PG-2 Evidence of increased HIV cases in greater Kinshasa urban health zones: Democratic Republic of Congo (2017–2018)
Authors: Pour Mohammad , James Linda , Bondo Gaetan , Fumunguya Jonathan , Mavinga Jeansy , Mulenda Basimike , Niles Jonathan , Omakoy Medard , Tshangala Yves , Tshibaka Francois , Mampunza Samuel , McArthur Carole 
Published: April 2019

Background:
The 2018 The President's Emergency Plan for Aids Relief (PEPFAR) Annual Report to the US Congress declared that new HIV cases in the Democratic Republic of the Congo (DRC) in 2016 exceeded HIV mortality. This suggests a loss of epidemic control. USAID and PEPFAR national estimates of HIV prevalence in 2016 were 1.6% for urban Kinshasa and 0.9% for rural areas. In 2016 PEPFAR/DRC tested 915,609 individuals and determined an overall rate of 2.86%; in 2017 a similar study resulted in 2.93%. According to The World Bank, the average peak prevalence in the DRC reached 2.2% for adults (15–49) from 1996 to 2000, with a steady decline until today. HIV national prevalence in the DRC over the past decade has been generally lower than surrounding countries and has raised questions among PEPFAR, WHO and USAID stakeholders as to the reliability of data collection and/or estimates from computer modeling. Our recent data restricted to urban Kinshasa suggests that the HIV rate may be much higher than previous national estimates. USAID and WHO 2017 reports are based upon Spectrum estimates using computer modeling. These relatively low HIV estimates are inconsistent with the data we present in this sub-national study.

Methods:
A study was conducted to determine the rate of new HIV positive individuals in an existing Kinshasa urban HIV cohort between February 2017 and August 2018. After approval from Université Protestante au Congo Ethics Committee,</em> and training of a five-member post graduate medical team and a technician, a prospective adult HIV case-finding study was aggressively conducted. The network was directed by an experienced physician and immunologist with an on-going HIV research program. Individual participants provided demographic data and received an HIV test at 1 of 30 hospitals, community health centers and clinics in 2017, and 44 of the same and an additional 14 sites in 2018. The sites are in 22 of 35 different urban health zones and represented a range of levels of healthcare delivery services. Approximately half the sites were located in PEPFAR supported zones in Kinshasa Province.

Results:
Eight thousand five hundred twenty-six individuals (>18 years) were tested for HIV between February 2017 and May 2018. The number of new seropositive individuals sequentially tested and confirmed by the national algorithm (Determine HIV-1/2 [Determine; Alere, USA], Uni-Gold HIV [Uni-Gold; Trinity Biotech, Ireland], Vikia HIV 1/2 [Vikia; bioMérieux, France], was 1605 HIV positive and 6921 seronegative. The number of HIV positive women exceed the number of HIV positive men under 50 years. Interestingly, the number of men older than 50 years exceeded that of women suggesting women die earlier of HIV-related consequences. These sub-national preliminary data suggest the annual HIV positive rate (22.8 per 100 person-years in 2017 and 18.8 per 100 person-years in 2018) is significantly higher in this cohort than previous reports and estimates of prevalence in the DRC.

Discussion:
This study confirms apprehension in the 2017 PEPFAR DRC Country Operational Plan concerning the reliability of estimates from the DRC. We encountered a noticeable lack of testing and confirmation resources and limited access for patients to HIV therapy and viral load testing. HIV test kit stock-outs were common and the national data collection system was slow to respond due to poor internet connectivity. In this pilot study we focused on assuring test availability, high risk locations, and developed an improved data collection method with strengthening of site personnel relationships. The HIV prevalence we detected in Kinshasa in this preliminary study is generally 8-10-fold higher than recent previous estimates raising the alarm. The reason for the discrepancy is partly because most recent PEPFAR/WHO/Global Fund data is based upon 2012–2013 National statistics and UNAIDS 2015 Spectrum estimates (version 5.51). Reliable 2017 National empirical DRC data were not available to us. There were a number of limitations to this study, the primary shortcoming being that we have not determined the true HIV incidence. This will require follow-up of HIV negative patients over the coming 2 years to determine emergence of HIV seropositivity. Most important driving factors are test availability, personnel support, data integrity, and financial oversight.

Conclusions:
This study showed focused testing of high risk groups by a well-trained team in densely populated areas is a productive case-finding strategy. It reveals that HIV positive patients need prompt access to cART to induce viral suppression and prevent further spread within the Kinshasa community. Increased HIV in rural areas has already been documented.4 Results of this study suggest spatial variability. Sub-national data is vital to reliable modeling of national country estimates. Reliable data is essential for programmatic planning, effective scale-up, cost-effective use of resources and importantly, to obtain epidemic control. Like many sub-Saharan countries, more than 50% of the population in the DRC is under 22 year old. This cohort is rapidly becoming sexually active and entering reproductive years. It is unlikely the DRC will reach the UNAIDS 90:90:90 goals by 2020. Due to the large expansion in the youth population, we could experience an explosion in the HIV epidemic over the coming years. An urgent intervention is required to understand and manage the DRC epidemic.