Overview
A population-based cross-sectional survey conducted in 2018 in Eshowe/Mbongolwane, KwaZulu-Natal, reveals that while new HIV infections have declined in high-prevalence settings, a subset of HIV-positive individuals with high-risk sexual behavior and limited ART engagement continues to sustain transmission. Focusing on adults aged 15–59, the study analyzes HIV awareness, ART uptake, viral suppression, and sexual behavior to identify groups most at risk of onward transmission.
Key Findings: Awareness, ART, and Viral Suppression
Among 862 HIV-positive participants aged 15–59, 10.1% were unaware of their HIV status, 15.8% were not on ART, and 16.3% had a viral load of 1000 copies/mL or more. Among those who had sexual activity in the prior year, 46.9% consistently used condoms, and about 7.5% reported more than one sexual partner. Alarmingly, 10.6% fell into high or very high risk for transmitting HIV when combining viral load, partner number, and condom use. Notably, half of the very high-risk group were unaware of their status, and three-quarters were not on ART, underscoring gaps in TasP implementation at the community level.
Age and Gender Patterns Driving Transmission Risk
Youth (15–24) and adults aged 20–34 years emerged as focal points. Men aged 20–59 and women aged 20–34 accounted for large shares of those at high risk, with substantial proportions of virally unsuppressed individuals despite some awareness of HIV status. In particular, the very high-risk category included a majority of men 20–59 years who were virally unsuppressed, often with more than one partner and inconsistent condom use.
Condom Use and Sexual Behavior
Condom use, though present in nearly half of those reporting sexual activity, varied by age and partnership status. Consistent condom use was lowest among those with multiple partners, who also showed higher rates of being unaware of their status or untreated. The data suggest that reduced condom use with higher sexual frequency contributes to ongoing transmission in this rural setting.
Implications for Public Health Interventions
The study underscores that broad ART coverage alone does not guarantee transmission reduction unless paired with targeted efforts to diagnose undiagnosed HIV, link individuals to care, and sustain viral suppression—especially among men and young adults who engage in multiple partnerships. Key recommendations include:
- Age-gender targeted HIV testing and awareness campaigns to identify undiagnosed infections rapidly.
- Enhanced adherence support and rapid identification of ART treatment failure to maintain viral suppression.
- Strengthened behavioral-risk reduction strategies and reinvigorated condom distribution efforts, particularly for those with multiple partners.
- Continued expansion of ART access and support for adherence to maximize the population-level impact of TasP.
Limitations and Context
Data reflect the 2018 snapshot; ongoing HIV burden in KwaZulu-Natal means findings remain relevant for guiding interventions. Self-reported information on sexual behavior and ART use may introduce bias, although some measures were validated with laboratory data.
Conclusion
The rural KwaZulu-Natal findings point to a concentrated core of individuals—especially men aged 20–59 and women aged 20–34—whose untreated or unsuppressed HIV and high-risk sexual behaviors sustain transmission. Addressing this residual transmission requires precise targeting of testing, viral load monitoring, ART initiation and retention, and robust behavioral interventions to reduce risk and increase condom use.
