Authors: 

Mansoor Farahani, Shannon M. Farley, Theodore F. Theodore, Felix Ndagije, Limpho Maile, Herbert Longwe, David Hoos, Wafaa M. El-Sadr

Abstract: 

Background: Lesotho has made substantial efforts to control its HIV epidemic. This study aimed to assess progress towards the UNAIDS 95-95-95 targets by comparing data from the Lesotho Population-based HIV Impact Assessments (LePHIA) conducted in 2016 and 2020.

Methods: Consenting participants from randomly selected households in the 2016 and 2020 surveys provided demographic and clinical information and blood samples for household HIV testing per national guidelines. HIV+ results were confirmed via a lab-based assay. Estimates of HIV awareness (the first 95) and being on antiretroviral therapy (ART) (the second 95) were based on self-report or antiretroviral detection in blood. Viral load suppression (VLS), the third 95, was defined as HIV-1 RNA <1,000 copies/mL. In this analysis, we applied Poisson regression models using survey weights, and variances were estimated via the Taylor-linearized variance estimation.

Findings: In the 2016 and 2020 surveys, 11,682 and 12,718 participants aged 15–59 were enrolled, respectively. The overall HIV incidence showed a significant decrease to 0·50% (95% CI 0·26–0·74) in 2020 from 1·10% (95% CI 0·68–1·52) in 2016 (p=0·026). Among adults living with HIV (ALWH) who tested positive in the survey, the awareness of their HIV status improved notably to 89·6% (95% CI 88·3–90·8) in 2020 from 81·0% (95% CI 79·6–82·3) in 2016. Furthermore, the on-treatment status among those aware of their HIV status increased to 96·9% (95% CI 95·9–97·6) in 2020 from 91·8% (95% CI 90·5–93·0) in 2016, and the prevalence of VLS among those on treatment rose to 90·8% (95% CI 89·5–91·9) in 2020 from 87·7% (95% CI 86·1–89·1) in 2016.After adjusting for demographic covariates, ALWH were significantly more likely in 2020 compared to 2016 to know their HIV+ status (adjusted prevalence ratio [aPR] of 1·09, 95% CI 1·07–1·12, p<0·0001), to be on treatment if aware of their status (aPR: 1·05, 95% CI 1·03–1·07, p<0·0001), and to have VLS if on treatment (aPR: 1·03, 95% CI 1·01–1·06, p=0·004).

Interpretation: Lesotho has made significant progress toward the UNAIDS 95-95-95 targets between 2016 and 2020, surpassing the second 95 target and demonstrating improvements in HIV awareness, ART coverage, and VLS, with a decline in HIV prevalence and incidence. Lesotho’s experience provides valuable insights for other countries striving to control their HIV epidemics.