Universal testing and treatment of HIV in East Africa led to improved coverage with antiretroviral therapy and improved viral suppression

1. This cluster randomized control trial found that implementing community-based testing and treatment program in East Rural Africa significantly increased the proportion of HIV-positive individuals who were virally suppressed after two years, compared to baseline.

2. Age and sex disparities were obvious at baseline, and remained after 2 years of intervention

Evidence Rating Level: 1 (Excellent)

Study Rundown: It is known that early detection and treatment of HIV reduces the rates of viral transmission and improves the health of patients. In 2014, UNAIDS issued a mandate that by 2020, 90% of persons infected with HIV should be diagnosed, 90% of those diagnosed should receive treatment, and 90% of those receiving treatment should reach viral suppression (HIV RNA <500 copies/mL). The Sustainable East Africa Research in Community Health Study (SEARCH) is an ongoing cluster randomized control trial across 32 pair-matched communities in East Africa, studying the effect of a cascade-wide test and treat strategy versus a country-specific standard of care. Here, authors provide an observational study for 16 of these communities. With community-based testing and treatment programs, more patients became aware of their HIV status (64.9% baseline vs. 95.9% after two years). This in turn led to an increase in HIV viral suppression rates (35.5% increase, p < 0.001).

This study shows progress towards achieving the UNAIDS target goal in rural Uganda and Kenya. But, it is not without its limitations. First, the trial is not yet complete and thus the current analysis serves as a status report rather than a definitive declaration of success. Second, the analyses were based on stable community residents with full exposure to the intervention; a scenario that may not be reflective of the general population. Further studies should seek to confirm this response.

Click to read the study, published in JAMA

Relevant Reading: Status and methodology of publicly available national HIV care continua and 90-90-90 targets: A systematic review.

In-Depth [observational study]: This observational study took place across 16 rural communities in East Sub-Saharan Africa. The study consisted of 77,774 stable residents who were 15 years of age or older across these communities. Population-based HIV testing was conducted at baseline and annually thereafter. All HIV-positive individuals were eligible for ART with efavirenz plus tenofovir disoproxil fumarate, co-formulated either with emtricitabine or lamivudine. These eligible patients were also offered linkage to care consisting of (1) immediate appointments at government clinics, (2) personal introductions to clinic staff, (3) a clinician phone number, (4) transport voucher, (5) tracking of individuals who did not link to care. Streamlined ART delivery included (1) a 3-month follow-up schedule for clinically stable patients, (2) flexible hours and a welcoming environment, (3) a clinician phone number, (4) text or telephone- based appointment reminders, and (5) HIV RNA measures, with structured discussion of results with patients to support visit and medication adherence.

At baseline, 44.7% of HIV-positive residents had achieved HIV viral suppression. After 2 years of intervention, this value increased by 35.5% points to 80.2% (95% CI, 34.4-36.6, p < 0.001). At baseline, 64.9% of HIV-positive residents were previously diagnosed, 80.3% had initiated ART, and 85.8% who had initiated ART had viral suppression. After 2 years, 95.9% of HIV-positive residents were previously diagnosed, 93.4% had initiated ART, and 89.5% had achieved viral suppression. Age and sex disparities were obvious at baseline and remained after 2 years of intervention (youth, aged 15-24 years, are less likely than older residents (>24 years) to be diagnosed, receive ART, and achieve viral suppression).

Image: PD

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