Who is missing from the HIV care cascade? Factors associated with not achieving the 90-90-90 targets among adults living with HIV in four African countries

BACKGROUND: While most attention is paid to the achievement of 90:90:90 UNAIDS targets, knowledge of characteristics of those who do not achieve these is important. We used population'based HIV impact assessment (PHIA) survey data from Eswatini, Malawi, Tanzania, and Zambia, to examine characteristics of adults living with HIV (ALHIV) who did not achieve these targets.
METHODS: Between 2015-2017, blood samples from consenting ALHIV were analyzed for HIV RNA and detectable antiretrovirals (ARV). Participants who reported no prior HIV diagnosis and had no detectable ARV were classified as unaware. Participants who were aware, reported not receiving treatment, and had no detectable ARV were classified as untreated. Participants on ARV with a nonsuppressed viral load (NVL) '¥1000 c/ml were classified as NVL. Logistic regression using weighted data were used to determine factors associated with each step of the cascade.
RESULTS: Of 9,465 ALHIV identified, 30.7% were unaware of their status, 9.1% were untreated, and 10.9% were nonsuppressed. Residing in Malawi, Zambia or Tanzania, male sex, younger age, being divorced, having tested but never receiving results, and not using condoms at last sex were associated with higher odds of being unaware of HIV status (Figure 1). ALHIV between 25-39 years, not attending a health facility in the last year, reporting denial of health services due to HIV status, and initiating treatment more than a year prior to the survey were associated with higher odds of being untreated. Younger age, reporting need to hide HIV status, and suboptimal adherence were associated with higher odds of NVL.

CONCLUSIONS: We found critical demographic and behavioral factors associated with gaps in 90:90:90 cascade. Efforts need to focus on case finding, particularly among young men. Stigma and other factors at the individual and health facility levels continue to inhibit the achievement of durable benefits from treatment for individuals and communities.