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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.

Background: Antiretroviral therapy (ART) has decreased HIV-related morbidity and mortality and increased life expectancy of people living with HIV (PLHIV). Globally, the number of older PLHIV (OPLH...

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

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.

Fourth-generation HIV rapid tests (RTs) claim to detect both p24 antigen (Ag) and HIV antibodies (Ab) for early identification of acute infections, important for targeting prevention and reducing HIV transmission. In a nationally representative household survey in Swaziland, 18,172 adults, age 18 to 49 years, received home-based HIV rapid testing in 2010 and 2011. Of the 18,172 individuals, 5,822 (32.0%) were Ab positive (Ab + ) by the Determine HIV-1/2 Ab/Ab combo test, and 5,789 (99.4%) of those were confirmed to be reactive in the Uni-Gold test. Determine combo identified 12 individuals as having acute infections (Ag + /Ab negative [Ab − ]); however, none had detectable HIV-1 RNA and 8 of 12 remained HIV negative at their 6-week follow-up visit (4 were lost to follow-up). All RT-nonreactive samples were pooled and tested by nucleic acid amplification testing (NAAT) to identify acute infections. NAAT identified 13 (0.1%) of the 12,338 HIV antibody-negative specimens as HIV RNA positive, with RNA levels ranging from 300 to >10,000,000 copies/ml. However, none of them were Ag + by Determine combo. Follow-up testing of 12 of the 13 NAAT-positive individuals at 6 months demonstrated 12 seroconversions (1 individual was lost to follow-up). Therefore, the Determine combo test had a sensitivity of 0% (95% confidence interval, 0 to 28) and positive predictive value of 0% for the detection of acute infections. The ability of the 4th-generation Determine combo to detect antigen was very poor in Swaziland. Thus, the Determine combo test does not add any value to the current testing algorithm; rather, it adds additional costs and complexity to HIV diagnosis. The detection of acute HIV infections may need to rely on other testing strategies.

Swaziland has the highest national HIV prevalence worldwide. The Swaziland HIV Incidence Measurement Survey (SHIMS) provides the first national HIV incidence estimate based on prospectively observed HIV seroconversions.A two-stage survey sampling design was used to select a nationally representative sample of men and women aged 18-49 years from 14 891 households in 575 enumeration areas in Swaziland, who underwent household-based counselling and rapid HIV testing during 2011. All individuals aged 18-49 years who resided or had slept in the household the night before and were willing to undergo home-based HIV testing, answer demographic and behavioural questions in English or siSwati, and provide written informed consent were eligible for the study. We performed rapid HIV testing and assessed sociodemographic and behavioural characteristics with use of a questionnaire at baseline and, for HIV-seronegative individuals, 6 months later. We calculated HIV incidence with Poisson regression modelling as events per person-years × 100, and we assessed covariables as predictors with Cox proportional hazards modelling. Survey weighting was applied and all models used survey sampling methods.Between Dec 10, 2010, and June 25, 2011, 11 897 HIV-seronegative adults were enrolled in SHIMS and 11 232 (94%) were re-tested. Of these, 145 HIV seroconversions were observed, resulting in a weighted HIV incidence of 2·4% (95% CI 2·1-2·8). Incidence was nearly twice as high in women (3·1%; 95% CI 2·6-3·7) as in men (1·7%; 1·3-2·1, p0·0001). Among men, partner's HIV-positive status (adjusted hazard ratio [aHR] 2·67, 1·06-6·82, p=0·040) or unknown serostatus (aHR 4·64, 2·32-9·27, p0·0001) in the past 6 months predicted HIV seroconversion. Among women, significant predictors included not being married (aHR 2·90, 1·44-5·84, p=0·0030), having a spouse who lives elsewhere (aHR 2·66, 1·29-5·45, p=0·0078), and having a partner in the past 6 months with unknown HIV status (aHR 2·87, 1·44-5·84, p=0·0030).Swaziland has the highest national HIV incidence in the world. In high-prevalence countries, population-based incidence measures and programmes that further expand HIV testing and support disclosure of HIV status are needed.President's Emergency Plan for AIDS Relief (PEPFAR) by the Centers for Disease Control and Prevention.

