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Moderate HIV Incidence and High ART Coverage in Rural Kwazulu-Natal: First Population Based Survey
Helena Huerga, Médecins sans Frontières, Adrian Puren, Malika Bouhenia, Jihane Ben Farhat, Alex Welte, Lubbe Wiesner, David Maman, Jean-François Etard *Epicentre Paris France, National Institute for Communicable Diseases of the NHLS Johannesburg South Africa, South African DST/NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA) Stellenbosch South Africa, Division of Clinical Pharmacology Cape Town South Africa *Institut de Recherche pour le Développement Montpellier France
Background: Kwazulu-Natal has one of the highest HIV prevalence in the world. Accurate data on HIV prevalence, HIV incidence and antiretroviral therapy (ART) services coverage are essential to define appropriate strategies of intervention in population. We assessed HIV prevalence, HIV incidence and ART coverage in Mbongolwane and Eshowe in Kwazulu-Natal, South Africa. Other HIV care services indicators were also evaluated. Methodology: Cross-sectional population-based survey. A cluster sampling and geospatial random selection was used to identify the households visited. Persons aged 15-59 years living in the area were eligible. Face-to-face interviews were carried out followed by rapid HIV testing on site and blood collection for CD4 count, ART levels and viral load in HIV positive cases. ART coverage was defined as the proportion of HIV positive on ART (detectable blood levels) among those eligible according to current National Guidelines. Incidence was estimated using HIV LAg-Avidity assay corrected by viral load and ART status. Results: In total 2377 houses were visited, 6688 individuals were eligible and 5649 (84.5%) were included: 62.3% women and 37.7% men. Overall HIV prevalence was 25.2% (95%CI: 23.6-26.9). Prevalence in women was twice that of men: 30.9% (95%CI: 29.0-32.9) vs 15.9% (95%CI: 14.0-18.0). Prevalence reached 56.0% (95%CI: 51.7-60.3) in women aged 30-39 years. Overall HIV incidence was 1.2/100 person-years (PY) (95%CI: 0.2-2.1), 2.5 times higher in women than in men: 1.6/100 PY (95%CI: 0.2-0.9) vs 0.6/100 PY (95%CI: 0.0-1.5). Women aged 20-29 years had the highest incidence: 4.0/100 PY (95%CI: 1.1-6.9) vs 1.0/100 PY (95%CI: 0.0-2.5) in men. ART coverage was 75.0% (741 on ART/988 eligible) and was better for women than men: 78.5% vs 63.9% (p<0.001). Coverage increased with age: 60.5% in younger than 30 years vs 81.3% in older (p<0.001). Among all individuals, 81.4% declared to have had an HIV test previously (88.4% of women vs 69.8% of men, p<0.001). Of the HIV positive, 75.8% were aware of their status prior to the survey. Viral load suppression (<1000 copies/ml) was achieved in 89.6% of individuals on ART for more than 6 months. Among the others, resistance to ART was found in 58.1% (95%CI: 44.7-70.3). Conclusions: Overall HIV incidence was moderate in this high prevalence area. However, incidence was very high in young women, four times higher than in men. ART coverage and viral load suppression were relatively good and may be linked to incidence rates. HIV programs should maintain quality of care while carefully identifying HIV prevention and treatment strategies addressed to specific groups such young women for prevention and men for HIV testing and ART initiation. Surveys such as this are critical to evaluate ART programs and identify which groups to target.