title: Attrition and Opportunities Along the HIV Care Continuum: Findings From a Population-Based Sample, North West Province, South Africa.
abstract: Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care, and viral suppression is critical to target programming.
  
  
  
  We conducted a population-based household survey, HIV rapid testing, point-of-care CD4 testing, and viral load measurement from dried blood spots using multistage cluster sampling in 2 subdistricts of North West Province from January to March, 2014. We used weighting and multiple imputation of missing data to estimate HIV prevalence, undiagnosed infection, linkage and retention in care, medication adherence, and viral suppression.
  
  
  
  We sampled 1044 respondents aged 18-49. HIV prevalence was 20.0% (95% confidence interval: 13.7 to 26.2) for men and 26.7% (95% confidence interval: 22.1 to 31.4) for women. Among those HIV positive, 48.4% of men and 75.7% of women were aware of their serostatus; 44.0% of men and 74.8% of women reported ever linking to HIV care; 33.1% of men and 58.4% of women were retained in care; and 21.6% of men and 50.0% of women had dried blood spots viral loads <5000 copies per milliliter. Among those already linked to care, 81.7% on antiretroviral treatment (ART) and 56.0% of those not on ART were retained in care, and 51.8% currently retained in care on ART had viral loads <5000 copies per milliliter.
  
  
  
  Despite expanded treatment in South Africa, attrition along the continuum of HIV care is slowing prevention progress. Improved detection is critically needed, particularly among men. Reported linkage and retention is reasonable for those on ART; however, failure to achieve viral suppression is worrisome.
authors.affiliation: *Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, CA; †Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA; ‡Department of Global Health, University of Washington, Seattle, WA; §International Training and Education Center for Health (I-TECH) South Africa, Pretoria, South Africa; ‖Department of Medicine, University of California, San Francisco, CA; ¶Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; and #School of Pathology, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Sheri A
authors.initials: SA
authors.lastname: Lippman
authors.forename: Starley B
authors.initials: SB
authors.lastname: Shade
authors.forename: Alison M
authors.initials: AM
authors.lastname: El Ayadi
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Gilvydis
authors.forename: Jessica S
authors.initials: JS
authors.lastname: Grignon
authors.forename: Teri
authors.initials: T
authors.lastname: Liegler
authors.forename: Jessica
authors.initials: J
authors.lastname: Morris
authors.forename: Evasen
authors.initials: E
authors.lastname: Naidoo
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Prach
authors.forename: Adrian
authors.initials: A
authors.lastname: Puren
authors.forename: Scott
authors.initials: S
authors.lastname: Barnhart
mesh_terms: D015492:AIDS Serodiagnosis; D000293:Adolescent; D000328:Adult; D018791:CD4 Lymphocyte Count; D003266:Continuity of Patient Care; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D015528:HIV Seroprevalence; D006801:Humans; D008297:Male; D008875:Middle Aged; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult