIV
prevalence rates were highest in the self-identified
transgender male-to-female category (22.4%), followed
105
 AIDS Reviews. 2018;20
Figure  1. Map and demographic information of Sierra Leone. Data were summarized from the World Bank Report on Sierra Leone1, the
World Health Organization Statistics Summary on Sierra Leone2, and the Sierra Leone Health and Demographic Survey3. Gross domestic
product; United States dollar.
by MSM (14%), IDU (8.5%), and FSW (6.7%)12. Other
KP groups with high prevalence rates were the trans-
gender female-to-male category (6.7%), clients of com-
mercial sex workers (2.9%), and prisoners (2.2%)11. In
a separate study, Djibo et al.13 observed that the HIV
prevalence rate was 3.3% among members of the Si-
erra Leone Armed Forces. Although not considered a
KP group per se, pregnant women are a high-risk
group, with an estimated prevalence rate of 3.2% re-
corded in 201010. In addition, considerable overlap
was found among members of the KP groups, implying
a mixed HIV transmission dynamic in the country12.
As anticipated, the HIV prevalence rates of the KP
groups are significantly higher than the prevalence rate
of the general population, i.e.,  2.2–22.4% versus 1.5-
1.7%, respectively (Table 1). While the data are broad-
ly reflective of comparable at-risk demographics in the
Sub-Saharan African region14, there may be serious
limitations to these estimates. For example, the serop-
revalence study of the KP groups was conducted at
the height of the Ebola epidemic in 2015, when the
level of respondent participation and their contact time
with health-care facilities may have been highly con-
strained due the prevailing public health emergency in
the country, thus potentially leading to an underestima-
tion of the scale of the problem among KP groups12,15,16.
HIV screening and diagnosis
Timely diagnosis of HIV infection is the crucial first
step to early initiation of ART and achieving virologic
106
 f the publisher.   © Permanyer 2018
No part of this publication may be reproduced or photocopying without the prior written permission o
suppression, which has been shown to improve HIV/
AIDS-related morbidity and mortality and interrupt the
HIV transmission cycle across all demographic
groups17,18. Towards achieving these goals, UNAIDS
announced its ambitious global 90-90-90 strategy in
2014, which aims for 90% of all HIV-infected people
to know their HIV-positive status, 90% of those in-
fected to be on effective antiretroviral treatment, and
90% of people on treatment to achieve virological sup-
pression by the year 202019. In response, the Govern-
ment of Sierra Leone unveiled its own “National Stra-
tegic Plan (NSP) on HIV and AIDS 2016-2020 - Toward
Making HIV and AIDS no longer a Public Health Threat
in Sierra Leone by 2020”, in which routine HIV testing
for all listed as one of three key components of the
national strategy to combating the HIV/AIDS epidem-
ic11. However, voluntary HIV testing levels have been
reported as low in the country. Brima et al.20 examined
the impact of voluntary HIV testing from the results of
the SLDHS of 20083, in which 6,475 participants were
surveyed countrywide. Of the 96 people that tested
HIV-positive (prevalence rate 1.5%), the majority
(78%) had been unaware of their HIV status and had
previously never taken a HIV test. It was further ob-
served that (i) young adulthood, i.e.,  age group  25-
44 years, (ii) residing in urban areas, (iii) female gen-
der, (iv)  higher level of education, (v) first sexual
intercourse at age 17 years or older, and (vi) using a
condom during the most recent sexual encounter were
all independently associated with higher rates of vol-
untary HIV testing20.
 Yendewa, et al.: HIV/AIDS in Sierra Leone

Table 1. HIV‑1 prevalence in Sierra Leone through the years

Period HIV‑1 prevalence (%) Population Route of HIV‑1 Reference
transmission

 f the publisher.   © Permanyer 2018

1990‑2001 3‑14.9 Countrywide n.d. Boillot et al.6,
(civil war) Spiegel et al.7,
Willough by et al.8

2002 0.9 Countrywide n.d. Kaiser et al.9

2004‑2006 9.7 Seeking VCT in n.d. Kouyoumdjian et al.22

Kenema district

2008 1.5 Countrywide n.d. Brima et al.20

2012‑2013 8.9 Febrile patients, n.d. Ansumana et al.32

Bo district

No part of this publication may be reproduced or photocopying without the prior written permission o
2013 22.4 Countrywide Transgender male NAS12
to female

14 Countrywide MSM

8.5 Countrywide IDU

6.7 Countrywide Transgender female

to male

2.9 Countrywide Clients of

commercial sex
workers

2.2 Countrywide Prison population

2013 3.3 Sierra Leone Armed n.d. Djibo et al.13

Forces

2014 2.5 Freetown n.d. NAS10

1 Rural areas n.d.

2016 1.7 Countrywide n.d. UNAIDS4

aAmong people aged 15‑49 years. VCT: voluntary counseling and testing; MSM; men who have sex with men; IDU: injected drug users; n.d.: not determined; NAS: national

