The City of Johannesburg can end AIDS by 2030: modelling the impact of achieving the Fast‐Track targets and what it will take to get there

Abstract

IntroductionIn 2014, city leaders from around the world endorsed the Paris Declaration on Fast‐Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The City of Johannesburg – one of South Africa's metropolitan municipalities and also a health district – has over 600,000 people living with HIV (PLHIV), more than any other city worldwide. We estimate what it would take in terms of programmatic targets and costs for the City of Johannesburg to meet the Fast‐Track targets, and demonstrate the impact that this would have.MethodsWe applied the Optima HIV epidemic and resource allocation model to demographic, epidemiological and behavioural data on 26 sub‐populations in Johannesburg. We used data on programme costs and coverage to produce baseline projections. We calculated how many people must be diagnosed, put onto treatment and maintained with viral suppression to achieve the 2020 and 2030 targets. We also estimated how treatment needs – and therefore fiscal commitments – could be reduced if the treatment targets are combined with primary HIV prevention interventions (voluntary medical male circumcision (VMMC), an expanded condom programme, and comprehensive packages for female sex workers (FSW) and young females).ResultsIf current programmatic coverage were maintained, Johannesburg could expect 303,000 new infections and 96,000 AIDS‐related deaths between 2017 and 2030 and 769,000 PLHIV by 2030. Achieving the Fast‐Track targets would require an additional 135,000 diagnoses and 232,000 people on treatment by 2020 (an increase in around 80% over 2016 treatment numbers), but would avert 176,000 infections and 56,500 deaths by 2030. Assuming stable ART unit costs, this would require ZAR 29 billion (USD 2.15 billion) in cumulative treatment investments over the 14 years to 2030. Plausible scale‐ups of other proven interventions (VMMC, condom distribution and FSW strategies) could yield additional reductions in new infections (between 4 and 15%), and in overall treatment investment needs. Scaling up VMMC in line with national targets is found to be cost‐effective in the medium term.ConclusionsThe scale‐up in testing and treatment programmes over this decade has been rapid, but these efforts must be doubled to reach 2020 targets. Strategic investments in proven interventions will help Johannesburg achieve the treatment targets and be on track to end AIDS by 2030.

HIV testing, care and viral suppression among men who have sex with men and transgender individuals in Johannesburg, South Africa

“…less likely to be virally suppressed, emphasising the need for regular and accessible testing and support to engage in HIV care for this group. We found a higher proportion of MSM/TG to be virally suppressed at 47% (32-62%) than the 34% estimated among all adult males living with HIV in Gauteng in 2017 [12], the 26% estimated in Johannesburg in 2016 [13] and similar to the 47% (95% CI 43-52%) estimated to be virally suppressed among the HIV-positive adult population in South Africa as a whole in 2017 [42]. This was the case even with our lower viral load cut-off of 50 copies/ml plasma as compared to 400/ml plasma.…”

“…Targets have not yet been reached in South Africa: among all males aged 15 years and above in Gauteng Province, 85% of those HIV-positive were estimated to be aware of their status, 43% on ART and 34% virally suppressed in 2017 [12]. A modelling study for Johannesburg estimated that among people aged 15 and older living with HIV in 2016, 73% were aware of their status, 45% on ART and 26% virally suppressed [13], indicating large gaps between diagnosis and access to treatment. It is possible, however, that the cascade for MSM and transgender populations differs substantially, but to date little empirical population-representative evidence from sub-Saharan Africa has been published to offer insight [14][15][16][17][18].…”

Optimization by Adaptive Stochastic Descent

“…An overview of this version of the model is presented in S1 Appendix , with further details provided in [ 14 ]. Subsequent modifications to the model have been described in [ 37 ], and the most recent version of the software can be accessed via hiv.optimamodel.com .…”

Modelling of HIV prevention and treatment progress in five South African metropolitan districts

“…Some components of these targets are not simple to measure using surveillance or study data, and models have been used to estimate progress toward these targets at different scales 17 . However, at the city level, few studies have used transmission models to estimate progress 18 , 19 . Stuart et al 18 applied the Optima model 20 to estimate progress towards and the impact of achieving the Fast-track targets in Johannesburg.…”