Community Viral Load and CD4 Count Distribution Among People Living With HIV in a South African Township: Implications for Treatment as Prevention

Introduction: The goals of scale-up of antiretroviral therapy (ART) have expanded from prevention of morbidity and death to include prevention of transmission. Morbidity and mortality risk are associated with CD4 count; transmission risk depends on plasma viral load (VL). This study aimed to describe CD4 count and VL distributions among HIV-infected individuals in a South African township to gain insights into the potential impact of ART scale-up on community HIV transmission risk. Methods: A random sample of 10% of the adult population was invited to attend an HIV testing service. Study procedures included a questionnaire, HIV testing, CD4 count, and VL testing. Results: One thousand one hundred forty-four (88.0%) of 1300 randomly selected individuals participated in the study. Two hundred sixty tested positive, giving an HIV prevalence of 22.7%[ 95% confidence interval (CI): 20.3 to 25.3]. A third of all HIV-infected individuals (33.5%, 95% CI: 27.8 to 39.6) reported taking ART. The median CD4 count was 417 cells per microliter (interquartile range, 285-627); 33 (12.7%, 95% CI: 8.9 to 17.4) had a CD4 count of <= 200 cells per microliter. VL measurements were available for 219 individuals (84.2%) and were undetectable in 72 (33.9%), >1500 copies per milliliter in 127 (58.0%) and >10,000 copies per milliliter in 96 (43.8%). Of those reporting they were receiving ART, 30.4% had a VL >1500 copies per milliliter compared with 58.0% of those reporting they were not receiving ART. Conclusions: A small proportion of those living with HIV in this community had a CD4 count of,200 cells per microliter; more than half had a VL high enough to be associated with considerable transmission risk. A substantial proportion of HIV-infected individuals remained at risk of transmitting HIV even after starting ART.