HIV/AIDS Secretariat

The alarmingly low uptake in HIV testing in Sierra
Leone has been confirmed in other studies. A survey
of 285 young adults (classified as age 18-35 years)
conducted in Bo District reported that only 33% of
study participants had ever undergone HIV testing21.
The rate of HIV testing was found to be higher among
women compared with men (i.e., 44% vs. 25%), re-
spectively. While over 85% of the study respondents
expressed willingness to undergo HIV testing, the
majority (> 90%) preferred to be tested privately. In
another study, Kouyoumdjian et  al.22 found that the
HIV prevalence rate among 2230 individuals who
underwent voluntary counseling and testing (1213
through antenatal testing and 1017 specifically for
routine HIV testing) was 12.6% in women and 6.7%
in men.
Stigmatization at both the individual and community
levels has been advanced as a major impediment to
voluntary testing, for HIV in particular and sexually
transmitted diseases in general, in Sierra Leone and
other Sub-Saharan African countries23-26. As a conse-
quence, UNAIDS estimated that < 36% of people living
with HIV in Sierra Leone know their status4 (Fig.  2a).
A more precise understanding of how behaviors, per-
ceptions, and local social and cultural pressures are
shaping attitudes toward HIV testing would be instru-
mental in helping craft and implement effective evi-
dence-based strategies aimed at reducing stigmatiza-
107
 AIDS Reviews. 2018;20

tion and increasing the utilization of HIV testing

services in the country.
A
80,000

 f the publisher.   © Permanyer 2018

Access to and retention in HIV care 100%

Number of individuals
60,000
67,000
Once diagnosed with HIV infection and initiated on
ART, adherence to treatment and retention in HIV care 40,000
are critical to maintaining sustained virologic suppres- 35.8%
sion and preventing the emergence of drug resistance 20,000 26.9%
24,000
mutations27. However, there is limited data describing 18,000
access to treatment and the various components of the 0
cascade of HIV care in Sierra Leone. In 2015, under People People People
living living living
one-third (29%) of the estimated 67000 people living with HIV with HIV with HIV
with HIV/AIDs in Sierra Leone were on ART, with treat- who know who are
ment coverage projected to increase to 35% in 2017, B their status on ART

No part of this publication may be reproduced or photocopying without the prior written permission o
and up to 80% by 202010,28. 400
100%
Recent prospective data by Kelly et  al.29 assessed

Number of HIV-infected
the cascade of care of 338 newly HIV diagnosed indi- 300 338
81.6%
viduals attending the largest HIV clinic in the country

individuals
255
during a 12-month period. ART eligibility was defined 200

as CD4 cell counts ≤350 cells/mm3 and/or WHO clinical 33.7%

Stage 3 or 4. Of the 225 participants staged for initia- 100 22.8%
114
tion of ART, more people in the pre-ART compared with 77
the ART-eligible group (59.6% vs. 41.8%, p = 0.03) 0
were retained in care, defined as attending clinic at Newly Staged Retained Effective
least once during the past 3  months of the 12-month diagnosed for cART in care HIV care

study period. 77 of 388 (22.8%) newly diagnosed HIV-

positive individuals from both the pre-ART and ART-
eligible groups remained in “effective HIV care”, de-
fined as having completed the cascade of care for the
entire 12-month study period. Of patients retained in
care, ART adherence was estimated at 57.5% (50 of
87 persons). Loss to follow-up (LTFU) was a major
impediment to completing the cascade of HIV care,
with the majority of LTFU cases (66.3%) occurring dur-
ing the pre-ART period (Fig. 2b).
In the era of widespread ART availability, treatment
coverage should be scaled up in Sierra Leone to meet
the UNAIDS 90-90-90 targets and the Government of
Sierra Leone’s own strategic policy objectives. Imple-
mentation of evidence-based approaches to optimize
linkage to and retention in care will assist the realization
of the full benefits of treatment in individual patients, and
additionally have ripple public health effects in interrupt-
ing the HIV transmission cycle in the wider population.
Clinical characteristics of the HIV/AIDS
epidemic
While few studies have examined the clinical charac-
teristics of the HIV/AIDs epidemic in Sierra Leone, three
108
Figure 2. A: Number of adults and children living with HIV in Sierra
Leone, including those who know their HIV status and patients who
are on antiretroviral treatment, antiretroviral therapy. Data extracted
from the UNAIDS Global AIDS Update 2016 report4. B: Cascade of
HIV care for newly diagnosed patients in Freetown, Sierra Leone
over a 12-month period. Adapted from Kelly et al.29.
observations are worth noting that may be impacting
the scale and direction of the HIV/AIDS epidemic.
HIV and coinfections
Endemic to Sierra Leone is a multitude of viruses
(e.g., Lassa virus, LASV; and Ebola virus, EBOV) that
may be cocirculating with HIV in the general population.
Interestingly, HIV has shared routes of transmission
with many of these pathogens (through sexual contact
and/or bloodborne exposure). Significant bidirectional
effects have previously been described in HIV coinfec-
tion with hepatitis B virus, hepatitis C virus, herpes
simplex virus, and human papillomavirus  -  these in-
clude increased HIV transmissibility, accelerated pro-
gression to AIDS, and overall worse clinical out-
comes30,31. It is likely that coinfection with these
endemic viruses and other non-viral pathogens may be

