Fearon E, Tenza S, Mokoena C, et al. HIV testing, care and viral suppression among men who have sex with men and transgender individuals in Johannesburg, South Africa. PLoS One. 2020;15(6):e0234384. Published 2020 Jun 17. doi:10.1371/journal.pone.0234384
Abstract
Introduction: Men who have sex with men and transgender individuals (MSM/TG) carry a disproportionately high burden of HIV, including in South Africa. However, there are few empirical population-representative estimates of viral suppression and the HIV care cascade including HIV testing among this population, nor of factors associated with these outcomes.
Methods: We conducted a respondent driven sampling (RDS) survey among 301 MSM/TG in Johannesburg in 2017. Participants gave blood samples for HIV testing and viral load. Participants self-completed a survey including sociodemographics, HIV testing history, and engagement in care. We calculated RDS-II weighted estimates of the percentage of HIV-negative MSM/TG reporting HIV testing in the previous 6 months, their testing experience and preferences. Among those HIV-positive, we estimated the percentage status-aware, on ART, and virally suppressed (<50 viral copies/ml plasma). We conducted RDS-weighted robust Poisson regression to obtain weighted prevalence ratios of factors associated with 1) HIV testing among those HIV-negative; and 2) viral suppression among those HIV-positive.
Results: There were 118/300 HIV-positive MSM/TG, (37.5%). Of the HIV-negative MSM/TG, 61.5% reported that they had tested for HIV in the previous 6 months, which was associated with selling sex to men (Prevalence Ratio = 1.67, 95% CI 1.36-2.05). There were 76/118 HIV-positive MSM/TG (56.5%) who reported having previously tested positive for HIV and 39/118 (30.0%) who reported current ART. There were 58/118 HIV-positive MSM/TG with viral loads <50 copies/ml plasma (46.9%). Viral suppression was associated with older age (adjusted PR = 1.03, 95% CI 1.00-1.06 for each year), neighbourhood, and having bought sex from men (adjusted PR = 1.53, 95% CI 1.12-2.08).
Conclusions: HIV prevalence was very high. Viral suppression among those HIV-positive was similar to the general male population in South Africa, but remains far short of national and international targets. A majority of HIV-negative MSM/TG had HIV tested in the previous 6 months, though there is room for improvement.
Discussion excerpt
We estimated a very high HIV prevalence among MSM/TG in Johannesburg, and found half of those HIV-positive to be virally unsuppressed. These findings indicate gaps in the HIV care cascade that represent missed opportunities to improve the health of HIV-positive MSM/TG and to prevent ongoing HIV transmission. Younger MSM/TG who were HIV-positive were less likely to be virally suppressed, emphasising the need for regular and accessible testing and support to engage in HIV care for this group.
We found a higher proportion of MSM/TG to be virally suppressed at 47% (32-62%) than the 34% estimated among all adult males living with HIV in Gauteng in 2017 [12], the 26% estimated in Johannesburg in 2016 [13] and similar to the 47% (95% CI 43-52%) estimated to be virally suppressed among the HIV-positive adult population in South Africa as a whole in 2017[42]. This was the case even with our lower viral load cut-off of 50 copies/ml plasma as compared to 400/ml plasma. Our estimate is also higher than modelled estimates for virological suppression among South African MSM (22%, data from 2013-2015)[43]. It is plausible that in addition to challenges related to having sex with men, HIV-positive MSM/TG experience some of the same barriers to achieving viral suppression that men as whole do, as estimates for viral suppression among women are higher than those of men overall (43% compared to 58% nationally among adults[42]). Knowledge of status and current ART use among HIV-positive MSM/TG were much higher than that reported amongst MSM in two districts of neighbouring Mpumalanga province in 2012-2013, (56.5% compared to 28.1% and 14.1% aware of status, 30% versus 14% and 10% on ART)[44]. Our higher estimates could be related to having an urban sample of MSM/TG and to our more recent data collection. Nonetheless, the percentage of HIV-positive MSM/TG whom we found to be virally suppressed remains well below the UNAIDS target of 73% of all those HIV-positive, indicating gaps in the HIV care cascade. It is encouraging however that HIV-positive MSM/TG receiving HIV care, 76% of whom were attending public clinics and hospitals, reported high levels of satisfaction with the service they received.
We found that HIV-positive MSM/TG who had bought sex from a man in the past 12 months were more likely to be virally suppressed. Our findings could possibly reflect a higher recognition of risk and thus increased care engagement among those buying sex, but we are not able to determine causality. Studies among other MSM/TG populations have found that substance use, alcohol use and mental health are associated with worse care cascade outcomes[45], and the fact that we did not find statistically significant associations with these characteristics should be treated with caution. Our sub-sample was small, statistical error remains a possibility and we have not disaggregated different types of drug use.
Almost two thirds of HIV-negative MSM/TG reported having HIV tested within the previous 6 months, higher than among MSM in Soweto in 2008 (28%)[24,25] and MSM in Mpumalanga in 2014-2015 prior to a testing intervention (38%)[46]. Encouragingly, testing was associated with some indicators of higher risk, including selling sex to men, though not self-reported STI symptoms. There remains a need for sustained HIV/STI testing messages. Transfeminine individuals were less likely than cisgender male individuals to have HIV tested, similar to findings from Cape Town[47], though the statistical evidence for an association between testing and gender identity was weak; further investigation is needed. Of MSM/TG who did attend HIV testing, it is encouraging that high levels of privacy and respect at last testing experience were reported. That there was not a clear majority preference for testing location and person performing the tests underscores the need for a high volume and variety of accessible and acceptable services for a diverse MSM/TG population. While few MSM/TG reported a preference for HIV self-testing in our study, it is possible that this stems from unfamiliarity: a recent study of MSM in Mpumalanga found high levels of satisfaction with HIV self-testing and increased testing frequency amongst those who had tried it[46], though studies from elsewhere have also found that men are reluctant to receive a diagnosis on their own[48].