Lesotho's progress towards UNAIDS 95-95-95 targets from 2016 to 2020: comparison of Population-based HIV Impact Assessments.

Background: Lesotho has made substantial efforts to control its HIV epidemic. We aimed to assess progress towards UNAIDS 95-95-95 targets in Lesotho by comparing data from the Lesotho Population-based HIV Impact Assessments conducted in 2016-17 (LePHIA 2016) and 2019-20 (LePHIA 2020).

Methods: The LePHIA surveys used a cross-sectional, two-stage, stratified cluster sampling design to obtain a nationally representative sample of adults aged 15-59 years (LePHIA 2016) or aged 15 years and older (LePHIA 2020) from all ten districts of Lesotho. From November, 2016 to May, 2017 (LePHIA 2016) and from December, 2019 to March, 2020 (LePHIA 2020), consenting participants from randomly selected households provided demographic and clinical information and blood samples for household HIV testing according to national guidelines. HIV-reactive test results were confirmed by a laboratory assay. We estimated HIV status awareness and antiretroviral therapy (ART) use on the basis of self-reports or detection of antiretroviral drugs in blood samples. Viral load suppression was defined as HIV-1 RNA less than 1000 copies per mL. We applied Poisson regression models using survey weights and estimated variances using the Taylor series linearisation approach.

Findings: 11 682 participants were enrolled in LePHIA 2016 and 12 718 participants were enrolled in LePHIA 2020. Overall HIV incidence decreased significantly from 1·10% (95% CI 0·68-1·52) in 2016 to 0·50% (0·26-0·74) in 2020 (p=0·026). Among adults who tested positive for HIV, awareness of HIV status improved from 81·0% (79·6-82·3) in 2016 to 89·6% (88·3-90·8) in 2020 (p<0·0001). Furthermore, between the two surveys, the proportion on ART among those aware of their HIV status increased from 91·8% (90·5-93·0) to 96·9% (95·9-97·6; p<0·0001) and the prevalence of viral load suppression among those on ART increased from 87·7% (86·1-89·1) to 90·8% (89·5-91·9; p<0·0020). After adjusting for demographic covariates, adults living with HIV were significantly more likely in 2020 than in 2016 to know their HIV status (adjusted prevalence ratio 1·09, 95% CI 1·07-1·12, p<0·0001), to be on ART if aware of their status (1·05, 1·03-1·07, p<0·0001), and to be virally suppressed if on ART (1·03, 1·01-1·06, p=0·0045).

Interpretation: Between 2016 and 2020, Lesotho made significant progress towards the UNAIDS 95-95-95 targets, surpassing the second target (ART coverage) and showing improvements in HIV status awareness and viral load suppression (the first and third targets) as well as declines in HIV prevalence and incidence. Lesotho's experience provides valuable insights for other countries working to control their HIV epidemics.

Funding: The US President's Emergency Plan for AIDS Relief.