A study in the Bukoba municipality of Tanzania has suggested that scaling up HIV testing, improving linkages to HIV care, and strengthening retention of antiretroviral therapy interventions can help increase viral load suppression (VLS).

By 2020, sub-Saharan African countries are aiming to achieve VLS among 90% of people using antiretroviral therapy (ART) and among 73% of all persons living with HIV.

In Tanzania, where 1.4 million people are living with HIV, 49.6% of HIV-positive people aged 15-49 years had achieved VLS in 2017. Bukoba municipality has approximately 150,000 residents total, and is the capital of the Kagera Region, which has the 4th highest prevalence of HIV among residents aged 15-49 years.

In 2014, the Bukoba Combination Prevention Evaluation (BCPE) scaled up new HIV testing, opportunities for linkage to care, and retention on ART interventions.

Interventions
Interventions between 2014-2017 included HIV testing offered at 11 health care facilities, in homes, and in community venues; services to help HIV-positive people enroll early in care; and services to help HIV-positive people resume services after they'd stopped receiving care.

Among residents aged 18-49 years in sampled enumeration areas, 73% of 6532 patients participated in preintervention survey interviews and testing. Even more—74%—participated in postintervention survey interviews and testing.

By the end of the intervention in 2017, BCPE had achieved 109% and 100% of HIV diagnostic and enrollment-in-care targets, respectively, for HIV-positive people aged 18-49 years.

The Results
Before the 2014 interventions, the prevalence of HIV was 8.9% among the approximately 66,134 residents between ages 18 years and 49 years. Among the approximately 5903 HIV-positive residents, 47.4% had previously received an HIV diagnosis, 40.8% were currently in HIV care, and 32.2% were using ART. Of those using ART, 88.7% had achieved VLS.

During the intervention between 2014 and 2017, BCPE conducted 133,695 HIV tests. Of those, 4731 clients tested positive for HIV, 4143 of whom received a new diagnosis; 3918 enrolled in HIV care, and 2521 initiated ART within 3 months.

After the intervention in 2017, the estimated prevalence of HIV among residents aged 18-49 years was 8.4%—a 0.5% decrease. Although this may seem like a small difference, other results were observed. VLS sex and age disparities in 2014 were nearly eliminated by 2017. Cell phone and television ownership were the only observed disparities in 2017; there were no other observed disparities for any sociodemographic characteristics.

CDC analysis of the results found that VLS prevalence among HIV-positive people aged 18-49 years increased approximately twofold overall (28.6%-64.8%). Among men, the prevalence of VLS increased nearly threefold, from 20.5% to 59.1%.

Implications
The results of the Bukoba municipality interventions have already been scaled up across Tanzania during 2019, with support from the US President's Emergency Plan for AIDS Relief.

The twofold overall increase in VLS prevalence suggests that comprehensive medical outpatient department and community-based HIV testing strategies, combined with recommended linkage and defaulter-tracing services, can substantially increase VLS prevalence and reduce VLS-associated sex and age group disparities.


Reference

Mackellar D, Steiner C, Rwabiyago OE, et al. Threefold Increases in Population HIV Viral Load Suppression Among Men and Young Adults—Buboka Municipal Council, Tanzania, 2014-2017. MMWR Morbidity and Mortality Weekly Report. 2019;68(30):658-663. doi:10.15585/mmwr.mm6830a2.