Southern African countries nearing 90% viral suppression targets

Southern African countries are approaching UNAIDS’ crucial target of ensuring 90% of people living with HIV on treatment are virally suppressed, an analysis of population‐based HIV surveys from Eswatini, Lesotho, Malawi, Zambia and Zimbabwe suggests.

But young people (ages 15 to 24) were found to be two to three times less likely to be virally suppressed than middle-aged people (ages 45 to 59), and men are still faring worse than women.

Many people experiencing viral failure are not being swapped to alternative ‘second-line’ antiretroviral treatment (ART), probably because of limited access to viral monitoring. Despite 3% of people on treatment experiencing viral failure each year only between 0.06% and 0.73% are switching regimens.

Data was analysed from nationally representative, cross‐sectional household surveys conducted between 2015 and 2017.

Out of the 13,850 adults (ages 15 to 59) living with HIV, around 10,000 (68%) were on treatment, well below the first UNAIDS’ target of 90% treatment coverage. Of those on treatment, 88.8% were virally suppressed.

One‐quarter of people who were virally unsuppressed had stopped taking ART. The remaining three‐quarters were experiencing viral failure, which is when people are taking treatment but it is not working.

Almost half (44.8%) of those experiencing viral failure had CD4 counts less than 200 cells/µL, which is one of the indicators for an AIDS diagnosis, but few had switched to second‐line ART. This suggests access to viral load monitoring remains poor in Southern Africa. Without this, treatment failure often remains undetected and people are either not switched to alternative treatment or are switched once HIV has progressed to a more severe level.

Young people, men, those on efavirenz-based treatment, people with low educational levels, people who had never married and those who had not told a family member they were HIV-positive were more likely to be virally unsuppressed than others.

People in Zimbabwe, Lesotho or Zambia were also more likely to be virally unsuppressed compared to the other countries.

Women had almost half the odds of viral failure than men, but were more likely to interrupt ART. Poor retention in care and treatment adherence among women who started ART during pregnancy under Option B+, which recommends rapid ART initiation for pregnant and breastfeeding women, may explain this finding.

Being married, having a high CD4 count, being on ART for less than two years and alcohol use were also associated with lower odds for viral failure but higher odds for interrupted ART.

These findings suggest that men, people who never married, and those with a poor response to long‐term ART are at increased risk of viral failure and would particularly benefit from viral load monitoring.

It also suggests that treatment support, particularly for young people, and switching more people who are experiencing treatment failure to second-line regimens will further improve viral suppression rates.