Abstract
SummaryBackgroundMonitoring knowledge of HIV status among people living with HIV is essential for an effective national HIV response. This study estimates progress and gaps in reaching the UNAIDS 2020 target of 90% knowledge of status, and the efficiency of HIV testing services in sub-Saharan Africa, where two thirds of all people living with HIV reside.MethodsFor this modelling study, we used data from 183 population-based surveys (including more than 2·7 million participants) and national HIV testing programme reports (315 country-years) from 40 countries in sub-Saharan Africa as inputs into a mathematical model to examine trends in knowledge of status among people living with HIV, median time from HIV infection to diagnosis, HIV testing positivity, and proportion of new diagnoses among all positive tests, adjusting for retesting. We included data from 2000 to 2019, and projected results to 2020.FindingsAcross sub-Saharan Africa, knowledge of status steadily increased from 5·7% (95% credible interval [CrI] 4·6–7·0) in 2000 to 84% (82–86) in 2020. 12 countries and one region, southern Africa, reached the 90% target. In 2020, knowledge of status was lower among men (79%, 95% CrI 76–81) than women (87%, 85–89) across sub-Saharan Africa. People living with HIV aged 15–24 years were the least likely to know their status (65%, 62–69), but the largest gap in terms of absolute numbers was among men aged 35–49 years, with 701 000 (95% CrI 611 000–788 000) remaining undiagnosed. As knowledge of status increased from 2000 to 2020, the median time to diagnosis decreased from 9·6 years (9·1–10) to 2·6 years (1·8–3·5), HIV testing positivity declined from 9·0% (7·7–10) to 2·8% (2·1–3·9), and the proportion of first-time diagnoses among all positive tests dropped from 89% (77–96) to 42% (30–55).InterpretationOn the path towards the next UNAIDS target of 95% diagnostic coverage by 2025, and in a context of declining positivity and yield of first-time diagnoses, disparities in knowledge of status must be addressed. Increasing knowledge of status and treatment coverage among older men could be crucial to reducing HIV incidence among women in sub-Saharan Africa, and by extension, reducing mother-to-child transmission.FundingSteinberg Fund for Interdisciplinary Global Health Research (McGill University); Canadian Institutes of Health Research; Bill & Melinda Gates Foundation; Fonds the recherche du Québec—Santé; UNAIDS; UK Medical Research Council; MRC Centre for Global Infectious Disease Analysis; UK Foreign, Commonwealth & Development Office.
Highlights
Efficient and effective HIV testing services are a key component of efforts to end the AIDS epidemic
A positive diagnosis enables people living with HIV to receive lifesaving antiretroviral therapy (ART)[1] and, for pregnant women living with HIV, risk of mother-to-child HIV transmission can be almost entirely prevented.[2]
In sub-Saharan Africa, where more than two thirds of people living with HIV reside, HIV testing services were initially provided through voluntary counselling and testing upon request in stand-alone sites.[5]
Summary
Efficient and effective HIV testing services are a key component of efforts to end the AIDS epidemic. A positive diagnosis enables people living with HIV to receive lifesaving antiretroviral therapy (ART)[1] and, for pregnant women living with HIV, risk of mother-to-child HIV transmission can be almost entirely prevented.[2] At the population level, early diagnosis and treatment could reduce incidence by dramatically lowering viraemia such that those with a suppressed viral load are unable to contribute to onward transmission.[3] HIV testing services help to identify people who are vulnerable to HIV acquisition and link them to effective HIV prevention services.[4]. In sub-Saharan Africa, where more than two thirds of people living with HIV reside, HIV testing services were initially provided through voluntary counselling and testing upon request in stand-alone sites.[5] As ART became more widely available, provider-initiated HIV testing and counselling emerged, expanding HIV testing to all patients in health facilities. Such facility-based services were gradually expanded and implementation of communitybased services enabled underserved rural and marginal ised key populations to be reached by HIV testing and treatment services.[6,7,8] The development of new testing e284 www.thelancet.com/hiv Vol 8 May 2021
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