Attrition and Opportunities Along the HIV Care Continuum: Findings From a Population-Based Sample, North West Province, South Africa

Abstract

Background Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care and viral suppression is critical to target programming. Methods We conducted a population-based household survey, HIV rapid testing, point-of-care CD4 testing, and viral load measurement from dried blood spots (DBS) using multi-stage cluster sampling in two sub-districts of North West Province from January–March, 2014. We used weighting and multiple imputation of missing data to estimate HIV prevalence, undiagnosed infection, linkage and retention in care, medication adherence, and viral suppression. Results We sampled 1044 respondents ages 18–49. HIV prevalence was 20.0% (95% CI: 13.7–26.2) for men and 26.7% (95%CI: 22.1–31.4) for women. Among those HIV-positive, 48.4% of men and 75.7% of women were aware of their serostatus; 44.0% of men and 74.8% of women reported ever linking to HIV care; 33.1% of men and 58.4% of women were retained in care; and 21.6% of men and 50.0% of women had DBS viral loads < 5000 copies/mL. Among those already linked to care, 81.7% on ART and 56.0% of those not on ART were retained in care and 51.8% currently retained in care on ART had viral loads < 5000 copies/mL. Conclusions Despite expanded treatment in South Africa, attrition along the continuum of HIV care is slowing prevention progress. Improved detection is critically needed, particularly among men. Reported linkage and retention is reasonable for those on ART, however failure to achieve viral suppression is worrisome.

Improvements in the South African HIV care cascade: findings on 90‐90‐90 targets from successive population‐representative surveys in North West Province

“…The listing was used to randomly select up to 36 inhabited dwelling units (DU) or households from each EA for inclusion (1561 DUs in total). One adult (18 to 49 years) was randomly selected per DU for participation [15]. In 2016, sampled EAs were enumerated using aerial maps including all structures within the EA boundary; research teams then drove through the EAs to note structures that were no longer inhabited and/or new structures to add to the map.…”

“…Across surveys the EAs ranged in size from 14 to 355 dwellings, resulting in probability of DU selection ranging from 1.0 to 0.13. Results and detailed methods from the first survey have been published [15].…”

“…Following the survey, point-of-care HIV rapid antibody testing was performed by trained community health workers (CHWs) using serial HIV-1/2 antibody rapid testing using the Alere Determine HIV-1/2 (Alere Medical Co., Ltd, Chiba, Japan) and, if reactive, the First Response HIV 1-2 (Premier Medical Corporation Ltd, Daman, India) [15]. Participants testing positive or with discrepant results were asked to undergo lancet finger-prick to create ten 50 lL dried blood spots (DBS) using one Munktell filter card (Ahlstrom Munktell, Helsinki, Finland) and one Whatman Protein Saver #903 card, and then referred to the nearest public health care facility.…”

Evaluation of the Tsima community mobilization intervention to improve engagement in HIV testing and care in South Africa: study protocol for a cluster randomized trial

“…Though South Africa has the largest ART program in the world, only an estimated 52% of eligible patients are on treatment [10], and only an estimated 31% of those living with HIV have initiated treatment [7]. Furthermore, population-based data from rural areas in the North West province in 2014 indicate that less than half of those on ART are virally suppressed [11]. At current rates of testing and treatment coverage, South Africa will fall far short of meeting the 90-90-90 goals.…”

Application opportunities of geographic information systems analysis to support achievement of the UNAIDS 90-90-90 targets in South Africa

“…For example, since a high number of HIVinfected males in SA remain undiagnosed, with low HTS uptake also recorded among men in other LMICs, [38,39] visualising male population density by ward would be useful to identify specific areas with high concentrations of men. These areas, identified as wards 27, 30 and 45 in CoJ Region D (Fig.…”