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

1. Introduction

The global HIV response has gained considerable momentum in increasing testing and treatment availability in the most heavily burdened regions. Spurred by findings that viral suppression would benefit not only people living with HIV (PLHIV) but also prevent transmission to uninfected sexual partners 1, international agencies and governments have instituted policies and targets to rapidly expand treatment access. UNAIDS first introduced testing and treatment targets in 2014 which specify that by 2020, 90% of HIV‐positive people are aware of their status, 90% of those diagnosed receive sustained antiretroviral therapy (ART) and 90% of those on ART achieve viral suppression 2. Governments adopted these targets and have more than doubled the number of people on ART in recent years. For example, the proportion of PLHIV on ART in Eastern and Southern Africa increased from 24% in 2010 to 54% in 2015 3, and reached 60% by 2017 4.

Home to the most PLHIV, with an estimated HIV prevalence of 20.6% among adults 15 to 49, 5 and the largest national treatment programme, South Africa has progressively expanded eligibility criteria for ART access 6 and ART availability in primary health settings 7. In 2012, 37.8% of HIV‐positive men and 55.0% of HIV‐positive women were aware of their HIV status 8, 63.1% of men and 68.4% of women in care were on ART, and 73.7% of those on treatment achieved viral suppression 9. ART initiation criteria were extended from CD4 <200 to CD4 <350 in 2013, then from CD4 <350 to CD4 <500 in January 2015, with universal test and treatment (ART initiation regardless of CD4 count) introduced in September 2016 10. In addition, the simplicity of the first‐line regimen improved, with South Africa rolling‐out fixed dose combination (FDC) first‐line ART (comprised of Tenofovir/Emtricitabine/Efavirenz) in April 2013 11. Finally, additional efforts to streamline treatment with strategies such as providing fast track ART pick‐up with longer medication supplies for stable patients were introduced in 2016 12. Introduction of FDC, expanded ART eligibility, and new measures to streamline treatment and improve adherence are likely to make a large impact on care engagement and adherence, moving South Africa closer to meeting the 90‐90‐90 targets following these policy changes. In fact, the summary findings of the National HIV Prevalence, Incidence, Behaviour and Communication Survey 2017 note recent improvements in 90‐90‐90 targets. Although targets vary regionally, survey findings estimated that nationally, 78.0% and 88.9% of HIV‐positive males and females respectively were aware of their status; 67.4% and 72.2% of males and females aware of their status were on ART; and 82.1% and 89.9% and of males and females on ART were virally suppressed 5.

We implemented two sequential population‐representative surveys in 2014 and 2016 in two municipalities in North West Province (NW). The surveys were conducted in conjunction with an HIV prevention programme, providing an opportunity to both evaluate the impact of an HIV prevention programme focusing on increasing HIV testing uptake through community‐based testing campaigns and home‐based testing services, and to assess trends in the HIV care continuum in an understudied but high prevalence area. While we had hypothesized that HIV testing and care engagement would increase in the municipality receiving the combination prevention programme compared to the municipality not receiving these services, we found that changes in the 90‐90‐90 indicators between the two communities were equivalent. However, changes over time in the 90‐90‐90 indicators in both communities reflect trends with important implications in evaluating the impact of national policies because the surveys were implemented at different stages of national ART access expansion. As a result, we describe changes in the 90‐90‐90 targets through comparison of population‐based data from the two municipalities before (early 2014) and after (late 2016) expanded treatment policies were introduced.

2. Methods

3. Results

In 2014, 43 of the 46 selected EAs were successfully enumerated; fieldworkers were not granted access to three farm areas. Of the 1527 enumerated DUs, 98.5% were approached; contact was made at 91.7%, yielding 1146 eligible individuals. A total of 1048 (91.0% of eligible participants) consented to participate; four were later determined ineligible (due to fieldworker error enrolling a non‐selected DU member), resulting in a total sample of 1044. Median cluster size was 25 (IQR: 22 to 28). In 2016, we approached 1925 DUs (95.7% of those targeted) in 46 selected EAs and were able to assess 1571 (81.6% of those approached) for study eligibility; 1060 (67.5%) dwellings had at least one eligible household member. A total of 980 participants (92.5%) enrolled; six were later determined ineligible (enrolment of non‐selected DU or DU member), data were lost for two surveys due to errors saving and uploading the survey files, and one survey was not matched to a household, resulting in an analytic sample of 971 participants. Median cluster size in 2016 was 21.5 (IQR: 17 to 27). Most common reasons for declining participation in both surveys were reported disinterest, lack of time and not feeling well. Across the surveys, 77.1% consented to HIV testing through rapid test or DBS (n = 1555).

