Abstract
IntroductionThe antiretroviral therapy (ART) programme supported by Médecins Sans Frontières in the rural Malawian district of Chiradzulu was one of the first in sub-Saharan Africa to scale up ART delivery in 2002. After more than a decade of continuous involvement, we conducted a population survey to evaluate the cascade of care, including population viral load, in the district.MethodsA cross-sectional household-based survey was conducted between February and May 2013. Using a multistage cluster sampling method, we recruited all individuals aged 15 to 59 years living in 4125 randomly selected households. Each consenting individual was interviewed and tested for HIV at home. All participants who tested positive had their CD4 count and viral load measured. The LAg-Avidity assay was used to distinguish recent from long-term infections. Viral suppression was defined as a viral load below 1000 copies/mL.ResultsOf 8271 individuals eligible for the study, 7269 agreed to participate and were tested for HIV (94.1% inclusion for women and 80.3% for men). Overall HIV prevalence and incidence were 17.0% (95% CI 16.1 to 17.9) and 0.39 new cases per 100 person-years (95% CI 0.0 to 0.77), respectively. Coverage at the other steps along the HIV care cascade was as follows: 76.7% (95% CI 74.4 to 79.1) had been previously diagnosed, 71.2% (95% CI 68.6 to 73.6) were under care and 65.8% (95% CI 62.8 to 68.2) were receiving ART. Finally, the proportion of participants who were HIV positive with a viral load ≤1000 copies/mL reached 61.8% (95% CI 59.0 to 64.5).ConclusionsThis study demonstrates that a high level of population viral suppression and low incidence can be achieved in high HIV prevalence and resource-limited settings.
Highlights
The antiretroviral therapy (ART) programme supported by Medecins Sans Frontieres in the rural Malawian district of Chiradzulu was one of the first in sub-Saharan Africa to scale up ART delivery in 2002
Prevalence was higher among widows (54.4%, 95% CI 48.1 to 60.6) than among married participants (18.5%, 95% CI 17.3 to 19.7) or among those who never married (2.7%, 95% CI 2.0 to 3.6)
We found that almost two-thirds of the HIV-positive individuals living in the district of Chiradzulu achieved a viral load B1000 copies/mL, 10 years after scaling up ART services and a median time on ART of almost four years
Summary
The antiretroviral therapy (ART) programme supported by Medecins Sans Frontieres in the rural Malawian district of Chiradzulu was one of the first in sub-Saharan Africa to scale up ART delivery in 2002. All participants who tested positive had their CD4 count and viral load measured. The proportion of participants who were HIV positive with a viral load 51000 copies/mL reached 61.8% (95% CI 59.0 to 64.5). Conclusions: This study demonstrates that a high level of population viral suppression and low incidence can be achieved in high HIV prevalence and resource-limited settings. UNAIDS recently set up an ambitious 90Á90Á90 targets, with the objective that by 2020 90% of all people living with HIV will know their status, 90% of those diagnosed will receive sustained antiretroviral therapy (ART) and 90% of those on ART will reach undetectable viral load [1]. Despite wider ART availability in recent years, uncertainty remains whether such levels of population viral suppression can be achieved, especially in resource-limited settings. It provides an opportunity to evaluate what the population impact of universal ART treatment would be on the cascade and on ART eligibility, as recommended by the World Health Organization (WHO) since September 2015 [6]
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