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Nationally representative household surveys of the general population can provide critical assessments of the status of HIV epidemics and the impact of national HIV programs. With lessons learned from earlier surveys, PEPFAR has supported HIV-focused surveys in high burden countries to measure known HIV status, access to HIV treatment, and viral suppression, and, by using novel HIV recency assays, to estimate HIV incidence. The results from the initial population-based HIV impact assessments have transformed global HIV programming, demonstrating unexpected progress in population viral suppression and the persistent burden of high HIV incidence among adolescent girls and young women. The findings highlight the importance of tailoring programs to engage men more effectively in HIV testing and treatment. The collection of manuscripts summarized in this overview of the Supplement describe the methods and selected key findings from the initial population-based HIV impact assessment surveys. Taken together, the efforts described in these manuscripts have advanced survey and laboratory capacity and guided HIV programs toward the goal of ending the global epidemic.

Objective: Early initiation of antiretroviral treatment (ART) at CD4+ cell count greater or equal to 500 cells per microliter reduces morbidity and mortality in HIV-infected adults. We determined the proportion of HIV-infected people with high viral load (VL) for whom transmission prevention would be an additional benefit of early treatment. Design: A randomly selected subset of a nationally representative sample of HIV-infected adults in Swaziland in 2012. Methods: Eight to 12 months after a national survey to determine adult HIV prevalence 1067 of 5802 individuals identified as HIV-infected were asked to participate in a follow-up cross-sectional assessment. CD4+ cell enumeration VL measurements and ART status were obtained to estimate the proportion of currently untreated adults and of the entire HIV-infected population with high VL (greater than or equal to 1000 copies/mL) whose treatment under a test-and-treat or VL threshold eligibility strategy would reduce HIV transmission. Results: Of the 927 (87% of 1067) participants enrolled 466 (50%) reported no ART use. Among them 424 (91%) had VL greater than or equal to 1000 copies per milliliter; of these 148 (35%) were eligible for ART at the then existing CD4+ count threshold of less than 350 cells per microliter; an additional 107 (25%) were eligible with expanded CD4+ criterion of less than 500 cells per microliter; and 169 (40%) remained ART ineligible. Thus 36% of the 466 currently untreated and 18% of the total 927 had high VL yet remained ART ineligible under a CD4+ criterion of less than 500 cells per microliter. Conclusions: A test-and-treat or VL threshold for treatment eligibility is necessary to maximize the HIV transmission prevention benefits of ART. Copyright © 2015 Wolters Kluwer Health Inc.