Tigray War and HIV Care Cascade Entry in Mekelle, Ethiopia

Importance: Armed conflicts disrupt health care delivery, yet quantitative evidence on conflict-related HIV care cascade disruptions in sub-Saharan Africa remains limited. Objective: To examine associations between the Tigray War and HIV diagnosis, linkage to care, and antiretroviral therapy (ART) initiation in Mekelle City, Tigray, Ethiopia. Design, Setting, and Participants: This cohort study used an interrupted time-series analysis using quarterly electronic medical record data from 7 health facilities in Mekelle City, Tigray, Ethiopia (quarter [Q] 1 2005 to Q1 2025; 81 quarters; 2020 retained as a separate pandemic period). All individuals accessing HIV care services at participating facilities were included. Data were analyzed from October 2024 to May 2025. Exposure: Four study periods: prewar (Q1 2005 to Q4 2019; reference), pandemic (Q1 to Q4 2020), war (Q1 2021 to Q4 2022), and postwar (Q1 2023 to Q1 2025). Main Outcomes and Measures: Quarterly counts of HIV diagnoses, linkages to care, and ART initiations, modeled using negative binomial segmented regression with seasonal harmonics. Autoregression with integrated moving averages with intervention regressors served as a complementary analysis. Results: Over the study period, 13 478 HIV diagnoses, 11 959 linkages to care, and 9399 ART initiations were recorded; women represented 7913 diagnoses (58.7%), and individuals aged 35 to 44 years had the most diagnoses (4414 [32.7%]). During the pandemic, HIV diagnoses declined relative to prewar trajectories (incidence rate ratio [IRR], 0.65; 95% CI, 0.51-0.83; P < .001). During the war, HIV diagnoses declined further (IRR, 0.71; 95% CI, 0.58-0.86; P < .001), with comparable reductions in linkages to care (IRR, 0.68; 95% CI, 0.53-0.86; P = .002) and ART initiations (IRR, 0.70; 95% CI, 0.54-0.91; P = .008). Women experienced larger war-period reductions than men (diagnoses: IRR, 0.57; 95% CI, 0.46-0.72 vs IRR, 0.92; 95% CI, 0.74-1.15). Individuals aged 0 to 24 years showed the largest declines in diagnoses (IRR, 0.59; 95% CI, 0.43-0.81). Secondary facilities showed war-period increases in diagnoses (IRR, 1.44; 95% CI, 1.09-1.90), while tertiary and primary facilities showed reductions (tertiary: IRR, 0.18; 95% CI, 0.10-0.32; P < .001; primary: IRR, 0.29; 95% CI, 0.17-0.50; P < .001). The nongovernmental organization-managed facility showed war-period and postwar IRRs of 0.21 (95% CI, 0.13-0.36) and 0.20 (95% CI, 0.12-0.35), with no recovery. Conclusions and Relevance: In this cohort study of HIV care services in Mekelle, Ethiopia, the Tigray War period was associated with substantial declines in HIV diagnoses, linkages to care, and ART initiations, with services remaining below counterfactual expectations more than 2 years after the ceasefire.