Abstract
BACKGROUND: Globally, approximately half of new HIV acquisitions occur among African adults. This analysis examines which cisgender men are at highest risk of acquiring HIV-1 and in greatest need of HIV pre-exposure prophylaxis (PrEP). SETTING: National population-based surveys from Eswatini, Ivory Coast, Kenya, Lesotho, Malawi, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. METHODS: The 13 surveys were pooled and sampling weights were applied to represent all susceptible men aged 15-59 years old. HIV-1 incidence was calculated based on a recent HIV-1 testing algorithm. A least absolute shrinkage and selection operator (Lasso) regression model was fit with 28 variables to predict recent HIV-1. Models were trained and internally cross-validated to estimate area under the receiver-operating characteristic curve (AUC). Along the receiver-operating characteristic curve, at sensitivity levels from 10% to 90%, performance tradeoffs were evaluated. RESULTS: Of 167,121 participants, 112 had recent HIV-1, representing 256,000 new annual infections among 122 million men. Only 2 variables were retained-reporting a male sexual partner and living in a subnational area where a high proportion of adults have detectable HIV-1 viremia. Overall AUC was 0.80 (95% Confidence Interval: 0.71 to 0.89); cross-validated AUC was 0.76 (95% CI: 0.64 to 0.87). At 10% sensitivity, 25,000 cases could be averted if 357,000 men adhered to PrEP (Number Needed to Treat = 14). At 90% sensitivity, 229,000 cases could be averted if 50 million men adhered to PrEP (Number Needed to Treat = 219). CONCLUSIONS: This predictive, parsimonious, generalizable risk assessment tool could help policymakers weigh tradeoffs between PrEP reach and efficiency.