title: Closer to 90-90-90. The cascade of care after 10 years of ART scale-up in rural Malawi: a population study.
abstract: BACKGROUND
  The antiretroviral therapy (ART) programme supported by Médecins Sans Frontières in the rural Malawian district of Chiradzulu was one of the first in sub-Saharan Africa to scale up ART delivery in 2002. After more than a decade of continuous involvement, we conducted a population survey to evaluate the cascade of care, including population viral load, in the district.
  
  
  METHODS
  A cross-sectional household-based survey was conducted between February and May 2013. Using a multistage cluster sampling method, we recruited all individuals aged 15 to 59 years living in 4125 randomly selected households. Each consenting individual was interviewed and tested for HIV at home. All participants who tested positive had their CD4 count and viral load measured. The LAg-Avidity assay was used to distinguish recent from long-term infections. Viral suppression was defined as a viral load below 1000 copies/mL.
  
  
  RESULTS
  Of 8271 individuals eligible for the study, 7269 agreed to participate and were tested for HIV (94.1% inclusion for women and 80.3% for men). Overall HIV prevalence and incidence were 17.0% (95% CI 16.1 to 17.9) and 0.39 new cases per 100 person-years (95% CI 0.0 to 0.77), respectively. Coverage at the other steps along the HIV care cascade was as follows: 76.7% (95% CI 74.4 to 79.1) had been previously diagnosed, 71.2% (95% CI 68.6 to 73.6) were under care and 65.8% (95% CI 62.8 to 68.2) were receiving ART. Finally, the proportion of participants who were HIV positive with a viral load ≤ 1000 copies/mL reached 61.8% (95% CI 59.0 to 64.5).
  
  
  CONCLUSIONS
  This study demonstrates that a high level of population viral suppression and low incidence can be achieved in high HIV prevalence and resource-limited settings.
authors.affiliation: Epicentre, Paris, France; david.maman@epicentre.msf.org.
authors.forename: David
authors.initials: D
authors.lastname: Maman
authors.affiliation: Ministry of Health, Lilongwe, Malawi.
authors.forename: Benson
authors.initials: B
authors.lastname: Chilima
authors.affiliation: Médecins Sans Frontières, Lilongwe, Malawi.
authors.forename: Charles
authors.initials: C
authors.lastname: Masiku
authors.affiliation: UMI 233 TransVIHMI, Institut de Recherche pour le Développement (IRD), Montpellier 1 University, Montpellier, France.
authors.forename: Ahidjo
authors.initials: A
authors.lastname: Ayouba
authors.affiliation: Epicentre, Paris, France.
authors.forename: Sophie
authors.initials: S
authors.lastname: Masson
authors.affiliation: Médecins Sans Frontières, Paris, France.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Szumilin
authors.affiliation: UMI 233 TransVIHMI, Institut de Recherche pour le Développement (IRD), Montpellier 1 University, Montpellier, France.
authors.forename: Martine
authors.initials: M
authors.lastname: Peeters
authors.affiliation: Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
authors.affiliation: Médecins Sans Frontières, Paris, France.
authors.forename: Annette
authors.initials: A
authors.lastname: Heinzelmann
authors.affiliation: Service de Biostatistique, Hospices Civils de Lyon, Lyon, France.|Université de Lyon, UMR CNRS 5558, Lyon, France.|Laboratoire de Biométrie et Biologie Evolutive, Equipe Biotatistique-Santé, CNRS UMR5558, Villeurbanne, France.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Riche
authors.affiliation: Epicentre, Paris, France.|UMI 233 TransVIHMI, Institut de Recherche pour le Développement (IRD), Montpellier 1 University, Montpellier, France.
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Etard
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000821:virology; D006801:Humans; D015994:Incidence; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012424:Rural Population; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents
keywords: HIV; incidence; prevalence; viral load