Less than half of adolescent girls and young women with HIV in some of the countries with the highest burden of HIV in sub-Saharan Africa have a fully suppressed viral load on antiretroviral treatment, well below the average for the population as a whole, findings from national surveys published this month in Mortality and Morbidity Weekly Reports show.
Despite sustained efforts to reduce HIV incidence among adolescent girls and young women, the prevalence of HIV remains much higher among adolescent girls and young women aged 15 to 24 than their male peers in sub-Saharan Africa. National surveys have found an especially high prevalence in this age group in Lesotho and Swaziland, where between one in ten and one in seven young women aged 15-24 was living with HIV in 2016 or 2017.
Population-based HIV Impact Assessment (PHIA) surveys are household surveys that are being carried out by national ministries of health with funding from the President’s Emergency Plan for AIDS Relief. The surveys are designed to measure HIV incidence, prevalence and viral load suppression so as to monitor national and regional progress towards the 90-90-90 targets for HIV diagnosis, treatment and viral suppression. Ideally, if 90% of people with HIV are diagnosed, 90% of diagnosed people are on treatment and 90% of people on treatment have fully suppressed viral load, 73% of all people with HIV should have suppressed viral load (below 1000 copies/ml).
A fully suppressed viral load is the aim of antiretroviral treatment. Maintaining a fully suppressed viral load prevents HIV disease progression, prevents the development of drug resistance and prevents sexual transmission of HIV. Achieving very high levels of viral suppression should minimise AIDS-related deaths and greatly reduce HIV incidence.
PHIA surveys
In each household, participants aged 15-59 are offered home-based HIV counselling and rapid antibody testing and questioned about risk behaviours, HIV testing and treatment history. The findings are then weighted for population size and demographics to develop estimates of HIV prevalence, incidence, treatment coverage and viral load suppression.
The study of adolescent girls and young women combined data from surveys carried out between 2015 and 2017 in seven countries (Lesotho, Malawi, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe). Of the 32,273 adolescent girls and young women eligible to take part in the study, 87% consented to take part and underwent HIV rapid testing, with HIV viral load testing by dried blood spot.
Overall HIV prevalence was 3.6% but ranged from 3.3% in Uganda and 3.4% in Malawi to 11.1% in Lesotho and 13.9% in Swaziland. The proportion of adolescent girls and young women who knew that they had HIV infection ranged from 40% in Zambia and 46% in Tanzania to 61% in Lesotho and 70% in Swaziland.
Self-reported antiretroviral treatment use varied less between countries, ranging from 78.9% in Zambia to 89.7% in Lesotho.
Viral suppression among those on treatment ranged from 75.8% in Uganda and 76.4% in Lesotho to 89% in Zimbabwe and 90.6% in Tanzania. Considering all adolescent girls and young women with HIV who took part in the studies, not just those who said they were on treatment, this represents viral suppression rates of 33% in Zambia, 44.9% in Uganda and 55% in Swaziland – far below the 73% target. Overall, only 45% of adolescent girls and young women with HIV across the seven countries had fully suppressed viral load.
Kristin Brown of the US Centers for Disease Control and Prevention and colleagues conclude: “In contrast to […] successes in the general adult population, the 45% prevalence for viral load suppression among adolescent girls and young women is well below the 73% target, suggesting that the strategies that have been more broadly successful in initiating and keeping adults with HIV on ART [antiretroviral therapy] are less successful in this population…In these countries, additional, targeted strategies are needed to reach [….] adolescents girls and young women.”
Brown K et al. Status of HIV epidemic control among adolescent girls and young women aged 15-24 years – seven African countries, 2015-2017. MMWR 67 (1): 29-32, 2018.