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Background: South Africa has adopted UNAIDS'' treatment targets of 90% of people living with HIV (PLHIV) tested for HIV, 90% of those tested on antiretroviral treatment (ART), and 90% of those on ART having a suppressed HIV RNA viral load (VL). Using innovative record linkage techniques, we constructed HIV Care Cascades (HCC) to measure progress to these targets.
Methods: We defined the HCC for April 2014-March 2015 using four categories:
1) PLHIV,
2) engaged in HIV care,
3) on ART, and 4) virally suppressed.
PLHIV numbers were estimated using population size and HIV prevalence data from StatsSA and the Human Sciences Research Council. Numbers engaged in care were calculated as the number of individual patients with a CD4 count or viral load during this period, as assessed in newly-deduplicated data from the National Health Laboratory Service. Patients on ART were reported from District Health Information System. Persons with a VL test result < 400 copies/ml were considered suppressed.
Results: Figure 1

Figure 1. South African HIV Care Cascade by Sex and Age Group, April 2014 to March 2015
[Figure 1. South African HIV Care Cascade by Sex and Age Group, April 2014 to March 2015]

shows HCC by sex and age group. Overall there were an estimated 6.47 million PLHIV (61% female, 6% aged < 15 years), of whom 53% were in care, 46% on ART and 26% VL suppressed. An estimated 3.02 million PLHIV are either not yet diagnosed with HIV or diagnosed but not engaged in HIV care. Men and children aged < 15 years fared worse across the cascade.
Conclusions: Large gaps remain across the HCC in South Africa, particularly those engaged in HIV care. In order to meet the 90-90-90 treatment targets, 73% of PLHIV in South Africa need to be virologically suppressed (far higher than the current 26%). Increasing the testing and initiation of those newly diagnosed on ART will have the largest impact on meeting these targets. Excellent monitoring data linking patients to their laboratory results are essential.