influencing the pathogenesis of HIV infection and alter-
ing disease outcome in coinfected individuals in Sierra
Leone in thus far undetermined ways.
Late HIV diagnosis
Late diagnosis remains a major hurdle to early initia-
tion of HIV treatment and achieving virologic suppres-
sion. Considering that there are significant gaps at
every level of the cascade of HIV care in an under-
resourced health-care system in Sierra Leone29, it is
possible that a significant proportion of new HIV diag-
noses is late presenters (defined as CD4 count
<  350  cells/mm3  and/or AIDS-defining criteria present
with CD4 count > 350 cells/mm3). Late HIV diagnosis
represents a missed opportunity at timely ART initiation
and interrupting the HIV transmission cycle – treatment
as prevention (TAP).
Fever, an emerging confounder in HIV
diagnosis
An extremely common but often overlooked observa-
tion is the emerging role of fever as an important clin-
ical presentation and feature of new HIV infection. In a
recent study, Ansumana et al.32 showed that up to 24%
of newly diagnosed HIV-positive patients had a febrile
illness at presentation. In an earlier study, Willough by
et  al.8 had reported a 92.5% occurrence of fever in
106  patients presenting with strong clinical suspicion
for HIV infection during a 2-year period. This observa-
tion is of paramount importance in Sierra Leone and
Sub-Saharan Africa, where fever is a cardinal and ex-
tremely common presenting feature of a host of com-
mon infections, suspicion usually being highest for
malaria and typhoid fever. As a result, it is possible
that unless a high index of suspicion is assumed, a
significant proportion of new HIV cases initially pre-
senting with febrile illness may be missed, thus con-
tinuing the onward transmission of HIV infection in the
general population.
HIV molecular epidemiology and drug
resistance
Two types of HIV resulting from distinct zoonotic in-
troductions have been recognized: HIV Type 1 (HIV-1),
predominant throughout the world, and HIV Type  2
(HIV-2), found primarily in West Africa33-36. HIV-1 has
been subdivided into four highly divergent groups,
i.e.,  M, O, N, and P37-40. The HIV-1 group  M is cur-
Yendewa, et al.: HIV/AIDS in Sierra Leone
rently comprised at least 14 subtypes (A1 to K) and 90
circulating recombinant forms41,42. Over 90% of current
and new HIV infections are associated with HIV-1
 f the publisher.   © Permanyer 2018
Group M strains and are responsible for the global HIV/
AIDS epidemic38.
There are limited data describing the circulating
HIV strains, transmitted drug resistance, or the prev-
alence and characteristics of drug resistance in pa-
tients failing ART in Sierra Leone. The 2005 country-
wide HIV seroprevalence study reported that 91% of
HIV infections in the general population of Sierra
Leone were associated with HIV-1, with 4.5% related
to HIV-2 mono-infections, and 4.5% to HIV-1/HIV-2
dual-infections43. A  few case reports have docu-
mented the HIV-1 subtype A and CFR02_AG strains,
No part of this publication may be reproduced or photocopying without the prior written permission o
identified mainly in individuals migrating to Eu-
rope44-48.
HIV-2 is endemic in West Africa and is postulated to
have ancestry from simian immunodeficiency virus-
specific to the sooty mangabey primates (SIVsm)33,34.
Interestingly, several studies have previously docu-
mented the endemicity of SIVsm in primates in Sierra
Leone49,51. The virological and clinical characteristics
of HIV-2 differ significantly from HIV-152-54, an important
fact to remember in the diagnosis, treatment and clin-
ical follow-up of HIV-2 infected individuals in Sierra
Leone and other places with populations having recent
origin or ties to West Africa. HIV-2 infection is gener-
ally characterized by a more indolent asymptomatic
course, slower CD4 cell count decline and lower plas-
ma RNA levels compared with HIV-1 infection52-54. At
present, there are no FDA-approved assays for quan-
tification of HIV-2 RNA; infected patients are usually
monitored by measurement of CD4 cell count55. Similar
to viruses from the HIV-1 Group  O56-58, HIV-2 strains
are intrinsically resistant to first-generation non-nucle-
otide reverse transcriptase inhibitors (NNRTIs),
(i.e., efavirenz [EFV] and nevirapine [NVP])59,60, which
constitute the first-line treatment and currently the most
widely used ART regimens in the country61 (see treat-
ment and prevention strategies section). The preferred
regimen for treatment of HIV-2 infection combines a
two-drug nucleoside or NRTI backbone with a select
protease inhibitor62 (e.g., darunavir, lopinavir, or saqui-
navir  -  currently in short supply) or integrase strand
transfer inhibitor63 (e.g.,  dolutegravir and DTG  -  cur-
rently unavailable in the country). ART options are,
therefore, limited for HIV-2 infected patients in Sierra
Leone, and their clinical management requires the op-
timal harnessing of the currently available ART drugs
in the country.
