Changes in HIV outcomes and progress towards epidemic control from 2016 to 2020 in Lesotho: comparing results from two nationally representative surveys

BACKGROUND: With the second highest HIV prevalence in the world, Lesotho has made substantial efforts to expand its HIV testing, linkage to care, and treatment programs. We estimated progress towards the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 targets using data from the 2016-2017 and 2020 Lesotho Population-based HIV Impact Assessments (LePHIA2016 and LePHIA2020).
METHODS: The LePHIA surveys were cross-sectional nationally representative household surveys. Individuals who slept in the household the night before were eligible for participation, which included an interview, HIV testing, and viral load measurement. We estimated the 90-90-90 cascade using self-reported data for adults 15-59 years of age on HIV awareness (First 90), self-reported treatment (antiretroviral therapy (ART)) among those aware (Second 90), and viral load suppression (VLS) (HIV RNA<1000 copies/ml) (Third 90). All estimates were weighted, jackknife variance estimation conducted, and differences between surveys were assessed using a Z statistic distribution. The analysis included 11,682 adults (41% men; 59% women) 15-59 years of age in LePHIA 2016 and 12,718 (42% men; 58% women) in 2020.
RESULTS: HIV prevalence decreased significantly from 25.6% in 2016 to 23.5%, in 2020 (p: 0.0028) and among all age groups including adolescent girls and young women aged 15-24 (11.1% vs 8.5%, p: 0.0074). Among those who tested HIV-positive, there was an increase in awareness of HIV-positive status from 77.2% to 86.4% (p: < 0.0001).Among those aware and on ART, treatment coverage increased from 90.2% to 95.8% (p: < 0.0001), and VLS among those on ART increased from 88.3% to 91.4% (p: 0.0032). At the population level, prevalence of VLS increased from 67.6% in 2016, to 79.9% in 2020 (p: <0.0001).
CONCLUSIONS: LePHIA 2020 results demonstrate significant progress in reaching UNAIDS 90-90-90 targets since 2016. With the Lesotho Ministry of Health adopting test and start, index testing, and viral load scale up since 2016, Lesotho has almost achieved the first 90 target and has exceeded the second and third 90 targets, moving the country closer towards HIV epidemic control. These findings position the country well as it aims to achieve the new UNAIDS targets of reaching 95-95-95 by 2025.