Protocol for Monitoring the Implementation of the 95-95-95 Strategy in Tshwane: A Quantitative Analysis of Local Progress 2018-2024.

Background

HIV/AIDS persistently poses a global threat to public health. UNAIDS is focused on reaching the 9595-95 goals and eradicating HIV/AIDS as a global health threat by 2030.⁴ Meeting these targets could slow down the rate of new infections, mother-to-child transmission (MTCT), and death related to HIV/AIDS.⁵ Despite efforts achieve these goals, many countries are still behind. In 2019, only 67% of people living with HIV around the world were receiving ART. The very same year, up to 1.7 million people globally were newly infected, and around 690,000 died from HIV-related illnesses. These numbers were similar in 2018, showing there is a lot to be done.⁵ Experts also estimated that 9.1 million more people globally would have needed to start treatment in 2020 to help the world reach the 95-95-95 goals.⁵ The idea behind it is to achieve the U=U (Undetectable = Untransmittable) campaign goals. This means that when a person with HIV is on treatment and that person has an undetectable viral load, they cannot transmit the virus to others.⁶ This includes primary prevention (preventing the spread of the virus to those who are not infected), secondary prevention (making sure people living with HIV receive regular viral load checks and health assessments), and tertiary prevention (enhancing the well-being and quality of life of those living with HIV).⁶ The U=U message has been included in many public health initiatives and medical guidelines.⁶ By the end of 2020, global efforts to fight HIV had shown good progress. Approximately 84% of people living with HIV (PLHIV) were aware of their HIV-positive status. Among those who knew their status, 87% were receiving antiretroviral therapy, and of those on treatment, 90% had suppressed the virus to undetectable levels.⁷ Countries such as Eswatini and Switzerland reached high levels of viral suppression, exceeding 86% of all PLHIV, reflecting progress toward the global 95-95-95 treatment targets. Additionally, by 2020, six other nations, Rwanda, Qatar, Botswana, Slovenia, Uganda, and Malawi, had successfully met the earlier 90-90-90 treatment targets.³ By 2018, South Africa saw a great improvement in HIV care: among the 8.2 million individuals living with HIV, 90% knew their status, 68% started antiretroviral treatment (ART), and 86% were virally suppressed.¹ This proves that these targets can be reached. Since 2016, all people who test positive have been able to start treatment immediately.⁸ Many HIV programs are deployed to keep viral suppression rates high while also reducing the number of new infections.⁹ To deal with this, the department of health on a district level has started community programs, such as door-to-door education, easier access to testing and treatment, and efforts to reduce stigma and support treatment adherence.⁹ Inequalities in treatment mean that certain groups within the population are still left out and remain at risk of continued HIV transmission.⁷ Modelling studies have shown that if some groups, such as men, young people, and key populations, do not get proper access to ART and support, the 95-95-95 targets may not be reached. For example, a study by Dimitrov⁴ showed that different levels of treatment coverage and viral suppression across groups can greatly affect how much new HIV infections decline in South Africa. According to Tlhoaele,¹⁰ a higher number of women accessed the clinic for ART medication and remained in care compared to men in Tshwane. The study highlighted differences in ART medication uptake and retention in care between male and female participants.¹⁰

Rationale

The rationale for this study lies in the critical need to assess and address the barriers preventing the successful implementation of the 95-95-95 targets for HIV care in the Tshwane District, Gauteng. The 95-95-95 targets aim to diagnose 95% of people living with HIV, ensure 95% of those diagnosed receive antiretroviral therapy (ART), and achieve viral suppression in 95% of those on treatment. UNAIDS 95-95-95 targets have been promising, but sub-national performance varies significantly. According to the District Health Barometer¹¹ and SANAC,¹² South Africa reports approximately 95% HIV status awareness, 91% ART coverage, and about 88% viral suppression among people on treatment. However, these averages can obscure important disparities at district and facility levels. Tshwane District, located in Gauteng Province, has one of the highest HIV burdens in the country and includes both urban and peri-urban populations with diverse healthcare needs. Tshwane Sub-District 1, in particular, serves areas with a high density of informal settlements, high patient mobility, and a mix of socio-economic challenges that can impact HIV service delivery. According to the Gauteng Department of Health,¹³ reports from Tier. Net and DHIS suggest that while HIV testing and ART initiation are relatively high, some facilities in Sub-District 1 report viral suppression rates below 85%, falling short of the third UNAIDS target According to Ritshidze, 2023 several facilities have shown incomplete viral load data capture and inconsistent follow-up rates, which makes it difficult for programme managers to track progress or intervene effectively. There is currently no disaggregated public reporting at the sub-district or facility level, which creates a gap in understanding local implementation success and barriers.¹⁴ The failure to address these challenges undermines national and global efforts to end the HIV/AIDS epidemic. This study is essential because it will provide a focused examination of the barriers faced by these populations in the Tshwane District, offering insights into how the implementation of the 95-95-95 targets can be improved. By investigating the current gaps in access to ART and care, the study will help inform the design of targeted interventions that are both inclusive and sensitive to the needs of these vulnerable groups. Furthermore, this research will contribute to strengthening the understanding of local health system limitations, policy implications, and resource allocation, ultimately helping to shape more effective HIV/AIDS strategies and ensure equitable healthcare access in the region.

Study purpose

The purpose of this study is to assess the implementation of 95-95-95 HIV targets in the Tshwane Sub-District 1, Gauteng, South Africa.

