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Invited Commentary
Infectious Diseases
November 1, 2019

HIV Prevention and Treatment Scale-up and Community HIV Incidence in KwaZulu-Natal, South Africa

Author Affiliations
  • 1Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Department of Biostatistics, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland
  • 3Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland
  • 4Department of Health, Behavior and Society, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland
JAMA Netw Open. 2019;2(11):e1914408. doi:10.1001/jamanetworkopen.2019.14408

Nearly 4 decades into the HIV epidemic, we now have multiple proven efficacious biomedical tools for HIV prevention, including antiretroviral therapy (ART) treatment as prevention, medical male circumcision (MMC), and preexposure prophylaxis. A plan has been set for reaching the goal of ending the HIV epidemic for countries like the United States.1 However, in hyperendemic settings such as rural South Africa, despite the enriched toolbox for HIV prevention and the significant efforts and resources invested in the scale-up of these HIV prevention interventions, major challenges remain for the interventions to reach and be adopted by high-risk groups that sustain HIV transmissions in the communities.

Using data from 2 cross-sectional population-based surveys conducted in 2014 to 2015 and 2015 to 2016, Kharsany et al2 report prevalence of HIV and risk behaviors and coverage of treatment and prevention service in men and women aged 15 to 49 years in rural and periurban communities in KwaZulu-Natal, South Africa. Increases in MMC coverage, ART uptake, and viral suppression were attributable to the continued scale-up of HIV prevention and treatment services as well as local outreach campaigns, such as the Isibaya samaDoda (Zulu expression meaning including/bringing in the men) campaign launched in 2015 that focuses on reaching and enhancing HIV care in men. Embedded in each cross-sectional survey was a prospective follow-up survey of initially HIV-negative individuals aged 15 to 35 years, allowing estimations of HIV incidence during approximately 18 months of follow-up. Comparison of HIV incidence rates between the 2 prospective cohorts (2016 cohort and 2017 cohort) offered insights on the community-level outcomes associated with the scale-up of HIV treatment and prevention programs and the targeted outreach campaigns.

The prevalence of HIV remained at approximately 35% to 36% from both surveys, which was expected considering the relatively short duration between the 2 cross-sectional surveys (approximately 1-2 years). It was reassuring to see that coverage of all HIV preventive services was moving in the right direction during this time: knowledge of HIV status increased from 52% to 63% in men and 65% to 73% in women; self-reported MMC increased from 32% to 36%, and women-reported MMC of their male partners increased from 36% to 48%; ART coverage of HIV-positive individuals increased from 37% to 49% in men and 46% to 59% in women. Increasing coverage of these key indicators of HIV services was observed in all age-stratified subgroups, suggesting a community-level penetration of the HIV service programs. Corresponding to the increase in ART coverage, viral suppression increased from 42% to 50% in HIV-positive men and from 55% to 62% in HIV-positive women.

For the primary outcome of HIV incidence, the overall incidence rate decreased from 2.31 to 1.96 per 100 person-years (PYs) between the 2016 cohort (incidence during 2014 or 2015 to 2016) and the 2017 cohort (incidence during 2015 or 2016 to 2017). Incidence decreases were observed in both men (1.44 to 1.32 per 100 PYs) and in women (3.44 to 2.80 per 100 PYs). Except in men aged 25 to 29 years and women aged 20 to 24 years, decreasing incidences were observed in all age categories. Although the decreases were most often not statistically significant (P > .05), the consistent decreasing trend observed by sex and in most age categories was informative and reassuring. Similarly, the P value of .04 for the significant decrease in incidence in women aged 15 to 19 years should not be overinterpreted. Given the multiplicity inherent in tests for the many subgroups,3 such unadjusted (for multiplicity) statistical significance may not hold after considering the multiple tests. Nonetheless, HIV incidence decreased from 4.63 to 2.74 per 100 PYs in this age group of young women (an estimated 43% reduction), recapitulating the general decreasing trend between the 2016 and 2017 cohorts.

The 43% decrease in HIV incidence in women aged 15 to 19 years was thought to be most likely linked to the increased ART uptake and better viral suppression observed in older HIV-positive men (ie, age groups older than 25 years). This was plausible given that preexposure prophylaxis was not available during the study period and that self-reported sexual behaviors in women aged 15 to 19 years did not show a major change. The phylogenetic analysis also demonstrated age-disparate sexual partnerships where HIV-positive women in this age group were often linked to HIV-positive men who were approximately 10 years older.2,4 From these phylogenetic results, however, the direction of HIV transmission within these partnerships (women to men or vice versa) cannot be determined. It is also unknown how often sexual relationships in the study communities involved partners from outside communities and whether there was a major change in mobility patterns in the study area during the study period. Analysis directly linking increased ART uptake and viral suppression in older HIV-positive men to the decline in HIV incidence in women aged 15 to 19 years would be difficult. Therefore, a causal relationship between the 2 observations cannot be determined. Nevertheless, the high HIV incidence in women younger than 25 years and the higher incidence in men aged 25 years and older (compared with younger men), which were consistently found in the surveys, highlight the need to prioritize HIV prevention efforts to these subgroups.

It is notable that although MMC coverage was increasing, it only reached 36% in the latter survey, and in both surveys, MMC coverage was lower in men aged 25 years and older despite higher HIV incidence in these age groups compared with younger men. Rollout of MMC in KwaZulu-Natal started in 2010.5 The current data suggest a slow increase in uptake (approximately 4% increase in coverage between the cross-sectional surveys). Medical male circumcision provides direct protection for men against infection with HIV and other sexually transmitted diseases such as herpes simplex virus type 2 and human papillomavirus,6 and scale-up of MMC programs has been shown to be associated with lower community-level HIV incidence in men.7 Further behavioral and structural interventions that can help normalize and increase MMC in the local communities will be necessary. Adoption of MMC, particularly by men aged 25 years and older, could greatly facilitate a more immediate impact on community-level HIV incidence.

As the authors indicated, it was not feasible to estimate the causal effects of programs of HIV prevention and treatment services on community-level HIV incidence. However, the observational data that the authors presented provided valuable real-world information. These observational data were based on well-planned HIV surveillance and program evaluation. The survey participation and follow-up rates were high, especially considering the resource-limited setting. It was very encouraging to see that all HIV preventive outcomes were moving in a positive direction within a few years. The impact of HIV prevention and treatment programs on population-level HIV incidence is expected to take longer to be observed.

Learning from this study, a plan of data collection for the purpose of program monitoring and evaluation should be built into the programmatic implementation of HIV prevention and treatment services. Data should also be analyzed in a timely manner to identify barriers and facilitators of program implementation and to direct subsequent resource allocation, so as to ensure HIV treatment and preventive services reach high-risk communities and individuals, thus optimizing program impact.

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Article Information

Published: November 1, 2019. doi:10.1001/jamanetworkopen.2019.14408

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Kong X. JAMA Network Open.

Corresponding Author: Xiangrong Kong, PhD, Johns Hopkins School of Medicine, Wilmer Eye Institute, 600 N Wolfe St, Woods 155B, Baltimore, MD 21287 (xkong4@jhu.edu).

Conflict of Interest Disclosures: None reported.

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