Background
Universal testing and treatment (UTT) is a potential strategy to reduce HIV incidence,
yet prior trial results are inconsistent. We report results from HPTN 071 (PopART), the
largest HIV prevention trial to date.
Methods
In this community-randomized trial (2013-18), 21 communities in Zambia and South Africa
were randomized to Arm A (PopART intervention, universal antiretroviral therapy [ART]),
Arm B (PopART intervention, ART per local guidelines), and Arm C (standard-of-care). The
PopART intervention included home-based HIV-testing delivered by community workers who
supported linkage-to-care, ART adherence, and other services. The primary outcome, HIV
incidence between months 12-36, was measured in a Population Cohort (PC) of ~2,000
randomly-sampled adults/community aged 18-44y. Viral suppression (VS, <400 copies
HIV RNA/ml) was measured in all HIV-positive PC participants at 24m.
Results
The PC included 48,301 participants. Baseline HIV prevalence was similar across study
arms (21%-22%). Between months 12-36, 553 incident HIV infections were observed over
39,702 person-years (py; 1.4/100py; women: 1.7/100py; men: 0.8/100py). Adjusted
rate-ratios were A vs. C: 0.93 (95%CI: 0.74-1.18, p=0.51); B vs. C: 0.70 (95%CI:
0.55-0.88, p=0.006). At 24m, VS was 71.9% in Arm A; 67.5% in Arm B; and 60.2% in Arm C.
ART coverage after 36m was 81% in Arm A and 80% in Arm B.
Conclusions
The PopART intervention with ART per local guidelines reduced HIV incidence by 30%. The
lack of effect with universal ART was surprising and inconsistent with VS data. This
study provides evidence that UTT can reduce HIV incidence at population level.
Trial registration
ClinicalTrials.gov NCT01900977
We aimed to model the incidence of infection with Mycobacterium tuberculosis among adults using data on infection incidence in children, disease prevalence in adults, and social contact patterns. We conducted a cross-sectional face-to-face survey of adults in 2011, enumerating “close” (shared conversation) and “casual” (shared indoor space) social contacts in 16 Zambian communities and 8 South African communities. We modeled the incidence of M. tuberculosis infection in all age groups using these contact patterns, as well as the observed incidence of M. tuberculosis infection in children and the prevalence of tuberculosis disease in adults. A total of 3,528 adults participated in the study. The reported rates of close and casual contact were 4.9 per adult per day (95% confidence interval: 4.6, 5.2) and 10.4 per adult per day (95% confidence interval: 9.3, 11.6), respectively. Rates of close contact were higher for adults in larger households and rural areas. There was preferential mixing of close contacts within age groups and within sexes. The estimated incidence of M. tuberculosis infection in adults was 1.5–6 times higher (2.5%–10% per year) than that in children. More than 50% of infections in men, women, and children were estimated to be due to contact with adult men. We conclude that estimates of infection incidence based on surveys in children might underestimate incidence in adults. Most infections may be due to contact with adult men. Treatment and control of tuberculosis in men is critical to protecting men, women, and children from tuberculosis.
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