In Swaziland, where one in four adults is HIV positive, identifying and addressing barriers to a strong referral system is critical to ensure continuity of care for HIV positive individuals. This study examines the referral system from the perspectives of health providers, community health workers, traditional healers, clients seeking facility-based care, and managers of private health organizations. Structured and semi-structured questionnaires were administered to 52 senior providers, 161 providers, and 307 clients in 52 health facilities. In 82 randomly selected communities, 81 traditional healers and 247 CHWs also participated. Staff from private health agencies providing HIV-related care were also interviewed. Referral is commonly understood as sending clients to seek care at higher level facilities and is an individualized process dependent on various factors. Providers sending clients rarely hear back on any regular basis about those clients. Referrals and linkages for certain services are particularly weak including nutrition support, psychosocial support, palliative care and home-based care. Many providers recommended that referral protocols with improved communication tools are needed and said referred clients should be given priority at referral-receiving sites. Policy recommendations include: referral form redesign; formalizing or reforming the referral protocol; strengthening communication and linkages between community- and facility-based providers; and improving patient-flow at referral sites.

Objectives: National population-wide HIV prevalence and incidence trends in sub-Saharan Africa (SSA) are indirectly estimated using HIV prevalence measured among pregnant women attending antenatal clinics (ANC), among other data. We evaluated whether recent HIV prevalence trends among pregnant women are representative of general population trends. Design: Serial population-based household surveys in 13 SSA countries. Methods: We calculated HIV prevalence trends among all women aged 15–49 years and currently pregnant women between surveys conducted from 2003 to 2008 (period 1) and 2009 to 2012 (period 2). Log-binomial regression was used to test for a difference in prevalence trend between the two groups. Prevalence among pregnant women was age-standardized to represent the age distribution of all women. Results: Pooling data for all countries, HIV prevalence declined among pregnant women from 6.5 [95% confidence interval (CI) 5.3–7.9%] to 5.3% (95% CI 4.2–6.6%) between periods 1 and 2, whereas it remained unchanged among all women at 8.4% (95% CI 8.0–8.9%) in period 1 and 8.3% (95% CI 7.9–8.8%) in period 2. Prevalence declined by 18% (95% CI −9–38%) more in pregnant women than nonpregnant women. Estimates were similar in Western, Eastern, and Southern regions of SSA; none were statistically significant (P > 0.05). HIV prevalence decreased significantly among women aged 15–24 years while increasing significantly among women 35–49 years, who represented 29% of women but only 15% of pregnant women. Age-standardization of prevalence in pregnant women did not reconcile the discrepant trends because at older ages prevalence was lower among pregnant women than nonpregnant women. Conclusion: As HIV prevalence in SSA has shifted toward older, less-fertile women, HIV prevalence among pregnant women has declined more rapidly than prevalence in women overall. Interpretation of ANC prevalence data to inform national HIV estimates should account for both age-specific fertility patterns and HIV-related sub-fertility.

Background The 2011 Swaziland HIV Incidence Measurement Survey (SHIMS) was conducted as part of a national study to evaluate the scale up of key HIV prevention programs. Methods From a randomly selected sample of all Swazi households, all women and men aged 18-49 were considered eligible, and all consenting adults were enrolled and received HIV testing and counseling. In this analysis, population-based measures of HIV prevalence were produced and compared against similarly measured HIV prevalence estimates from the 2006-7 Swaziland Demographic and Health. Also, measures of HIV service utilization in both HIV infected and uninfected populations were documented and discussed. Results HIV prevalence among adults aged 18-49 has remained unchanged between 2006-2011 at 31-32%, with substantial differences in current prevalence between women (39%) and men (24%). In both men and women, between since 2006-7 and 2011, prevalence has fallen in the young age groups and risen in the older age groups. Over a third (38%) of the HIV-infected population was unaware of their infection status, and this differed markedly between men (50%) and women (31%). Of those aware of their HIV-positive status, a higher percentage of men (63%) than women (49%) reported ART use. Conclusions While overall HIV prevalence remains roughly constant, age-specific changes strongly suggest both improved survival of the HIV-infected and a reduction in new HIV infections. Awareness of HIV status and entry into ART services has improved in recent years but remains too low. This study identifies opportunities to improve both HIV preventive and care services in Swaziland.

Since its inception in 2003, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has been an important driving force behind the global scale-up of HIV care and treatment services, particularly in expansion of access to antiretroviral therapy. Despite initial concerns about cost and feasibility, PEPFAR overcame challenges by leveraging and coordinating with other funders, by working in partnership with the most affected countries, by supporting local ownership, by using a public health approach, by supporting task-shifting strategies, and by paying attention to health systems strengthening. As of September 2011, PEPFAR directly supported initiation of antiretroviral therapy for 3.9 million people and provided care and support for nearly 13 million people. Benefits in terms of prevention of morbidity and mortality have been reaped by those receiving the services, with evidence of societal benefits beyond the anticipated clinical benefits. However, much remains to be accomplished to achieve universal access, to enhance the quality of programs, to ensure retention of patients in care, and to continue to strengthen health systems.