Along with similar findings from several other HIV population surveys, including two surveys released at SAAIDS this week, the MSF results provide strong evidence that achieving the 90-90-90 targets is possible in South Africa, along with hopeful data suggesting that the number of new infections is decreasing in certain areas. The 90-90-90 target is an important indicator of the success of a country’s HIV response, with South Africa’s national results estimated at 85-71-86 (HSRC, 2018). “We’ve shown that it’s possible to reach 90-90-90 in an area with one of the highest HIV infection rates in the country, where one in four people is living with HIV. These results are testament to the full engagement of the entire community. Everyone - from local civil society and patient groups, health staff and traditional health practitioners, traditional leaders and their members – was deeply involved in designing and helping this project to deliver from the beginning, said Dr Liesbet Ohler, Project Medical Referent, Eshowe. “Importantly, we have ensured 94% of people who tested HIV positive started treatment, including people who are much less likely to test for HIV and link to care, such as men.”
The MSF Epicentre population-based survey, which included 3,286 people aged 15 to 59 years, is a follow up to a 2013 survey done by MSF and Epicentre in the same area which was performed to inform priority activities. The 2018 survey found a significant increase in overall HIV status awareness (increased by 14%) and in starting people on treatment (increased by 24%) between 2013 and 2018. Among men, there were striking increases in knowledge of HIV status (first 90), from 68% to 83% and on treatment (second 90), from 68% to 87%.
Preliminary HIV incidence results (which means the number of new HIV infections) show a trend to decrease, from 1.2% in 2013 to 0.2% in 2018. This is supported by survey findings which show that among the people surveyed, the proportion of those living with HIV who were virally suppressed increased from 56% (2013) to 84% (2018), signifying a dramatic reduction in the number of people with the potential to transmit HIV.
However, MSF cautions against interpreting the survey results as an outright declaration of victory, with significant challenges remaining among specific age groups. “While incidence decreased among women aged 15-29 years from 2.9% to 1.2%, this figure remains high and points to the continued risk faced by adolescent girls and young women, said Dr Laura Trivino, MSF’s Medical Coordinator for South Africa. “Difficulties remain in reaching men, who overall achieve poorer treatment outcomes across the cascade. More than half of young men aged 15 to 29 years diagnosed with HIV are still not on treatment. We hope these findings will help focus our collective energies on reaching these groups who remain the most vulnerable to HIV.”
The ‘Bending the Curves’ project, which started in 2011 before the 90-90-90 targets were set by UNAIDS in 2013, aimed to bend the curves of new HIV infections, and HIV-related illness and death. Numerous activities were launched in partnership with communities and the KwaZulu Natal Department of Health to prevent HIV infection, increase HIV testing, link people quickly to care, and support their adherence, retention and suppression on treatment. Today the project covers ten clinics and two hospitals. Early on, the project invested in community-based prevention and HIV testing strategies, including extensive door-to-door testing by lay workers, with over 120,000 door-to-door tests conducted between 2012 and 2018. Between 2015 and 2018, 1,35 million condoms were distributed annually.
“How did Eshowe get to 90-94-95? I would say it’s the power of partnership. We had the total commitment of the traditional leadership, and close collaboration with the departments of Health and Education at each stage, says Musa Ndlovu, MSF’s Deputy Field Coordinator in Eshowe. “In the early days of this project, it was almost impossible for people to even imagine talking about HIV. Today people even stop our MSF vehicles and ask for an HIV test. We didn’t do it for the community, we did it with them.”
Note to Editors:
MSF will present the main findings of the 2018 MSF Epicentre survey for the first time at SAAIDS, Durban during an oral presentation Wednesday 12 June at 11:30am. The related abstract is available here.
About the 2018 MSF Epicentre survey:
The MSF Epicentre population-based door-to-door survey included 3,286 people aged 15 to 59 years living in Wards 1-14 of the uMlalazi Municipality in King Cetshwayo district (population 114,480). The results were compared to the findings of a 2013 MSF Epicentre survey of 5,649 people aged 15-59 years in the same area. Participants completed detailed questionnaires and had an HIV test done; if confirmed HIV positive, further blood tests were taken to measure viral load and CD4 counts.