Objectives

The objectives of this study are:

Study design

This study will employ a quantitative, cross-sectional design to assess progress toward achieving the UNAIDS 95-95-95 HIV targets in Tshwane Sub-District 1, Gauteng. Quantitative methods provide a structured and systematic approach to examining measurable phenomena, allowing the researcher to test hypotheses, identify patterns, and quantify relationships between variables while ensuring objectivity, consistency, and reproducibility.¹⁵ Data will be collected at a single point in time, offering a clear snapshot of the current status of HIV testing, antiretroviral therapy (ART) initiation, and viral suppression among the population. This design is suitable for highlighting both progress and remaining gaps in reaching the 95-95-95 goals.

Study setting

The study will be conducted in purposively selected clinics within Tshwane Sub-District 1. Clinics were selected to reflect diversity in facility type, patient volume, and HIV program performance. All selected facilities provide comprehensive HIV testing, treatment, and care services and utilize electronic monitoring systems, including Tier. Net and DHIS2, to ensure the availability of reliable routine data. Tshwane was chosen due to persistent difficulties in meeting the 95-95-95 targets,¹⁰ especially among vulnerable groups.

Study population and sampling

Target population

This study will use both primary and secondary data sources. Primary data will come from healthcare workers directly involved in HIV care in Tshwane Sub-district 1, such as nurses, HIV counsellors, and community health workers. Secondary data will include records of people living with HIV (PLHIV) that are already captured in Tier.Net and DHIS between 2018 and 2024.

Sampling methods

For the primary data, clinics will be purposively selected based on low HIV testing coverage or high ART interruption rates.¹⁶ Within those clinics, all eligible healthcare workers will be invited to participate using total sampling. For the secondary data, a census approach will be used to include all 23 public facilities in the sub-district.¹⁷ At the patient level, all qualifying records that meet the inclusion criteria (HIV testing, ART initiation, viral load results) will be included.

Sample size

The sample size for the primary data depends on the number of healthcare workers who will consent to take part in the study from the facilities. For secondary data, all complete and valid records from tier.net and DHIS between 2018 and 2024 will be included. Data will be cleaned to remove any duplicates or incomplete entries before analysis.

Inclusion and exclusion criteria

The study will include healthcare workers involved in HIV programs within Tshwane Sub-district 1 who have at least six months of experience and willingly consent to participate. It will exclude those not directly involved in HIV care, temporary staff, and anyone working outside the sub-district. For secondary data, only records of people living with HIV diagnosed between 2018 and 2024 with complete Tier.Net or DHIS information will be used, while incomplete, duplicate, or unlinked records, as well as patients transferred without full records, will be excluded.

Data collection

Secondary data has been extracted from Tier.Net and DHIS2. Data cleaning procedures will include the removal of duplicates, correction of inconsistencies, and handling of missing values. Each 95-95-95 cascade indicator will be defined according to UNAIDS standards. Primary data will be collected through structured surveys designed for quantitative analysis, including Likert-scale, yes/no, and numeric responses. The instruments will be pretested to check that all questions are clear, relevant, and easy to understand before data collection begins. After that tools will be pretested to ensure reliability and consistency.

Variables and measures

The primary outcome variables are: the first 95 (proportion of PLHIV diagnosed), the second 95 (proportion of diagnosed PLHIV initiated on ART), and the third 95 (proportion of PLHIV on ART achieving viral suppression). Covariates will include age, sex (gender), type of facility, and HCW cadre. Primary data measures will focus on healthcare worker's reported indicators of service delivery and adherence to HIV program protocols.

Data analysis

All data will be analysed quantitatively. Descriptive statistics will summarize patient and HCW characteristics, while chi-square tests and t-tests will assess differences across facilities. Regression modelling will explore predictors of gaps in the 95-95-95 cascade indicators. Integration of primary and secondary quantitative data will allow comparison between routine program performance and HCW-reported implementation challenges.

Data management and confidentiality

Data will be stored on secured password-protected servers, and personal identifiers will be removed. Each participant and patient record will have a unique study ID. Access to data will be limited to study investigators, and all procedures comply with POPIA and local ethical requirements.

Dissemination

Findings will be shared with district health Authorities, Policymakers, NGOs, and communities through reports, policy briefs, presentations, and possible journal publications. Community feedback sessions may be arranged to ensure affected populations have access to the results. Any amendments to the study protocol, such as changes in methodology or participant recruitment, will be submitted to ethics committees for approval before implementation. In the unlikely event of early study termination, collected data will be securely stored and stakeholders promptly informed of the rationale. Overall, despite its limitations, the study aims to provide practical, actionable insights to strengthen HIV service delivery, improve ART adherence support, address data gaps, and accelerate progress toward the 95-95-95 targets in Tshwane.

Study status

Pilot testing of the data extraction templates and survey instruments started in November 2025. The full extraction of routine data from Tier.Net and DHIS2, along with the survey of healthcare workers, is planned still progress. Data analysis is expected to take place in January-February 2026, with results and findings to be shared in mid-2026.

Anticipated findings

This study will assess how the UNAIDS 95-95-95 targets are being implemented in Tshwane sub-district 1, using both the routine program data and surveys of health care workers. By combining these sources, we aim to understand not just overall progress but also the practical challenges faced in the clinics with low testing coverage or high patient loss to follow-up. A key limitation of the study is its cross-sectional design, which provides only a snapshot in time and does not allow for assessment of trends or causal relationships. In addition, secondary data from 2018-2024 may be incomplete or inconsistent, particularly for vulnerable populations such as MSM or sex workers, which could affect the reliability of some analyses.