109
 AIDS Reviews. 2018;20
Treatment and prevention strategies
Treatment, monitoring, and routine clinical
follow-up
The main goals of HIV treatment are to achieve and
maintain durable virological suppression, preserve or
improve immune function, and prevent the selection of
drug-resistance mutations64. Due to its success in main-
taining sustained undetectability when adherence levels
are high, ART is now considered one of the most effec-
tive prevention strategies in HIV care (TAP or “undetect-
able equals untransmit table”)65. Current international
treatment guidelines recommend ART for all HIV-infect-
ed individuals, regardless of CD4 cell count64,66,67.
Of the 60,000 HIV-positive individuals in Sierra Le-
one, in 2015, under one-third (about 29%) were esti-
mated to be on ART10. In its NSP on HIV/AIDS 2016-
2020, the Ministry of Health and Sanitation highlighted
the enrolment and retention of all known HIV-positive
individuals in the country on ART as a key policy pre-
scription in the effort to bring the HIV/AIDS epidemic
under control. During the first 2 years of the implemen-
tation of this strategic plan (2016-2017), the objective
was to provide ART treatment to all patients with CD4
cell count < 500  cells/mm3; with the goal of further
expanding ART coverage to all HIV-positive individuals
in the country by 2018, regardless of CD4 cell count10,28.
The latest antiretroviral treatment guidelines for Si-
erra Leone (adapted from the WHO) were published in
200661. No further updates or revisions have been un-
dertaken since; clinical practitioners rely on interna-
tional guidelines and other reference sources in the
clinical management of HIV patients. In keeping with
standard practice, a regimen based on a two-drug
NRTI backbone plus either a NNRTI or boosted-PI is
used in treatment. The current recommended first-line
ART regimens for adults are zidovudine/lamivudine
plus EFV or NVP61. However, the most widely used
regimen in the country for all demographic groups in-
cluding pregnant women and children currently ap-
pears to be the single pill once-daily coformulation of
tenofovir/lamivudine/EFV. Integrase inhibitors, which
are the first-line therapy recommended by current in-
ternational treatment guidelines, are presently not
available for use in the country.
Routine clinical monitoring is recommended for all
patients on ART every 3-6 months by measurement of
CD4 cell count, viral load, complete blood count, se-
rum chemistry, and liver function tests61. CD4 cell
110
count monitoring capability is available at the largest
HIV clinic in Freetown since 2006; this technology is,
however, still not widely accessible in rural areas where
 f the publisher.   © Permanyer 2018
the WHO staging is used to guide clinical decision-
making. Routine plasma HIV viral load measurement
by polymerase chain reaction was recently introduced
in 201668; however, this technology is not widely avail-
able for use in most clinics and health-care centers in
Sierra Leone. HIV drug resistance testing is currently
not available in clinical practice.
HIV prevention
With ART coverage effectively below 35%, condom
use rather than ART TAP remains the most widely used
No part of this publication may be reproduced or photocopying without the prior written permission o
preventive strategy in the country. The SLDHS 2013
report estimated that overall, 4.7% of sexual women
and 12.6 % of men aged 15-49 reported using a con-
dom regularly3. Condom use was found to be posi-
tively associated with (i) adolescence or young adult-
hood (age 15-24  years) (70.7%); (ii) higher level of
education (80.3%); (iii) higher socioeconomic status
(80.3%); and (iv) residence in urban areas (87.8%)3.
The NAS reported that, in 2015, the majority of FSW
(88.2%) surveyed reported the use of a condom with
their most recent client28. Notwithstanding, the low rate
of condom usage in the general population, there ap-
pears to be a high level of awareness that condoms
can prevent HIV transmission (79% men vs. 68% wom-
en)3. Programmatic efforts to increase access to con-
doms and other preventive methods should be scaled
up to realize their full benefits in reducing transmission
rates. More studies should be undertaken aiming to
examine the local religious, social, and cultural barriers
to HIV prevention.
Facing the goals and challenges of the
future
In Sierra Leone, the HIV/AIDS epidemic poses more
than just a pressing public health problem that now
needs tackling urgently. As in many low-middle income
countries (LMICs) in Sub-Saharan Africa where the
HIV/AIDS epidemic has not been brought under control,
there are huge economic and developmental dimen-
sions to the problem. The 2016-2020 NSP recognizes
this complex interplay of factors in its policy adaptation
of the United Nations’ Sustainable Development Goals,
which seeks to eliminate HIV/AIDS as a public health
threat in Sierra Leone by 2030. This strategic policy
 Yendewa, et al.: HIV/AIDS in Sierra Leone

