Can the Heterosexual HIV Epidemic be Eliminated in South Africa Using Combination Prevention? A Modeling Analysis

Abstract

Little is known about how combining efficacious interventions for human immunodeficiency virus (HIV) prevention could lead to HIV elimination. We used an agent-based simulation model, the HIV calibrated dynamic model, to assess the potential for HIV elimination in South Africa. We examined several scenarios (from continuation of the current status quo to perfect achievement of targets) with differing combinations of male condom use, adult male circumcision, HIV testing, and early antiretroviral therapy (ART). We varied numerous parameters, including the proportion of adult males circumcised, the frequency of condom use during sex acts, acceptance of HIV testing, linkage to health care, criteria for ART initiation, ART viral suppression rates, and loss to follow-up. Maintaining current levels of combination prevention would lead to increasing HIV incidence and prevalence in South Africa, while the perfect combination scenario was projected to eliminate HIV on a 50-year time scale from 2013 to 2063. Perfecting testing and treatment, without changing condom use or circumcision rates, resulted in an 89% reduction in HIV incidence but not elimination. Universal adult male circumcision alone resulted in a 21% incidence reduction within 20 years. Substantial decreases in HIV incidence are possible from sufficient uptake of both primary prevention and ART, but with continuation of the status quo, HIV elimination in South Africa is unlikely within a 50-year time scale.

Sexually transmitted infections and HIV in the era of antiretroviral treatment and prevention: the biologic basis for epidemiologic synergy

“…Mathematical modelling has been used to understand the spread of HIV and compare prevention strategies . Such combination interventions generally include voluntary male circumcision, behaviour change (which generally includes emphasis on detection and treatment of STIs), and ART used as “treatment as prevention” (TaSP) or PrEP.…”

Low HIV incidence in pregnant and postpartum women receiving a community-based combination HIV prevention intervention in a high HIV incidence setting in South Africa

“…One of South Africa’s strategic health objectives is to reduce HIV incidence by 50% by the end of 2016 [ 36 ]. However, to decrease HIV incidence and prevalence over a 50-year time-scale, it has recently been shown that substantial scale-up of combination HIV prevention programs will be required [ 37 ]. Community health workers have been drafted as a priority workforce in South Africa’s approach to re-engineering primary healthcare [ 25 ].…”

Impact of the test and treat policy on delays in antiretroviral therapy initiation among adult HIV positive patients from six clinics in Johannesburg, South Africa: results from a prospective cohort study

“…[7][8][9][10][11][12][13][14] In September 2016, South Africa removed the CD4 cell count threshold for ART eligibility and adopted the WHO 2015 Universal Test and Treat (UTT) policy, making all HIV positive patients eligible for ART at diagnosis. [15][16][17] Clinical trials showed that, compared with patients who deferred ART, patients who started treatment immediately after HIV diagnosis had lower rates of AIDS-related adverse events and improved viral suppression rates with no difference in post-initiation attrition rates. [18][19][20][21] Moreover, patients who started ART immediately after diagnosis were less likely to transmit HIV than patients who deferred ART.…”