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J Int AIDS Soc. 2018 Jul;21 Suppl 4:e25128. doi: 10.1002/jia2.25128.

The impact of population dynamics on the population HIV care cascade: results from the ANRS 12249 Treatment as Prevention trial in rural KwaZulu-Natal (South Africa).

Author information

Centre Population et Développement, Institut de Recherche pour le Développement, Université Paris Descartes, Inserm, Paris, France.
Africa Health Research Institute, KwaZulu-Natal, South Africa.
School of Nursing and Public Health, Africa Health Research Institute, University of KwaZulu-Natal, KwaZulu-Natal, South Africa.
Faculty of Medicine and Faculty of Social, Human and Mathematical Sciences, University of Southampton, Southampton, UK.
Research Department of Infection and Population Health, University College London, London, UK.
Department of Global Health & Infection, Brighton and Sussex Medical School, Falmer, Brighton, UK.
ISPED, Inserm, Bordeaux Population Health Research Center, Université de Bordeaux, Bordeaux, France.
Department of Global Health & Population, Harvard School of Public Health, Harvard University, Boston, MA, USA.
Institute of Public Health, Faculty of Medicine, Heidelberg University, Heidelberg, Germany.
Division of Infection and Immunity, University College London, London, UK.



The universal test and treat strategy (UTT) was developed to maximize the proportion of all HIV-positive individuals on antiretroviral treatment (ART) and virally suppressed, assuming that it will lead to a reduction in HIV incidence at the population level. The evolution over time of the cross-sectional HIV care cascade is determined by individual longitudinal trajectories through the HIV care continuum and underlying population dynamics. The purpose of this paper is to quantify the contribution of each component of population change (in- and out-migration, HIV seroconversion, ageing into the cohort and definitive exit such as death) on the HIV care cascade in the context of the ANRS 12249 Treatment as Prevention (TasP) cluster-randomized trial, investigating UTT in rural KwaZulu-Natal, South Africa, between 2012 and 2016.


HIV test results and information on clinic visits, ART prescriptions, viral load and CD4 count, migration and deaths were used to calculate residency status, HIV status and HIV care status for each individual on a daily basis. Position within the HIV care continuum was considered as a score ranging from 0 (undiagnosed) to 4 (virally suppressed). We compared the cascade score of each individual joining or leaving the population of resident adults living with HIV with the average score of their cluster at the time of entry or exit. Then, we computed the contribution of each entry or exit on the average cascade score and their annualized total contribution, by component of change.


While the average cascade score increased over time in all clusters, that increase was constrained by population dynamics. Permanent exits and ageing into the people living with HIV cohort had a marginal effect. Both in-migrants and out-migrants were less likely to be retained at each step of the HIV care continuum. However, their overall impact on the cross-sectional cascade was limited as the effect of in- and out-migration balanced each other. The contribution of HIV seroconversions was negative in all clusters.


In a context of high HIV incidence, the continuous flow of newly infected individuals slows down the efforts to increase ART coverage and population viral suppression, ultimately attenuating any population-level impact on HIV incidence.


NCT01509508 ( (South African National Clinical Trials Register).


Cross-sectional cascade; HIV care continuum; Migration; Population dynamics; Public health; Rural South Africa; Structural drivers

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