Mental Health Healthcare

Personnel Governmental

 f the publisher.   © Permanyer 2018

Resources Private

Laboratory Testing
Routine HIV
Capabilities for
Testing
Diagnosis &
Clinical Follow-up Philantrophy Public

Global Access
Linkage to & to cART
Retention in
HIV Care International
Global Partners
Social Support
Services

Healthcare Delivery & Funding

Public Health Systems
Social, Behavioral & Research
Gender Aspects Capacity

No part of this publication may be reproduced or photocopying without the prior written permission o
Universities Medical
Stigmatization
Poverty Institutions

International
Gender Collaborations
Issues HIV/AIDs
Education
Networks

Discrimination Governmental

Figure 3. Challenges and key areas of improvement to control the HIV/AIDS epidemic in Sierra Leone.

plan aims to achieve the triple objectives of “Zero new
infections, Zero AIDS-related deaths, and Zero AIDS-
related discrimination”10. As ambitious as this agenda
is, the road ahead is fraught with uncertainty, and the
resources and political commitment invested in ad-
dressing these challenges here and now will ultimately
determine the long-term successes of efforts. This will
require visionary thinking, innovativeness, bold leader-
ship, and multi-sectoral collaborative approaches. We
identify four keys areas that need new impetus and
strengthening (Fig. 3).
Sustainable health-care delivery and
public health systems
A decade-long civil war, a stunted economy,
and  competing governmental priorities have left an
impoverished country with a feeble public health sys-
tem that was swiftly overpowered by the recent Ebola
epidemic. To address current challenges and prepare
for inevitable future threats, a restructuring of the pub-
lic health system is imperative, within which the expan-
sion of HIV/AIDS services will need prioritizing. At pres-
ent, Sierra Leone suffers massively from a shortage of
human resources in the HIV field, including doctors,
nurses, and other allied health-care personnel – exac-
erbated further by the chronic “brain drain” phenom-
enon that has become the fate of many Sub-Saharan
African countries69,70. All other aspects of HIV care
require urgent updating and scaling up, including rou-
tine HIV testing, linkage to and retention in HIV care,
access to ART, laboratory facilities, mental health, and
social welfare services for people living with HIV.
Funding challenges
Historically, the national HIV/AIDS response has
been funded mainly by international health and agen-
cies. Since May 2005, the Global Fund has served as
the primary source of funding for the HIV/AIDS control
program in Sierra Leone and has to date committed
$129 million US dollars71, accounting for 95% of pro-
gram costs10. International support will remain vital for
the foreseeable future. However, increasing govern-
ment budget  allocation will be crucial in bringing the
epidemic under control.
111
 AIDS Reviews. 2018;20
Social, cultural, and gender aspects  
Being a largely traditional society, stigmatization and
gender inequality are deeply entrenched in the society
and remain major challenges that are off-setting efforts
aiming to eradicate the threat of the HIV/AIDS epi-
demic23-26. Effective community-based educational and
sensitization programs can help reduce stigma and
attitudes toward people living with HIV/AIDS.
Research capacity building
There is a paucity of reliable scientific data on the
characteristics of the HIV/AIDS epidemic in Sierra Le-
one. Research capacity building of local institutions will
be vital in helping generate reliable, high-quality scien-
tific data that will underpin clinical decision-making for
individual patients, as well as inform public health strat-
egies and policies at the wider population level. The
long-term utility and impact of international partnerships
between institutions in wealthy countries and LMICs to
solve global challenges have faced scrutiny in recent
years72-73 but will undoubtedly continue to play in the
Sierra Leone context in one form or another. Sierra
Leone can draw from the extensive experiences of East
and Southern African countries, which have enjoyed
long, uninterrupted, and fruitful partnerships with inter-
national research institutions that have led to tremen-
dous gains in the fight to bring the HIV/AIDS epidemic
under control in that part of the world. These partner-
ships have incubated and fostered of a culture of public
health research in issues relevant to the local context,
facilitated the transfer of scientific expertise and tech-
nology in the region, and most crucially sought to pro-
mote local ownership the latter being key to achieving
long-term sustainability of efforts and gains74,75.
Conflict of interest
The authors declare no conflicts of interest. This work
was supported in part by grants from NIH-T32 AI07024
Training in Geographic Medicine and Infectious Dis-
eases, School of Medicine, Case Western Reserve
University (G.A.Y), the Roe Green Travel Medicine
Award 2017, University Hospitals Cleveland Medical
Center (M.E.Q-M, G.A.Y), and the P30 AI036219
CWRU/UHCMC, and Center for AIDS Research
