HIV testing in South Africa: on track to reach the first “90”?

Changes in self-reported HIV testing during South Africa's 2010/2011 national testing campaign: gains and shortfalls.

Maughan-Brown B, Lloyd N, Bor J, Venkataramani AS. J Int AIDS Soc. 2016; 19(1): 20658.

Objectives: HIV counselling and testing is critical to HIV prevention and treatment efforts. Mass campaigns may be an effective strategy to increase HIV testing in countries with generalized HIV epidemics. We assessed the self-reported uptake of HIV testing among individuals who had never previously tested for HIV, particularly those in high-risk populations, during the period of a national, multisector testing campaign in South Africa (April 2010 and June 2011).

Design: This study was a prospective cohort study.

Methods: We analyzed data from two waves (2010/2011, n=16 893; 2012, n=18 707) of the National Income Dynamics Study, a nationally representative cohort that enabled prospective identification of first-time testers. We quantified the number of adults (15 years and older) testing for the first time nationally. To assess whether the campaign reached previously underserved populations, we examined changes in HIV testing coverage by age, gender, race and province sub-groups. We also estimated multivariable logistic regression models to identify socio-economic and demographic predictors of first-time testing.

Results: Overall, the proportion of adults ever tested for HIV increased from 43.7% (95% confidence interval (CI): 41.48, 45.96) to 65.2% (95% CI: 63.28, 67.10) over the study period, with approximately 7.6 million (95% CI: 6,387,910; 8,782,986) first-time testers. Among black South Africans, the country's highest HIV prevalence sub-group, HIV testing coverage improved among poorer and healthier individuals, thus reducing gradients in testing by wealth and health. In contrast, HIV testing coverage remained lower for men, younger individuals and the less educated, indicating persistent if not widening disparities by gender, age and education. Large geographic disparities in coverage also remained as of 2012.

Conclusions: Mass provision of HIV testing services can be effective in increasing population coverage of HIV testing. The geographic and socio-economic disparities in programme impacts can help guide best practices for future efforts. These efforts should focus on hard-to-reach populations, including men and less-educated individuals.

Abstract [1] Full-text [free] access [2]

Editor’s notes: In South Africa, around one in eight people are living with HIV yet around half of these people do not know that they are HIV positive. To meet the 90-90-90 treatment target by 2020, there needs to be considerable expansion of HIV testing coverage. This analysis used independent nationally representative data on self-reported HIV testing to demonstrate that coverage of HIV testing increased substantially following the national multi-sector HIV testing campaign in 2010/11. Despite the expansion in coverage, in the 2012 survey one in three people aged >15 years reported never having received an HIV test. There was marked gender disparity, some 72% of women versus 57% men reported ever having tested in the 2012 survey. There were also prominent gaps among certain socio-economic groups, suggesting persistent inequities in access to HIV testing. 

Although South Africa performs around 10 million HIV tests per year, the number of people tested falls substantially below the target of 30 million tests set for 2016 in the National Strategic Plan. In September, South Africa will implement the “test and treat” approach where all people living with HIV will be offered antiretroviral therapy. In addition, demonstration projects are underway of pre-exposure prophylaxis (PrEP) for HIV prevention. HIV testing services  is the gateway to all treatment and prevention services. The national campaign for HIV testing will clearly need to be revitalised in order to maximise the impact of these public health activities. At the same time, the data reported here would suggest that more innovative and focused approaches may be necessary for difficult to reach population groups.

Africa [8]
South Africa [9]
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