The main objective of the 2018 MSF survey was to estimate viral load suppression among HIV positive people aged 15-59, as well as quantify the cascade of care for HIV positive people and compare the results with the 2013 MSF survey.
Main findings of the 2018 MSF Epicentre survey
- HIV Cascade (90-90-90): from 76-70-93 (2013) to 90-94-95 (2018)
- First 90: Overall increase in HIV positive status awareness from 76.4% to 89.7% of the general population
- Second 90: Number of HIV positive people taking antiretrovirals increased from 69.9% to 93.8% of those who tested positive for HIV.
- Third 90: Overall viral suppression among those taking antiretrovirals was 94.5%. The proportion of HIV positive on treatment or not with viral load levels > 1,000 copies/ml decreased from 43% to 16%.
- HIV Incidence: Preliminary results suggest that overall annual incidence has decreased from 1.2% to 0.2%
- Advanced HIV Disease: The proportion of people living with CD4 <200 cells/µl decreased from 9.8% to 4.6%.
What’s behind the survey results and how replicable are they?
The 2013 and 2018 MSF Epicentre surveys were both cross-sectional surveys that allow broad snapshots in time which, when compared, reveal trends in HIV incidence and prevalence over time among the general population. However, one limitation of cross-sectional surveys is that they don’t provide evidence of causation, and we can’t infer precisely which activities may have had the greatest bearing on results.
However, from operational documentation and experience, MSF believes the following activities have had the greatest impact:
- Community ownership & engagement: Community leaders, local CSOs, traditional health practitioners, community members were directly engaged from the start of the project. MSF staff report that this has driven demand for services and appears to have shifted the community’s overall perceptions of HIV.
- Linking communities with HIV testing and basic health services: Multiple methods of HIV testing and counselling reached deep into communities to find those who simply don’t visit health centres and referring those in need to facilities. People were provided with vital information and guided towards treatment. As trust in HIV services has grown, fixed HIV testing sites which also offer basic health services and referral capacity have been placed within communities themselves.
- Reaching men: Men remain a difficult to reach population in the HIV response. Male-focused services were designed to reach men through community outreach and taxi ranks, yet their success remains unclear. MSF also collaborated with a local union and the health department on huge efforts to circumcise young men aged 15-34 in the sub-districts. Around 72% of males aged 15-19 years and 67% aged 20-24 years were circumcised, above the 60% target that the WHO recommends to have an impact on HIV incidence reduction.
- Door-to-door testing: Through its Community Health Agents Programme (CHAPs), huge distances were covered to bring HIV testing services closer to the community. The work of the community health workers in building relationships between the community and facilities, linking people to care and supporting counselling efforts has been significant. The Community Health Agents did far more than just test; they raised awareness of HIV, shared information, built trust and encouraged people visit health centres. MSF has costing data that show the door-to-door testing costs less than other ways of testing (fixed-site or facility-based testing)
- Adherence support: Helping HIV positive people start antiretrovirals and supporting their lifelong treatment journey is essential. Lay counsellors play a vital role in providing testing and counselling services in facilities and keeping people on treatment. At the same time, different ways of delivering treatment and support are very popular with patients, including adherence clubs, fast lane and community pick-ups. Today, 56% of eligible patients are in one of these models.
 1. The South African National HIV Prevalence, Incidence, Behavior and Communication Survey (HSRC, 2017); 2. The HIV Incidence Provincial Surveillance System (HIPSS) in Vulindlela and Greater Edendale subdistricts KwaZulu Natal; 3. DREAMS Evaluation Study HIV Incidence in eThekwini and uMgungundlovu in KwaZulu-Natal and City of Johannesburg and Ekurhuleni in Gauteng
 Viral suppression means that the antiretroviral treatment is successfully suppressing the amount of HIV virus in a person’s blood, ensuring overall health and greatly reducing the chances of HIV transmission. It was defined as viral load <1,000 copies/ml
 The landmark HPTN 052 (2011) study confirmed that people living with HIV who were taking treatment successfully and had viral suppression have a 96% reduced chance of transmitting HIV www.aidsmap.com/Treatment-is-prevention-HPTN-052-study-shows-96-reduction-in-transmission-when-HIV-positive-partner-starts-treatment-early/page/1879665/
 Survey only includes males 15 to 59 years , however males aged 12 years and above were circumcised