(M.E.Q-M). The views expressed in this review are
those of the authors and do not necessarily reflect
those of the institutions for which they work.
112
References
1. The World Bank 2016. Data Sierra Leone. Available from: http://www.
worldbank.org/en/country/sierraleone. [Last accessed on 2017
 f the publisher.   © Permanyer 2018
Dec 14].
2. The World Health Organization 2016. Sierra Leone Statistics Summary
(2002 - present). Available from: http://www.apps.who.int/gho/data/
node.country.country-SLE. [Last accessed on 2017 Dec 14].
3. Statistics Sierra Leone. Sierra Leone Health and Demographic Survey;
2013.Available from: https://www.dhsprogram.com/pubs/pdf/fr297/
fr297.pdf. [Last accessed on 2017 Dec 14].
4. UNAIDS 2016. Country Sierra Leone 2016. Available from: http://www.
unaids.org/en/regionscountries/countries/sierraleone. [Last accessed
on 2017 Dec 14].
5. National HIV/AIDS Secretariat. Sierra Leone National AIDS Response
Progress Report 2015. Freetown: National HIV/AIDS Secretariat; 2015.
6. Boillot F, Peeters M, Kosia A, Delaporte E. Prevalence of the human
immunodeficiency virus among patients with tuberculosis in Sierra
Leone, established from dried blood spots on filter paper. Int J Tuberc
Lung Dis. 1997;1:493-7.
7. Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection
in conflict-affected and displaced people in seven Sub-Saharan African
countries: a systematic review. Lancet. 2007;369:2187-95.
No part of this publication may be reproduced or photocopying without the prior written permission o
8. Willoughby VR, Sahr F, Russell JB, Gbakima AA. The usefulness of
defined clinical features in the diagnosis of HIV/AIDS infection in Si-
erra Leone. Cell Mol Biol (Noisy-le-grand). 2001;47:1163-7.
9. Kaiser R, Spiegel P. HIV Sero Prevalence and Behavioral Risk Factor
Survey in Sierra Leone. Atlanta: Centers for Disease Control and Pre-
vention; 2002.
10. National HIV/AIDS Secretariat. National Strategic Plan 2016-2020;
2015. Available from: http://www.nas.gov.sl/images/stories/publica-
tions/Sierra Leone National Strategic Plan 2016-2020.pdf. [Last ac-
cessed on 2017 Dec 13].
11. National HIV/AIDS Secretariat 2015. Population Size Estimation of Key
Populations. Available from: http://www.nas.gov.sl/images/stories/pub-
lications/Population%20Size%20Estimation%20Study%20Report%20
August%202013.pdf. [Last accessed on 2017 Dec 14].
12. National HIV/AIDS Secretariat 2015. HIV Sero-prevalence Study for Key
Populations; 2015. Available from: http://www.nas.gov.sl/images/sto-
ries/publications/Seroprevalence%20Study%20of%20Key%20Popula-
tions.pdf. [Last accessed on 2017 Dec 15].
13. Djibo DA, Sahr F, McCutchan JA, et al. Prevalence and risk factors for
human immunodeficiency virus (HIV) and syphilis infections among
military personnel in Sierra Leone. Curr HIV Res. 2017;15:128-36.
14. The World Health Organization 2016. Global AIDS Update 2016. Avail-
able from: http://www.who.int/hiv/pub/arv/global-AIDS-update-2016_
en.pdf. [Last accessed on 2017 Dec 15].
15. Gamanga AH, Owiti P, Bhat P, Harries AD, Kargbo-Labour I, Koroma M.
The ebola outbreak: effects on HIV reporting, testing and care in
Bonthe district, rural Sierra Leone. Public Health Act. 2017;7 Suppl
1:S10-15.
16. Brolin Ribacke KJ, Saulnier DD, Eriksson A, von Schreeb J. Effects of
the West Africa Ebola virus disease on health-care utilization-a system-
atic review. Front Public Health. 2016;4:222.
17. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection
with early antiretroviral therapy. N Engl J Med. 2011;365:493-505.
18. Insight Start Study Group, Lundgren JD, Babiker AG, et al. Initiation of
antiretroviral therapy in early asymptomatic HIV infection. N Engl J
Med. 2015;373:795-807.
19. UNAIDS 2014. 90-90-90 An ambitious treatment target to help end the
AIDS epidemic. Available from: http://www.unaids.org/sites/default/
files/media_asset/90-90-90_en.pdf. [Last accessed on 2017 Dec 15].
20. Brima N, Burns F, Fakoya I, Kargbo B, Conteh S, Copas A. Factors
associated with HIV prevalence and HIV testing in Sierra Leone: find-
ings from the 2008 Demographic Health Survey. PLoS One.
2015;10:E0137055.
21. Bhoobun S, Jetty A, Koroma MA, et al. Facilitators and barriers related
to voluntary counseling and testing for HIV among young adults in Bo,
Sierra Leone. J Community Health. 2014;39:514-20.
22. Kouyoumdjian FG, Seisay AL, Kargbo B, Khan SH. The voluntary HIV
counselling and testing service in Kenema District, Sierra Leone, 2004-
2006: a descriptive study. BMC Int Health Hum Rights. 2010;10:4.
23. Kelly JD, Weiser SD, Tsai AC. Proximate context of HIV stigma and its
association with HIV testing in Sierra Leone: a population-based study.
AIDS Behav. 2016;20:65-70.
24. Kelly JD, Reid MJ, Lahiff M, Tsai AC, Weiser SD. Community-level HIV
stigma as a driver for HIV transmission risk behaviors and sexually
transmitted diseases in Sierra Leone: a population-based study. J
Acquir Immune Defic Syndr. 2017;75:399-407.
25. Yuh JN, Ellwanger K, Potts L, Ssenyonga J. Stigma among HIV/AIDS
patients in Africa: a critical review. Proc Soc Behav Sci. 2014;140:581-5.

