HIV testing and treatment campaigns need to target women and the under 35s, says research from South Africa

A quarter of people living with HIV in KwaZulu-Natal are unaware of their infection status, according to research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The study also revealed that approximately three-quarters of people eligible for antiretroviral therapy (ART) were taking this treatment and just over half of all HIV-positive individuals had viral suppression. The majority of individuals who were untested, unaware of their infection status, untreated and unsuppressed were women and the under 35s. However, men had a much greater risk of all these outcomes.

“Certain demographic sub-groups remain at higher risk for being untested, untreated and virally unsuppressed, hence being at high risk for adverse health outcomes and having a high potential for transmitting HIV,” write the investigators. “These results highlight the first priority is to increase testing and treatment for young people and women, as well as the need to adapt HIV testing strategies to better target men.”

Identifying which sub-groups have poor engagement with the HIV care continuum from diagnosis through to viral suppression is essential so that appropriate strategies can be designed to target those not accessing HIV services. However, relatively little is known about the socio-demographic and behavioural characteristics associated with being untested, lack of awareness of infection status, uptake of therapy and viral suppression, especially in high-prevalence settings such as South Africa. KwaZulu-Natal is the South African province with the highest HIV prevalence and incidence.

Investigators wanted to gain a clear understanding of rates of engagement with the HIV care continuum in this province and also the factors associated with not accessing HIV services.

They therefore designed a cross-sectional population-based study involving households in Mbongolwane and Eshowe. A total of 5649 individuals aged between 15 and 59 years were recruited to the study. Each participant had a face-to-face interview with study staff when they were asked to provide demographic information, sexual histories and details of ART usage. All participants had a rapid HIV test and those people testing positive provided blood samples, which were monitored for the presence of antiretroviral drugs. CD4 cell count and viral load were also quantified.

Data were collected in 2013. At this time, pregnant women and people with a CD4 count below 350 cells/mm³ were eligible for ART.

Most (62%) of the participants were women and the median age was 26 years.

HIV testing rates were high, with 81% of people reporting having been screened for the infection. Testing rates were higher in women than men (88% vs. 70%). Participants aged under 35 years and men accounted for three-quarters and two-thirds, respectively, of untested individuals.

The overall HIV prevalence rate was 25% but was higher in women than men (31% vs. 16%).

Individuals who had been screened for HIV reported a median of three tests and 48% had been tested in the previous six months.

Three-quarters of people eligible for ART were taking this treatment, and these individuals represented 53% of all HIV-positive people.

Analysis of the people eligible for ART but not on treatment showed that 65% were women and 66% were aged less than 35 years. Overall, ART coverage was lower in men compared to women (64% vs. 79%, p < 0.001) and was also lower in younger people compared to older age groups. (p < 0.001).

Viral load was suppressed (below 1000 copies/ml) in 57% of all HIV-positive individuals. Of the people who had unsuppressed viral load, 71% were women and 66% were aged less than 35 years. Men and the under 35s were the groups most likely to have a viral load above 100,000 copies/ml (18% men vs. 10% women; 15% of under 35s vs. 8% of older age groups).

Analysis of participants with antiretrovirals in their blood showed that 94% had viral suppression and 90% of people who reported use of ART had a viral load below 1000 copies/ml.

Men were significantly more likely than women to be untested, unaware of their infection status, untreated and virally unsuppressed. In addition, people with higher numbers of sexual partners were more likely to have poor engagement with the HIV care continuum.

“This community survey helped to reveal gaps in HIV services provided in the area and identify who needs to be targeted for HIV testing and treatment,” conclude the authors. “HIV testing and treatment activities should be prioritized to target young people and women, and a right balance should be found between increasing access to test and treat for the bulk of people untested and untreated and specific strategies for those who are more difficult to reach.”