Increase in HIV viral suppression in KwaZulu-Natal, South Africa: Community-based cross sectional surveys 2018 and 2013. What remains to be done?

Introduction High coverage of antiretroviral therapy (ART) in people living with HIV (PLHIV) increases viral suppression at population level and may reduce incidence. Medecins sans Frontieres, in collaboration with the South African Department of Health, has been working in Eshowe/ Mbongolwane (KwaZulu Natal) since 2011 to increase access to quality HIV services. Five years after an initial survey, we conducted a second survey to measure progress in HIV diagnosis and viral suppression and to identify remaining gaps. Methods A cross-sectional, population-based, stratified two-stage cluster survey was implemented in 2018, using the same design as in 2013. Consenting participants aged 15-59 years were interviewed and tested for HIV at home. Those HIV-positive were tested for HIV viral load (viral suppression defined as <1000 copies/mL). Results Overall, 3,278 individuals were included. The proportion of HIV-positive participants virally suppressed was 83.8% in 2018 compared to 57.1% in 2013 (p< 0.001), with increases in all subpopulations. The largest gap remained in men aged 15-29 years, among whom viral suppression was 51.5%. Nevertheless, of the total unsuppressed participants, 60.3% were women, and 57.4% were individuals aged 30-59 years. Between 2013 and 2018, HIV-positive status awareness progressed from 75.2% to 89.9% and ART coverage among those aware from 70.4% to 93.8%, respectively. Among those on ART, 94.5% were virally suppressed in 2018. Conclusions Viral suppression improved significantly from 2013 to 2018, in all age and gender groups of PLHIV. However, almost half of HIV-positive young men remained unsuppressed, while the majority of virally unsuppressed PLHIV were women and older adults. To continue lowering HIV transmission, specific strategies are needed to increase viral suppression in those groups.