ABSTRACT
Background: Achieving UNAIDS global 95 targets among people living with HIV (PLHIV) is key to HIV epidemic control. Eswatini, a country with one of the severest HIV epidemics, has implemented an aggressive national HIV response with comprehensive HIV prevention and treatment services. We assessed progress towards these targets in the high HIV disease burden setting of Eswatini. Method(s): We compared 95-95-95 indicators and HIV incidence from two sequential Population-based HIV Impact Assessment (PHIA) surveys conducted in Eswatini in 2016 and 2021. These PHIAs were similarly designed as nationally representative household surveys among individuals 15 years and older. Respondents completed interviews and provided blood samples for HIV rapid testing (Determine and Unigold), antiretrovirals (ARV) testing, and viral load (VL) measurement. The first 95 (diagnosed PLHIV) was assessed by self-report or detectable ARVs;second 95 (on treatment) by self-report or detectable ARVs among diagnosed PLHIV, and third 95 (VL suppression, VLS) as VL < 1,000 copies/mL among PLHIV on treatment. Annual HIV incidence was estimated from recent infections (classified by HIV-1 LAg avidity assay, VL and ARV detection) using the formula recommended by the World Health Organization Incidence Working Group. Survey weights accounting for sample selection probabilities and adjusted for nonresponse and noncoverage were applied. Result(s): The 11,199 adults in the 2021 PHIA were at 94-97-96, while the 10,934 adults in the 2016 PHIA were at 87-89-91, a statistically significant increase of 5-10% in all 95 indicators (see Table). Target achievement varied by sex, but all 95 indicators improved among men (92-96-97 in 2021 vs 80-90-91 in 2016) and women (95-98-96 in 2021 vs 91-88-91 in 2016). Overall annual HIV incidence declined by 45% from 1.13% in 2016 to 0.62% in 2021 (p = 0.055). Annual HIV incidence in 2021 was nearly seven times higher among women (1.11%) than among men (0.17%). Conclusion(s): These findings reflect substantial progress toward HIV epidemic control, a remarkable achievement in the context of health, social and economic disruptions and challenges associated with the COVID-19 era. The 2021 data highlight remaining gaps in knowledge of HIV status, particularly among men, and HIV incidence reduction, particularly among women.