Trends in HIV Prevention, Treatment, and Incidence in a Hyperendemic Area of KwaZulu-Natal, South Africa

Ayesha B M Kharsany,Quarraisha Abdool Karim,Túlio De Oliveira ,Kassahun Ayalew ,Karidia Diallo,Gavin George,Lara Lewis,Eduan Wilkinson,Mary Glenshaw,Savathree Madurai,Nonhlanhla Yende‐Zuma ,Cherie Cawood,Natasha Samsunder,Sean Beckett,Adrian Puren,Carlos Toledo,Salim S Abdool Karim,Kaymarlin Govender,David Khanyile,Amy Herman‐Roloff ,Cheryl Baxter

doi:10.1001/jamanetworkopen.2019.14378

Abstract

In Africa, the persistently high HIV incidence rate among young women is the major obstacle to achieving the goal of epidemic control. To determine trends in coverage of HIV prevention and treatment programs and HIV incidence. This cohort study consisted of 2 sequential, community-based longitudinal studies performed in the Vulindlela and Greater Edendale area in KwaZulu-Natal, South Africa. Participants enrolled from June 11, 2014, to June 22, 2015 (2014 survey), with a single follow-up visit from June 24, 2016, to April 3, 2017 (2016 cohort), or enrolled from July 8, 2015, to June 7, 2016 (2015 survey), with a single follow-up visit from November 7, 2016, to August 30, 2017 (2017 cohort). Men and women aged 15 to 49 years were enrolled in the 2014 and 2015 surveys, and HIV-seronegative participants aged 15 to 35 years were followed up in the 2016 and 2017 cohorts. Analysis was conducted from January 1 through December 31, 2018. HIV prevention and treatment programs in a real-world, nontrial setting. Trends in sex- and age-specific HIV incidence rates, condom use, voluntary medical male circumcision, knowledge of HIV-seropositive status, uptake of antiretroviral therapy, and viral suppression. A total of 9812 participants (6265 women [63.9%]; median age, 27 years [interquartile range, 20-36 years]) from 11 289 households were enrolled in the 2014 survey, and 10 236 participants (6341 women [61.9%]; median age, 27 years [interquartile range, 20-36 years]) from 12 247 households were enrolled in the 2015 survey. Of these, 3536 of 4539 (annual retention rate of 86.7%) completed follow-up in the 2016 cohort, and 3907 of 5307 (annual retention rate of 81.4%) completed follow-up in the 2017 cohort. From 2014 to 2015, condom use with last sex partner decreased by 10% from 24.0% (n = 644 of 3547) to 21.6% (n = 728 of 3895; P = .12) in men and by 17% from 19.6% (n = 1039 of 6265) to 16.2% (n = 871 of 6341; P = .002) in women. Voluntary medical male circumcision increased by 13% from 31.9% (1102 of 3547) to 36.1% (n = 1472 of 3895); P = .007) in men, and the proportion of women reporting that their partner was circumcised increased by 35% from 35.7% (n = 1695 of 4766) to 48.2% (n = 2519 of 5207; P < .001). Knowledge of HIV-seropositive status increased by 21% from 51.8% (n = 504 of 3547) to 62.9% (n = 570 of 3895; P < .001) in men and by 14% from 64.6% (n = 1833 of 6265) to 73.4% (n = 2182 of 6341; P < .001) in women. Use of antiretroviral therapy increased by 32% from 36.7% (n = 341 of 3547) to 48.6% (n = 432 of 3895; P < .001) in men and by 29% from 45.6% (n = 1251 of 6265) to 58.8% (n = 1743 of 6341; P < .001) in women; HIV viral suppression increased by 20% from 41.9% (n = 401 of 3547) to 50.3% (n = 456 of 3895; P = .005) in men and by 13% from 54.8% (n = 1547 of 6265) to 61.9% (n = 1828 of 6341; P < .001) in women. Incidence of HIV declined in women aged 15 to 19 years from 4.63 (95% CI, 3.29-6.52) to 2.74 (95% CI, 1.84-4.09) per 100 person-years (P = .04) but declined marginally or remained unchanged among men and women in other age groups. This study showed a significant decline in HIV incidence in young women; however, to further reduce HIV incidence, HIV prevention and treatment program coverage must be intensified and scaled up.

Highlights

In Africa, ongoing high HIV incidence in young women[1,2,3] is the leading obstacle to achieving the United Nations goal of global epidemic control by the year 2030.4 In South Africa, the world’s worstaffected country, approximately 7.9 million people of all ages were living with HIV in 2017,5 and among adults aged 15 to 49 years, HIV prevalence was 20.6% (26.3% among women and 14.8% among men)
A total of 9812 participants (6265 women [63.9%]; median age, 27 years [interquartile range, 20-36 years]) from 11 289 households were enrolled in the 2014 survey, and 10 236 participants (6341 women [61.9%]; median age, 27 years [interquartile range, 20-36 years]) from 12 247 households were enrolled in the 2015 survey
Voluntary medical male circumcision increased by 13% from 31.9% (1102 of 3547) to 36.1% (n = 1472 of 3895); P = .007) in men, and the proportion of women reporting that their partner was circumcised increased by 35% from 35.7% (n = 1695 of 4766) to 48.2% (n = 2519 of 5207; P < .001)

Summary

Introduction

In Africa, ongoing high HIV incidence in young women[1,2,3] is the leading obstacle to achieving the United Nations goal of global epidemic control by the year 2030.4 In South Africa, the world’s worstaffected country, approximately 7.9 million people of all ages were living with HIV in 2017,5 and among adults aged 15 to 49 years, HIV prevalence was 20.6% (26.3% among women and 14.8% among men). In 2010, the South African Department of Health progressively scaled up HIV prevention and treatment programs These programs included access to HIV testing services with linkage to care, prevention of mother-to-child transmission of HIV,[12] voluntary medical male circumcision (VMMC),[13] provision of HIV preexposure and postexposure prophylaxis,[14,15,16] antiretroviral therapy (ART), and a treatment-as-prevention[15] strategy to improve HIV-related morbidity and mortality, increase life expectancy,[17,18] and reduce HIV transmission potential.[17,19,20] To accelerate the response toward achieving the goal to HIV epidemic control and to end the AIDS epidemic, the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 treatment target measures (ie, require 90% of all people living with HIV to know their HIV status, 90% of all people with diagnosed HIV infection to receive sustained ART, and 90% of all people receiving ART to achieve viral suppression),[21,22] universal test-and-treat strategy,[23] and HIV self-testing strategy[24] have been implemented. Criteria for initiation of ART, ART regimens, use of mobile clinics, nurse-initiated management of ART, and use of a fixed-dose drug combination have been implemented to streamline treatment, improve adherence, and achieve and sustain viral suppression.[15]

Methods

Results

Discussion

Conclusion