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Background: Data on the continuum of HIV care are necessary to track progress in the response to the epidemic; however, they are difficult to obtain, particularly at a sub-national level. We directly measured HIV diagnosis, receipt of ART, and viral suppression in a community-based sample of adults in Zambezi, the region of highest HIV prevalence in Namibia.
Methods: A cross-sectional, household-based survey was conducted from 12/2014 - 7/2015 in five purposefully selected sites of Namibia''s Zambezi region. Adults received HIV rapid testing using the national algorithm, completed behavioral interviews, and submitted dried blood spots (DBS) in their homes. Previous HIV diagnosis and receipt of ART within the past 90 days were measured through self-report and verified in patient-carried records when available. HIV-RNA viral load was quantified using DBS (Abbott Real-Time HIV-1 m2000 platform). Multivariable logistic regression was used to characterize disparities in outcomes.
Results: We enrolled 2,163 adults, of whom 1,312 [60.7% (95%CI: 58.6-62.7)] were female and 461 [21.3% (95%CI: 19.6-23.1) were HIV-positive. Among HIV-positives, 293 [63.6% (95%CI: 59.0-68.0)] were previously diagnosed. Among those diagnosed, 242 [82.6% (95%CI: 77.8-86.8)] were receiving ART. Of 209 DBS tested from participants receiving ART, 170 [81.3% (95%CI: 75.4-86.4)] were virally suppressed (i.e., < 1000 copies/uL), which equates to 36.9% (95%CI: 32.5-41.5) viral suppression among all HIV-positive adults. HIV diagnosis was significantly lower among men [Adjusted odds ratio (AOR): 0.24, P< 0.001] and youth (< 25 years) (AOR: 0.15, P=0.02). Receipt of ART was somewhat lower among rural residents (AOR: 0.33, P=0.08). Viral suppression was significantly lower among youth (< 25 years) (AOR: 0.27, P=0.002).
Conclusions: With 83% of previously diagnosed adults receiving ART and 81% of those on ART achieving viral suppression, the second and third benchmarks of the UNAIDS “90-90-90” targets are within reach for adults in Zambezi region. However, serostatus awareness among HIV-positive adults was well below the 90% target, especially among men and youth. Thus, overall prevention impact may be limited with only 37% of HIV-positive adults having unsuppressed virus. If the population-level prevention benefits of ART are to be maximized, “test and start” policies must be strengthened with new interventions to improve serostatus awareness.

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