Just over half of study participants were female (53.0%) and 49% were aged 18 to 29 years. (Table 1). Nearly all participants were South African citizens or permanent residents. The only characteristic that differed significantly between 2014 and 2016 samples was past year employment, at 54% and 30% in 2014 and 2016 respectively. Most participants were single or non‐cohabitating (70.3% and 72.5% in 2014 and 2016 respectively), and one quarter reported past month food insecurity (25.7% and 23.0% respectively).

4. Discussion

Using data from recent consecutive population‐representative surveys in two municipalities in North West Province, South Africa, we found strong evidence that HIV care engagement has improved in recent years. We found notable advances in both the second and third 90‐90‐90 targets. The proportion of PLHIV with known status who are on treatment reached 91% and the proportion of virally suppressed on treatment is estimated at 81%. Although our results suggest that prevention activities led to a higher proportion of individuals reporting HIV testing, these activities did not result in improvements in the first 90 target. Increased testing alone did not improve the proportion of PLHIV who knew their status, which remained similar over time at 69% in 2014 and 73% in 2016. Our findings suggest that shifts in the national programme are the drivers of change in these communities, as opposed to introduction of local activities designed to enhance testing and engagement in care. This finding is consistent with recent community trials, such as the ANRS Treatment as Prevention (TasP) trial in South Africa, which similarly found no difference in ART coverage in communities receiving a test and treat intervention as compared to a control condition, but demonstrated improvements overall between 2012 and 2016 during treatment expansion 26.

Our estimates of known status, the first 90, remained consistent at around 55% of men and 80% of women in 2014 and 2016, with only small, non‐significant increases. Our estimates are slightly higher than those from a comparable survey in KwaZulu‐Natal, where 52% of HIV‐positive men and 65% of women knew their status in 2014 to 2015 27, lower than another, similar study noting 68% of status knowledge among men, 28 and much lower than the 91.5% (overall) reported in the ANRS TasP trial 26. Our estimates are slightly lower than 2015 to 2016 national estimates of 74% with known status 29, and much lower than modelled estimates from mid‐2016 of 84% to 89% across provinces 30. They also diverge considerably from the 2017 National HIV Survey Summary, which estimated that 78.0% and 88.9% of HIV‐positive males and females respectively are aware of their status 5. The first “90” is the most difficult proportion to estimate as high quality data on the number of people who are living with HIV (the total population who should be included in the denominator), are not available 31. Also difficult to come by are precise estimates of how many diagnoses have been made (those who should also be in the numerator). Other discrepancies and the wide range of estimates of the first 90 might be due to large regional differences in testing uptake; although national and regional data in this case are similar. Nonetheless, our findings contribute to growing evidence that diagnosis remains a major barrier to achieving 90‐90‐90 32 and to the increasing consensus that given the large disparity in knowledge of status among men, who test less frequently and who have poorer HIV outcomes over the lifecourse as compared to women 33; new programming must creatively target men 9, 34, 35.

Our findings regarding the second 90 target, “on ART,” that 88.6% of men and 92.4% of women with known status are on treatment, are higher than similar surveys 27, 28 and national estimates 5. National HIV Survey Summary data estimate only 67.4% and 72.2% of males and females, respectively are on ART. However, this discrepancy is likely due to differences in calculating the denominator; if more people are believed to know their status, then the number on treatment will reflect a smaller proportion. Conversely, if fewer people are believed to know their status, the estimate of the proportion on treatment will be higher. Estimates of the third 90 in South Africa are reliably over 80% 5, 26, 27, which is consistent with our data. Our findings on the overall proportion of PLHIV who are virally suppressed, with 46% of men and 72% of woman living with HIV reaching viral suppression, are higher than the national survey findings of 43% and 58% of male and female PLHIV achieving suppression 5, and higher than the modelled provincial data for North West Province 36. These differences may be due to our use of an unconditional imputation model, as opposed to simple multiplication of the 90‐90‐90 estimates. Our model allows for HIV‐positive participants who may not know their status or be on treatment to have low viral loads suggestive of suppression, as this was observed in our data and has been found elsewhere 37. Additionally, our higher estimate of total viral suppression could be due to utilizing the higher viral suppression threshold of < 5000, based on the sample medium.

These data were collected during rapid treatment scale up and multiple treatment guideline revisions. The South African National Department of Health (NDoH) introduced the first line FDC, single pill (TDF/FTC/EFV), in 2013. As the new FDC was implemented in stages, it is likely that some patients in rural areas were still being transitioned to FDC in early 2014, at the time of the first survey, whereas by 2016 all clients would have been on a FDC regimen. Single‐pill regimens have been found to improve medication adherence 38, increase patient satisfaction 39, and can improve clinic attendance 40. Medication monitoring and storage is easier when patients and providers need to keep track of only one pill. Furthermore, the NDoH extended ART qualifying criteria twice in the interim of the two surveys, with implementation of treatment access for those with CD4 <500 in 2015, after the first survey, and universal access to care implemented approximately as the second survey began. While it is unlikely that universal access was implemented uniformly and immediately with the announcement, the ART expansion in 2015 likely had a large impact on increased the number of people on treatment and suppressed between the surveys. During this time, the government also introduced new adherence guidelines with efforts to streamline treatment, providing means to more rapid and longer ART prescribing for stable patients, along with introduction of strategies such as community adherence clubs in 2016. Finally, the health department also published more extensive guidance around tracing patients defaulting from care, including a push for PEPFAR partners to oversee implementation of partner tracing, which might have contributed to re‐engagement of patients.

