Can the Heterosexual HIV Epidemic be Eliminated in South Africa Using Combination Prevention? A Modeling Analysis

Abstract

Little is known about how combining efficacious HIV prevention interventions could lead to HIV elimination. We used an agent-based simulation model, the HIV Calibrated Dynamic Model (HIV-CDM), to assess the potential for HIV elimination in South Africa. We examined several scenarios (from continuation of current status quo to perfect targets) with differing combinations of male condoms, adult male circumcision, HIV testing, and early antiretroviral therapy (ART). We varied parameters including: proportion of adult males circumcised, frequency of condom use in sex acts, HIV test acceptance, linkage to care, ART initiation criteria, ART suppression rates, and loss to follow up. Maintaining current levels of combination prevention will lead to increasing HIV incidence and prevalence while the perfect combination scenario is projected to eliminate HIV on a 50-year time scale from 2013 to 2063. Perfecting testing and treatment, without changing condom use or circumcision rates, resulted in 89% incidence reduction but not elimination. Universal adult male circumcision alone resulted in a 21% incidence reduction within 20 years. Substantial decreases in HIV incidence are possible from sufficient uptake of both primary prevention and ART, but with continuation of the status quo, HIV elimination in South Africa is unlikely within a 50-year time scale.