Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.

This article presents key findings from the 2012 HIV prevalence, incidence and behaviour survey conducted in South Africa and explores trends in the HIV epidemic. A representative household based survey collected behavioural and biomedical data among people of all ages. Chi-squared test for association and formal trend tests (2002, 2005, 2008 and 2012) were used to test for associations and trends in the HIV epidemic across the four surveys. In 2012 a total of 38 431 respondents were interviewed from 11 079 households; 28 997 (67.5%) of 42 950 eligible individuals provided blood specimens. HIV prevalence was 12.2% [95% CI: 11.4-13.1] in 2012 with prevalence higher among females 14.4% than males 9.9%. Adults aged 25-49 years were most affected, 25.2% [95% CI: 23.2-27.3]. HIV prevalence increased from 10.6% [95%CI: 9.8-11.6] in 2008 to 12.2% [95% CI: 11.4-13.1] in 2012 (p < 0.001). Antiretroviral treatment (ART) exposure doubled from 16.6% in 2008 to 31.2% in 2012 (p < 0.001). HIV incidence in 2012 among persons 2 years and older was 1.07% [95% CI: 0.87-1.27], with the highest incidence among Black African females aged 20-34 years at 4.5%. Sexual debut before 15 years was reported by 10.7% of respondents aged 15-24 years, and was significantly higher among male youth than female (16.7% vs. 5.0% respectively, p < 0.001). Reporting of multiple sexual partners in the previous 12 months increased from 11.5% in 2002 to 18.3% in 2012 (p < 0.001). Condom use at last sex dropped from 45.1% in 2008 to 36.2% in 2012 (p < 0.001). Levels of accurate HIV knowledge about transmission and prevention were low and had decreased between 2008 and 2012 from 31.5% to 26.8%. South Africa is on the right track with scaling up ART. However, there have been worrying increases in most HIV-related risk behaviours. These findings suggest that there is a need to scale up prevention methods that integrate biomedical, behavioural, social and structural prevention interventions to reverse the tide in the fight against HIV.

People on HIV treatment with undetectable virus cannot transmit HIV sexually (Undetectable = Untransmittable, U = U). However, the science of treatment-as-prevention (TasP) may not be widely understood by people with and without HIV who could benefit from this information. We systematically reviewed the global literature on knowledge and attitudes related to TasP and interventions providing TasP or U = U information. We included studies of providers, patients, and communities from all regions of the world, published 2008–2020. We screened 885 papers and abstracts and identified 72 for inclusion. Studies in high-income settings reported high awareness of TasP but gaps in knowledge about the likelihood of transmission with undetectable HIV. Greater knowledge was associated with more positive attitudes towards TasP. Extant literature shows low awareness of TasP in Africa where 2 in 3 people with HIV live. The emerging evidence on interventions delivering information on TasP suggests beneficial impacts on knowledge, stigma, HIV testing, and viral suppression.Review was pre-registered at PROSPERO: CRD42020153725

BackgroundThe interpretation of HIV prevalence trends is increasingly difficult as antiretroviral treatment programs expand. Reliable HIV incidence estimates are critical to monitoring transmission trends and guiding an effective national response to the epidemic.Methods and FindingsWe used a range of methods to estimate HIV incidence in South Africa: (i) an incidence testing algorithm applying the Limiting-Antigen Avidity Assay (LAg-Avidity EIA) in combination with antiretroviral drug and HIV viral load testing; (ii) a modelling technique based on the synthetic cohort principle; and (iii) two dynamic mathematical models, the EPP/Spectrum model package and the Thembisa model. Overall, the different incidence estimation methods were in broad agreement on HIV incidence estimates among persons aged 15-49 years in 2012. The assay-based method produced slightly higher estimates of incidence, 1.72% (95% CI 1.38 – 2.06), compared with the mathematical models, 1.47% (95% CI 1.23 – 1.72) in Thembisa and 1.52% (95% CI 1.43 – 1.62) in EPP/Spectrum, and slightly lower estimates of incidence compared to the synthetic cohort, 1.9% (95% CI 0.8 – 3.1) over the period from 2008 to 2012. Among youth aged 15-24 years, a declining trend in HIV incidence was estimated by all three mathematical estimation methods.ConclusionsThe multi-method comparison showed similar levels and trends in HIV incidence and validated the estimates provided by the assay-based incidence testing algorithm. Our results confirm that South Africa is the country with the largest number of new HIV infections in the world, with about 1 000 new infections occurring each day among adults aged 15-49 years in 2012.

Test and Treat (UTT) policy calls for first-line antiretroviral treatment (ART) initiation among all known HIV-positive patients, irrespective of CD4 cell count. We evaluate treatment outcomes of patients initiated on first-line ART directly before and after the implementation of UTT. Methods: We analysed prospectively collected clinical cohort data among ART-naïve adult patients within two HIV clinics in Johannesburg, South Africa. We compare two groups: 1) an unexposed pre-UTT group initiating treatment from 01 December 2014 to 31 May 2015; and 2) an exposed UTT group initiating treatment from 01 December 2016 to 31 May 2017. Primary treatment outcomes included lost to follow-up (LTFU) (>90 days late for the last scheduled visit with no subsequent clinical visit). Cox proportional hazards models were used to estimate the association between pre-UTT vs UTT initiation on LTFU by 12 months. Results: We included 2410 patients. A total of 1267 (52.6%) patients initiated ART before UTT implementation and 1143 (47.4%) after the change in policy. LTFU (adjusted Hazard Ratio (aHR): 1.51; 95% Confidence Interval (CI): 1.16-1.98) between groups and specifically among those initiating with a CD4 cell count ≤500 cells/mm 3 (aHR: 1.59; 95% CI: 1.21-2.10) was higher among patients initiating ART under UTT. Conclusion: LTFU under UTT proved higher than that of previous periods. Patients initiating first-line therapy under the treat-all policy may often start treatment in better health, subsequently not perceiving a direct benefit to treatment which may deter patients from consistent engagement in HIV treatment programmes.