26. The People Living with HIV Stigma Index, January 2013. Available from:
http://www.stigmaindex.org/sites/default/files/reports/SierraLeoneStig-
maIndex-Feb252015-Finalcr.pdf. [Last accessed on 2018 Jan 18].
27. Nachega JB, Marconi VC, van Zyl GU, et al. HIV treatment adherence,
drug resistance, virologic failure: evolving concepts. Infect Disord Drug
Targets. 2011;11:167-74.
28. National HIV/AIDS Secretariat, 2015. National HIV/AIDS Monitoring and
Evaluation Plan 2016-2020. Available from: http://www.nas.gov.sl/im-
ages/stories/publications/2016%20-%202020%20HIV%20M&E-Plan.
pdf. [Last accessed on 2018 Jan 18].
29. Kelly JD, Schlough GW, Conteh S, Barrie MB, Kargbo B, Giordano TP.
The majority of the pre-antiretroviral population who were lost to follow-
up stopped their care in Free town, Sierra Leone: A 12-month prospec-
tive cohort study starting with HIV Diagnosis. PLoS One.
2016;11:e0149584.
30. Chun HM, Carpenter RJ, Macalino GE, Crum-Cianflone NF. The role of
sexually transmitted infections in HIV-1 Progression: a comprehensive
review of the literature. J Sex Transm Dis. 2013;2013:176459.
31. Mbopi-Keou FX, Robinson NJ, Mayaud P, Belec L, Brown DW. Herpes
simplex virus type 2 and heterosexual spread of human immunodefi-
ciency virus infection in developing countries: Hypotheses and re-
search priorities. Clin Microbiol Infect. 2003;9:161-71.
32. Ansumana R, Dariano DF, Jacobsen KH, et al. Prevalence of markers
of HIV infection among febrile adults and children in Bo, Sierra Leone,
2012-2013. BMC Res Notes. 2017;10:565.
33. Gao F, Yue L, Robertson DL, et al. Genetic diversity of human immu-
nodeficiency virus type 2: evidence for distinct sequence subtypes with
differences in virus biology. J Virol. 1994;68:7433-47.
34. Gao F, Bailes E, Robertson DL, et al. Origin of HIV-1 in the chimpanzee
pan troglodytes troglodytes. Nature. 1999;397:436-41.
35. Clavel F, Guétard D, Brun-Vézinet F, et al. Isolation of a new human
retrovirus from west african patients with AIDS. Science. 1986;233:343-6.
36. Korber B, Hahn B, Foley B, et al. Human retroviruses and AIDS. A
compilation and analysis of nucleic acid and amino acid sequences.
Theoretical Biology and Byophysics Group. Los Alamos, NM: Los Ala-
mos National Laboratory; 1997.
37. Janssens W, Buvé A, Nkengasong JN. The puzzle of HIV-1 subtypes
in Africa. AIDS. 1997;11:705-12.
38. Tebit DM, Arts EJ. Tracking a century of global expansion and evolution
of HIV to drive understanding and to combat disease. Lancet Infect
Dis. 2011;11:45-56.
39. Simon F, Mauclère P, Roques P, et al. Identification of a new human
immunodeficiency virus type 1 distinct from group M and group O. Nat
Med. 1998;4:1032-7.
40. Plantier JC, Leoz M, Dickerson JE, et al. A new human immunodefi-
ciency virus derived from gorillas. Nat Med. 2009;15:871-2.
41. Quinones-Mateu ME, Arts EJ. Recombination in HIV-1: update and
implications. AIDS Rev. 1999;1:89-100.
42. Foley B, Leitner T, Apetrei C, et al. HIV and SIV Nomenclature. HIV
Sequence Compendium - Published by Theoretical Biology and Bio-
physics Group. Los Alamos, NM: Los Alamos National Laboratory, NM,
LA-UR 17-25240; 2017.
43. National HIV/AIDS Secretariat 2005. National Population-Based HIV
Sero Prevalence Survey Sierra Leone; 2005. Available from: http://www.
nas.gov.sl/images/stories/publications/National%20Population-
Based%20HIV%20Seroprevalence%20Survey.pdf. [Last accessed on
2018 Jan 12].
44. Williamson C, Martin DP. HIV-1 genetic diversity. In: Abdool Karim SS,
Abdool Karim Q, editors. HIV/AIDS in South Africa. Cambridge: Cam-
bridge University Press; 2010.
45. Lospitao E, Alvarez A, Soriano V, Holguín A. HIV-1 subtypes in Spain:
a retrospective analysis from 1995 to 2003. HIV Med. 2005;6:313-20.
46. Davanos N, Panos G, Gogos CA, Mouzaki A. HIV-1 subtype charac-
teristics of infected persons living in southwestern greece. HIV AIDS
(Auckl). 2015;7:277-83.
47. Paraskevis D, Magiorkinis E, Magiorkinis G, et al. Molecular character-
ization of a complex, recombinant human immunodeficiency virus type
1 (HIV-1) isolate (A/G/J/K/?): evidence to support the existence of a
novel HIV-1 subtype. J Gen Virol. 2001;82:2509-14.
48. Hamers RL, Wensing AM, Back NK, Arcilla MS, Frissen JP. Multi-nu-
cleoside reverse transcriptase inhibitor resistant HIV type-1 in a patient
from Sierra Leone failing stavudine, lamivudine and nevirapine. Antivir
Ther. 2011;16:115-8.
49. Apetrei C, Metzger MJ, Richardson D, et al. Detection and partial
characterization of simian immunodeficiency virus SIVsm strains from
bush meat samples from rural Sierra Leone. J Virol. 2005;79:2631-6.
50. Ling B, Telfer P, Reed P, Robertson DL, Marx PA. A link between SIVsm
in sooty mangabeys (SM) in wild-living monkeys in Sierra Leone and
SIVsm in an American-based SM colony. AIDS Res Hum Retroviruses.
2004;20:1348-51.
51. Parsyan AE. Protective correlates against HIVs may have evolved in
human populations in the areas of historic occurrence of primate-to-
Yendewa, et al.: HIV/AIDS in Sierra Leone
