HIV incidence, viremia, and the national response in Eswatini: Two sequential population-based surveys

Abstract

With the highest HIV incidence and prevalence globally, the government of Eswatini started a substantial scale-up of HIV treatment and prevention services in 2011. Two sequential large population-based surveys were conducted before and after service expansion to assess the impact of the national response. Cross-sectional, household-based, nationally representative samples of adults, ages 18 to 49 years, were sampled in 2011 and 2016. We measured HIV prevalence, incidence (recent infection based on limiting antigen ≤1.5 optical density units and HIV RNA ≥1000 copies/mL), viral load suppression (HIV RNA <1000 copies/mL among all seropositive adults) and unsuppressed viremia (HIV RNA ≥1000 copies/mL among all, regardless of HIV status) and assessed for temporal changes by conducting a trend analysis of the log ratio of proportions, using a Z statistic distribution. HIV prevalence remained stable from 2011 to 2016 [32% versus 30%, p = 0.10]. HIV incidence significantly declined 48% [2.48% versus 1.30%, p = 0.01]. Incidence remained higher among women than men [2011: 3.16% versus 1.83%; 2016: 1.76% versus 0.86%], with a smaller but significant relative reduction among women [44%; p = 0.04] than men [53%; p = 0.09]. The proportion of seropositive adults with viral load suppression significantly increased from 35% to 71% [p < .001]. The proportion of the total adult population with unsuppressed viremia decreased from 21% to 9% [p < .001]. National HIV incidence in Eswatini decreased by nearly half and viral load suppression doubled over a five-year period. Unsuppressed viremia in the total population decreased 58%. These population-based findings demonstrate the national impact of expanded HIV services in a hyperendemic country.

Fig 1. HIV care continuum (conditional proportions)* by age and by sex in 2011 and 2016.

* Diagnosed was defined as self-reporting HIV-positive. Among those diagnosed, on treatment was defined as self-reporting current use of ART. Among those on treatment, virally suppressed was defined as viral load <1000 copies/mL.

Fig 2. Key national HIV policy and program achievements, Eswatini, 2003–2016 [13].

Black solid line: HIV tests; blue solid line: HIV tests (Male); light blue solid line: HIV tests (Female); red solid line: currently on treatment; orange dotted line: new on treatment; green dotted line: viral load tests; purple dotted line: VMMC; text boxes: key national HIV policy adoption.