In the full HIV‐positive population, we noted an approximately 9% point increase in reported retention in care (p = 0.139), a 12% point increase in the presence of ART analytes (p = 0.058), and 26% point increase in viral suppression (p < 0.001). We believe that the structural, policy‐level changes are largely responsible for the improvement in ART adherence and viral suppression. Others have attributed similar findings on improvements in initiation rates and therapeutic response to changes in guidelines 32. It is also possible that improvements in the later “90”s may be due to changes in social context of HIV treatment, including reduced stigma or increased comfort with disclosure and support seeking.

This study compared two sequential, population‐representative samples of the general population aged 18 to 49 years in North West Province, South Africa during a period of rapid policy transition. Our findings are representative of an area of comprising 230,000 people and provide insight into the impacts of policy changes in South Africa's HIV response in a district far from the major metropolitan areas. Our findings are subject to some biases. While fewer than 10% of eligible participants declined survey participation, 23% declined HIV testing in our survey. Our participation rates are still higher than the national survey, in which only 67.7% and 58.4% of men and women respectively agreed to HIV testing 5. We accounted for non‐response and multiply imputed missing data; however, these estimates are subject to bias if refusals were differential by HIV‐status 41. Self‐reported knowledge of status, linkage to care and retention in care is subject to misreporting. Guidance around the frequency of visits changed for stable patients between the surveys, which likely explains why our estimate of retention is lower than our estimate of those positive for ART analytes in 2016. Viral suppression is estimated from DBS; we used a high (>5000 copies/mL) threshold for defining viral suppression, as cellular proviral HIV DNA and virion RNA both contribute to copy number when using DBS instead of plasma from whole blood 17. As a result, viral suppression estimates might be inflated. However, we see similar improvements in viral suppression using all thresholds. Furthermore, while there were some differences between 2014 and 2016 samples, sensitivity analysis aimed at improving sample comparability yielded similar results.

5. Conclusions

Over the span of two and a half years during which the first line FDC was introduced, CD4 thresholds were steadily removed for ART eligibility, and guidance was published on facilitating treatment and tracking defaulting patients, we found that the second 90‐90‐90 target was reached and the third is within reach in a rural area of North West Province, South Africa. We conclude that South Africa's policies have improved and facilitated access to treatment. No significant improvements were evident in the first 90 target, despite testing campaigns in the area and increases in reported HIV testing. Our findings indicate that by late 2016, women in the research area had almost achieved the 73% suppression target. Our data also indicate that woman far outperform men in meeting this target, a finding common to recent large‐scale trials 42. It is possible that South Africa can meet the ambitious targets, but only if detection of infection among men is improved. This will require targeted and differentiated testing models to encourage uptake of HIV testing by men and others less inclined to attend a clinic. Accordingly, South Africa's new National Strategic Plan 43 calls for expanded testing services delivered outside health facilities, including self‐screening 44, with efforts to target men, adolescents and other populations not accessing testing services to close testing gaps. By expanding testing models beyond current clinic‐based approaches and pairing testing with facilitated linkage strategies, South Africa may be able in a position to meet its targets and grow closer to ending the threat of the HIV epidemic.

Competing interests

The authors declare no conflicts of interest.

Authors’ contributions

SAL, SBS, JSG, AP, TL, EV and SB conceived of this study. SAL, JSG, MJR, JLM and EN were responsible for study implementation and supervision. AP and TL were responsible for laboratory protocols and quality control. AME and EA were responsible for data merging and management. AME led the analysis with assistance from EA, SAL and SS. Data were interpreted by SAL, AME, JSG, AP, TL, WDFV, EN, SB and SS. SAL and AME wrote the paper. All authors reviewed, edited and approved the final manuscript.

Supporting information

Lippman, S. A. , El Ayadi, A. M , Grignon, J. S. , Puren, A. , Liegler, T. , Venter, W. D. F. , Ratlhagana, M. J. , Morris, J. L. , Naidoo, E. , Agnew, E. , Barnhart, S. , Shade, S. B. Improvements in the South African HIV care cascade: findings on 90‐90‐90 targets from successive population‐representative surveys in North West Province. J Int AIDS Soc. 2019; 22(6):e25295