man transmissions of SIVs ancestral to HIVs: studies in these popula-
tions may provide crucial insights for treatment and prevention of HIV
infection. Med Hypotheses. 2005;64:433-7.
52. Simon F, Matheron S, Tamalet C, et al. Cellular and plasma viral load
in patients infected with HIV-2. AIDS. 1993;7:1411-7.
 f the publisher.   © Permanyer 2018
53. Marlink R, Kanki P, Thior I, et al. Reduced rate of disease development
after HIV-2 infection as compared to HIV-1. Science. 1994;265:1587-90.
54. Popper SJ, Sarr AD, Travers KU, et al. Lower human immunodefi-
ciency virus (HIV) type 2 viral load reflects the difference in pathoge-
nicity of HIV-1 and HIV-2. J Infect Dis. 1999;180:1116-21.
55. Campbell-Yesufu OT, Gandhi RT. Update on human immunodeficiency
virus (HIV)-2 infection. Clin Infect Dis. 2011;52:780-7.
56. Quiñones-Mateu ME, Albright JL, Mas A, Soriano V, Arts EJ. Analysis
of pol gene heterogeneity, viral Quasispecies, and drug resistance in
individuals infected with group O strains of human immunodeficiency
virus type 1. J Virol. 1998;72:9002-15.
57. Quiñones-Mateu ME, Soriano V, Domingo E, Menéndez-Arias L. Char-
acterization of the reverse transcriptase of a human immunodeficiency
virus Type 1 group O isolate. Virology. 1997;236:364-73.
58. Quinones-Mateu ME, Ball SC, Arts EJ. Role of human immunodefi-
ciency virus type 1 group O in the AIDS pandemic. AIDS Rev.
2001;2:190-202.
59. Gallant JE, Gerondelis PZ, Wainberg MA, et al. Nucleoside and nucle-
otide analogue reverse transcriptase inhibitors: a clinical review of
antiretroviral resistance. Antivir Ther. 2003;8:489-506.
No part of this publication may be reproduced or photocopying without the prior written permission o
60. Parkin NT, Schapiro JM. Antiretroviral drug resistance in non-subtype
B HIV-1, HIV-2 and SIV. Antivir Ther. 2004;9:3-12.
61. National HIV/AIDS Secretariat, 2006. Sierra Leone ARV Guidelines;
2006. Available from: http://www.nas.gov.sl/images/stories/publica-
tions/Sierra%20Leone%20ARV%20Guidelines%20August%202006.
pdf. [Last accessed on 2018 Jan 9].
62. Brower ET, Bacha UM, Kawasaki Y, Freire E. Inhibition of HIV-2 prote-
ase by HIV-1 protease inhibitors in clinical use. Chem Biol Drug Des.
2008;71:298-305.
63. Gottlieb GS, Smith RA, Dia Badiane NM, et al. HIV-2 integrase variation
in integrase inhibitor-naïve adults in Senegal, West Africa. PLoS One.
2011;6:e22204.
64. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guide-
lines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and
Adolescents. Available from: https://www.aidsinfo.nih.gov/contentfiles/
lvguidelines/adultandadolescentgl.pdf. [Last on accessed on 2018 Feb
19].
65. World Health Organization 2012. Antiretroviral Treatment as Prevention
(TasP) of HIV and TB: 2012 update. Available from: http://www.apps.
who.int/iris/bitstream/10665/70904/1/WHO_HIV_2012.12_eng.pdf. [Last
on accessed on 2018 Jan 18].
66. European AIDS Clinical Society 2017. EACS Guidelines Version 9.0
October 2017. Available from: http://www.eacsociety.org/files/
guidelines_9.0-english.pdf. [Last on accessed on 2018 Feb 18].
67. Documento de consenso de Gesida/Plan Nacional sobre el SIDA re-
specto al tratamiento antiretroviral en adultos infectados por el virus
de la inmunodeficiencia humana. Available from: http://www.gesida-
seimc.org/wcontent/uploads/2018/01/gesida_TAR_Gesida_y_
PNS_2018.pdf. [Last on accessed on 2018 Jan 18; Last updated 2018
Jan].
68. National HIV/AIDS Secretariat, 2016. Re-advitised TOR and Request
for Expression of Interest for Viral Load Monitoring and EID; 2016.
Available from: http://www.nas.gov.sl/component/content/article/4-
newsflash/151-re-advitised-tor-and-request-for-expression-of-interest-
for-viral-load-monitoring-and-eid-august-2016. [Last on accessed on
2018 Jan 12].
69. Kasper J, Bajunirwe F. Brain drain in sub-Saharan Africa: contributing
factors, potential remedies and the role of academic medical centres.
Arch Dis Child. 2012;97:973-9.
70. Duvivier RJ, Burch VC, Boulet JR. A comparison of physician emigra-
tion from Africa to the United States of America between 2005 and
2015. Hum Resour Health. 2017;15:41.
71. The Global Fund, 2016. Country profile Sierra Leone. Available from:
https://www.theglobalfund.org/en/portfolio/
country/?loc=SLE&k=d9728bba-df64-4ff5-9968-f195de080917. [Last
on accessed on 2018 Jan 14].
72. Jones N, Bailey M, Lyytikäineni M. Research Capacity Strengthening
in Africa: trends, Gaps and Opportunities. London: Overseas Develop-
ment Institute; 2007.
73. Ijsselmuiden C, Marais DL, Becerra-Posada, Ghannem H. Africa’s ne-
glected area of human resources for health research-the way forward.
S Afr Med J. 2012;102:228-9.
74. Marjanovic, S, Hanlin R, Diepeveen S, Chataway J. Research capacity
building in Africa: networks, institutions and local ownership. J Int
Devel. 2013;25:936-46.
75. Grabowski MK, Serwadda DM, Gray RH, et al. HIV prevention efforts
and incidence of HIV-1 in Uganda. N Engl J Med. 2017;377:2154-66.
113