Only a quarter of people living with HIV in South Africa virally suppressed

The continuum of HIV care in South Africa: implications for achieving the second and third UNAIDS 90-90-90 targets.

Takuva S, Brown AE, Pillay Y, Delpech V, Puren AJ. AIDS. 2017 Feb 20;31(4):545-552. doi: 10.1097/QAD.0000000000001340.

Background: We characterize engagement with HIV care in South Africa in 2012 to identify areas for improvement towards achieving global 90-90-90 targets.

Methods: Over 3.9 million CD4 cell count and 2.7 million viral load measurements reported in 2012 in the public sector were extracted from the national laboratory electronic database. The number of persons living with HIV (PLHIV), number and proportion in HIV care, on antiretroviral therapy (ART) and with viral suppression (viral load <400 copies/ml) were estimated and stratified by sex and age group. Modified Poisson regression approach was used to examine associations between sex, age group and viral suppression among persons on ART.

Results: We estimate that among 6 511 000 PLHIV in South Africa in 2012, 3 300 000 individuals (50.7%) accessed care and 32.9% received ART. Although viral suppression was 73.7% among the treated population in 2012, the overall percentage of persons with viral suppression among all PLHIV was 23.8%. Linkage to HIV care was lower among men (38.5%) than among women (57.2%). Overall, 47.1% of those aged 0-14 years and 47.0% of those aged 15-49 years were linked to care compared with 56.2% among those aged above 50 years.

Conclusion: Around a quarter of all PLHIV have achieved viral suppression in South Africa. Men and younger persons have poorer linkage to HIV care. Expanding HIV testing, strengthening prompt linkage to care and further expansion of ART are needed for South Africa to reach the 90-90-90 target. Focus on these areas will reduce the transmission of new HIV infections and mortality in the general population.

Abstract access  [1]

Editor’s notes: To maximise the impact of ART, people living with HIV should be diagnosed early, enrolled and initiated on antiretroviral therapy (ART) and retained in ART care. Long-term adherence to achieve and maintain viral load suppression is the last step in the continuum of HIV care. Engagement along the complete treatment cascade will determine the long-term success of the global response to HIV.

In this manuscript, the authors used a combination of national HIV prevalence estimates and routine data collected through the National Health Laboratory Service to construct and characterize the different stages of the HIV care continuum in South Africa.

They estimate that, despite the expansion of the ART programme in South Africa, only about a quarter of people living with HIV were virally suppressed in 2012, contrasting with recent estimates from Botswana where about 70% of people living with HIV were reported to be virally suppressed. They estimate that only about half of all people living with HIV accessed care, but report that, once in care, the ART programme proves to be effective with three-quarters of people on ART achieving virologic suppression. Not surprisingly they found that men and younger persons have poorer linkage to care. They recommend that HIV testing needs to be expanded, and linkage to care needs to be promoted for people testing HIV-positive, if the UNAIDS 90-90-90 treatment target is to be reached.

This paper illustrates how, in the context of a national public sector laboratory diagnostic service, routine laboratory data can be used to monitor the public health response to HIV at a national level. 

Epidemiology [3], HIV testing [4], HIV Treatment [5]
Africa [6]
South Africa [7]
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