Background
As ART coverage expands in Africa, a greater proportion of persons remaining with viremia are predicted to be HIV serostatus aware and treatment-experienced, potentially reducing the need for population surveillance and community outreach. However, population-level data on the care status of persons with viremia remains limited in African settings achieving “95-95-95” treatment targets.
Methods
The Rakai Community Cohort Study (2021–23), a population-based study in Uganda, was leveraged to assess the care status of persons with viremia (>1000 copies/ml) in an African epidemic achieving “95-95-95”. Residents aged 15-49 self-reported HIV testing, diagnosis, and ART use history. Among those HIV seropositive, viral load testing was conducted. Participants with viremia were initially classified as: 1) newly diagnosed; 2) previously diagnosed but never treated; 3) treatment-experienced but not in care; or 4) treatment experienced and in care. Those with viremia received their viral load results, underwent counselling and were asked to reconfirm their HIV testing history, ART use, and care location. Clinical records were also abstracted. Based on updated self-reports, clinical records, and plasma ARV drug screening, participants were reclassified. ART initiation for newly diagnosed and untreated individuals was tracked ~3 months post-survey.
Results
Of 17,841 participants, 3,170 (17.8%) were HIV seropositive. Among 3,134 persons with viral load results, 316 (10.1%; 95%CI: 9.1-10.1) exhibited viremia. As shown in the Figure, the care status of 102 (32.3%) persons was eventually reclassified, including 55% of those who self-reported being in care. Men were 1.67 times (95%CI: 1.18-2.55) more likely to misreport their care status than women. Among those previously in care, the median time from last clinic visit was 2.79 years [IQR: 1.80-4.61]. Overall, 82.9% (n=262; 95%CI: 78.2-86.8%) of persons with viremia were not actively in care at time of survey, and 64.6% (n=204; 95%CI:59.0-69.8%) were ART naïve. Only 55% (n=75/135) of newly diagnosed individuals and 39.1% (n=27/69) of naïve persons initiated ART by follow-up.
Conclusions
In this setting with high population HIV suppression, >80% of individuals with viremia were not in care, with frequent misreporting of care status. Ongoing population surveillance and novel outreach strategies are essential to understand and engage underserved populations with viremia and achieve epidemic control in evolving African epidemics.
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