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Disparities in Engagement Within HIV Care in South Africa
Simbarashe Takuva1, Alison Brown2, William Macleod3, Yogan Pillay4, Valerie Delpech2, Adrian J. Puren1
1 National Institute for Communicable Diseases, NHLS, Johannesburg, South Africa. 2 HIV and STI Department, Centre for Infectious Diseases Surveillance, Public Health England, London, United Kingdom. 3 Center for Global Health and Development , Boston University, Boston, MA, United States. 4 National Department of Health, Pretoria, South Africa.
Background: South Africa (SA) has the largest population of persons living with HIV/AIDS (PLHIVA) in the world. While antiretroviral therapy (ART) provision has rapidly expanded with >2,000,000 people on ART by end of 2012, there were an estimated 400,000 number of new HIV infections in 2012. We characterise engagement within HIV care in 2012 to monitor the effectiveness of the HIV programme and identify areas for improvement.
Methods: National Health Laboratory Service electronic data, a repository for all public sector laboratory measurements in SA were used. Over 3,900,000 CD4 count and viral load measurements conducted in 2012 were extracted, matched then de-duplicated using probabilistic record linkage. The number of PLHIVA was estimated using HIV prevalence estimates from the national household survey. We calculated number and proportion of persons in HIV care, on ART and with viral suppression (viral load<400 copies/ml). We further stratified analysis by gender and age-group. Multivariate regression models were to examine viral suppression rates among those on ART.
Results: Among 6,422,000 PLHIVA in SA in 2012, an estimated 3,300,000 persons (51.4%) accessed care and 34% were on ART. While viral suppression rate was 73.5% among the treated population, the overall percentage of persons with viral suppression among the HIV-infected population was 25.0%, corresponding to potentially 4,500,000 infectious persons. Engagement in care among males was poorer across all stages with only 18.8% with viral suppression (see figure). In the 0-14 age-group, majority in care were on ART (167,000/171,000). Notably, among the sexually active 15-49 year age-group, 47.8% were linked to care, 31.7% were on ART and only 21.5% had viral suppression. Among individuals on ART, males (aPR=0.93, 95%CI 0.93-0.93) and younger persons (aPR=0.94, 95%CI 0.94-0.94; aPR=0.76, 95%CI 0.76-0.76 and aPR=0.77, 95%CI 0.76-0.77 for age-groups 25-49, 15-24 and 0-14 years vs. age 50+ years respectively) were less likely to achieve viral suppression.
Conclusions: Although the number receiving ART has massively increased in SA, an estimated three-quarters of PLWHA have not achieved viral suppression. Expanding HIV testing, strengthening and maintaining prompt linkage to care is crucial. Males and the sexually active 15-49 year age-group have poorer engagement in all stages of care. These groups should be the main focus of prevention efforts as they are potentially driving transmission of new HIV infections in the general population.