Location inherently linked to unsuppressed viral load among young South African women

Multiple partners, migration, and living in an HIV ‘hotspot’ have been identified as key drivers of unsuppressed viral load among young women living with HIV in KwaZulu-Natal, South Africa.

Researchers collected around 5,450 viral load measurements from 3,890 HIV positive women living in KwaZulu-Natal, a rural area with high HIV prevalence, during 2011, 2013 and 2014. It found 69% of women in 2011, 58% in 2013 and 53% in 2014 had unsuppressed viral loads.

Each woman was assessed for three socio-behavioural factors, namely: number of sexual partners, contraception use, and external migration history. The latter reflected the area’s position as a corridor for migration and commercial transportation, both within South Africa and to other countries in the region. A history of living in an HIV ‘hotspot’, defined as locations within KwaZulu-Natal with particularly high infection rates, was also examined.

Although there were improvements in viral load over the three years among certain groups of women in the study, such as young women and those with a history of marriage, those living in HIV hotspots showed no signs of improved viral loads. In fact, women residing in these areas were found to be more likely to have unsuppressed viral loads in 2013 and 2014 than in 2011. This suggests that neighbourhoods associated with high rates of HIV infection may be inherently linked to unsuppressed viral load.

Around half of the women included in the study reported having four or more sexual partners, not using contraception, and having an extensive history of migration. Around 82% had never been married and 91% had been pregnant.

During all three years, researchers found adolescent women (ages 15-19) with a history of extensive external migration, a greater number of sexual partners, and who lived in an HIV hotspot had alarmingly high levels of unsuppressed viral load.

The study, the first to examine predictors of high viral loads using data gathered directly from a sub-Saharan African community rather than from patient records, provides further evidence on the importance of location and certain socio-behavioural factors when it comes to HIV risk. It also emphasises the need to identify and effectively address the barriers that are preventing women living with HIV from seeking ART.

While much work remains to be done to develop effective, community-based interventions to improve viral suppression in South Africa, this study highlights how focusing on the needs of women who display certain risk characteristics, particularly those living in HIV hotspots, could better use limited resources in order to improve the health of both individuals and the wider population.