Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial

Iwuji, Collins; Orne-Gliemann, Joanna; Larmarange, Joseph; Balestre, Eric; Thiébaut, Rodolphe; Tanser, Frank; Okesola, Nonhlanhla; Makowa, Thembisa; Dreyer, Jaco; Herbst, Kobus; McGrath, Nuala; Bärnighausen, Till; Boyer, Sylvie; Rekacewicz, Claire; Bazin, Brigitte; Newell, Marie‐Louise; Pillay, Deenan; Dabis, François; Naidu, Kevi; Rochat, Tamsen; Viljoen, Johannes; Zuma, Thembelihle; Karcher, Sophie; Plazy, Mélanie; Prague, Mélanie; Tiendrebeogo, Thierry; Donfouet, Hermann Pythagore Pierre; Gosset, Andréa; March, Laura; Protopopescu, Camélia; Spire, Bruno; Calmy, Alexandra; Inghels, Maxime; Diallo, Hassimiou; Cálvez, Vincent; Derache, Anne; Marcelin, Anne‐Geneviève; Dray‐Spira, Rosemary; Farouki, Kamal El; Lessells, Richard J; Freedberg, Kenneth A.; Imrie, John; Chaix, Marie‐Laure; Newell, Colin; Hontelez, Jan A. C.

doi:10.1016/s2352-3018(17)30205-9

Cited by 198 publications

(192 citation statements)

References 51 publications

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“…Consistent with other African cohort studies, viral suppression among youth was lower than among older adults . Mobile populations in all the trials had lower rates of viral suppression compared to non‐mobile populations . Men had lower viral suppression rates than women at study start and only slightly lower rates of viral suppression than women at study end.…”

Section: Discussionmentioning

confidence: 90%

What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?

et al. 2020

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Introduction Achieving HIV epidemic control globally will require new strategies to accelerate reductions in HIV incidence and mortality. Universal test and treat (UTT) was evaluated in four randomized population‐based trials (BCPP/Ya Tsie, HPTN 071/PopART, SEARCH, ANRS 12249/TasP) conducted in sub‐Saharan Africa (SSA) during expanded antiretroviral treatment (ART) eligibility by World Health Organization guidelines and the UNAIDS 90‐90‐90 campaign. Discussion These three‐year studies were conducted in Botswana, Zambia, Uganda, Kenya and South Africa in settings with baseline HIV prevalence from 4% to 30%. Key observations across studies were: (1) Universal testing (implemented via a variety of home and community‐based testing approaches) achieved >90% coverage in all studies. (2) When coupled with robust linkage to HIV care, rapid ART start and patient‐centred care, UTT achieved among the highest reported population levels of viral suppression in SSA. Significant gains in population‐level viral suppression were made in regions with both low and high baseline population viral load; however, viral suppression gains were not uniform across all sub‐populations and were lower among youth. (3) UTT resulted in marked reductions in community HIV incidence when universal testing and robust linkage were present. However, HIV elimination targets were not reached. In BCPP and HPTN 071, annualized HIV incidence was approximately 20% to 30% lower in the intervention (which included universal testing) compared to control arms (no universal testing). In SEARCH (where both arms had universal testing), incidence declined 32% over three years. (4) UTT reduced HIV associated mortality by 23% in the intervention versus control communities in SEARCH, a study in which mortality was comprehensively measured. Conclusions These trials provide strong evidence that UTT inclusive of universal testing increases population‐level viral suppression and decreases HIV incidence and mortality faster than the status quo in SSA and should be adapted at a sub‐country level as a public health strategy. However, more is needed, including integration of new prevention interventions into UTT, in order to reach UNAIDS HIV elimination targets.

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Section: Discussionmentioning

confidence: 90%

What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?

et al. 2020

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“…provision of services that are tailored to the needs of a given individual or sub‐population to improve outcomes and efficiencies within health systems). While modelling data suggest an AIDS‐free generation may be possible and community‐based “fast‐track” ART initiation can achieve high rates of virological suppression , recent data on reducing HIV incidence has been disappointing . More data are needed to understand the mechanisms behind these findings and the role adherence plays, particularly among vulnerable populations.…”

Section: Discussionmentioning

confidence: 99%

ART adherence and viral suppression are high among most non‐pregnant individuals with early‐stage, asymptomatic HIV infection: an observational study from Uganda and South Africa

et al. 2019

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IntroductionThe success of universal antiretroviral therapy (ART) access and aspirations for an AIDS‐free generation depend on high adherence in individuals initiating ART during early‐stage HIV infection; however, adherence may be difficult in the absence of illness and associated support.MethodsFrom March 2015 to October 2017, we prospectively observed three groups initiating ART in routine care in Uganda and South Africa: men and non‐pregnant women with early‐stage HIV infection (CD4 > 350 cells/μL), pregnant women with early‐stage HIV infection and men and non‐pregnant women with late‐stage HIV infection (CD4 < 200 cells/μL). Socio‐behavioural questionnaires were administered and viral loads were performed at 0, 6 and 12 months. Adherence was monitored electronically.ResultsAdherence data were available for 869 participants: 322 (37%) early/non‐pregnant, 199 (23%) early/pregnant and 348 (40%) late/non‐pregnant participants. In Uganda, median adherence was 89% (interquartile range 74 to 96) and viral suppression was 90% at 12 months; neither differed among groups (p > 0.72). In South Africa, median adherence was higher in early/non‐pregnant versus early/pregnant or late/non‐pregnant participants (76%, 37%, 52%; p < 0.001), with similar trends in viral suppression (86%, 51%, 79%; p < 0.001). Among early/non‐pregnant individuals in Uganda, adherence was higher with increasing age and lower with structural barriers; whereas in South Africa, adherence was higher with regular income, higher perceived stigma and use of other medications, but lower with maladaptive coping and cigarette smoking.DiscussionART adherence among non‐pregnant individuals with early‐stage infection is as high or higher than with late‐stage initiation, supporting universal access to ART. Challenges remain for some pregnant women and individuals with late‐stage infection in South Africa and highlight the need for differentiated care delivery.

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“…Despite encouraging trends in antiretroviral therapy (ART) coverage and levels of viral load suppression, HIV incidence has not declined as much as predicted in HIV simulations, and remains high in young women in sub‐Saharan Africa and key populations [3]. Given the mixed results from recent cluster randomized trials of the population‐level effect of UTT on incidence declines and observed ongoing HIV incidence across populations, the UTT strategy and 90‐90‐90 goals may not be reaching all PLHIV [4‐6].…”

Section: Introductionmentioning

confidence: 99%

“…The rationale for UTT, that it will reduce population‐level HIV incidence, has relied primarily on results of mathematical models, which vary in their complexities and assumptions [7‐12]. Empirical data from cluster randomized trials of UTT have generated lower estimates of the population‐level HIV incidence impact of UTT [4‐6]. While there are several potential explanations for these discrepancies, one potential explanation is heterogeneity in viral suppression across sociodemographics and risk behaviours.…”

Section: Introductionmentioning

confidence: 99%

Evidence of sociodemographic heterogeneity across the HIV treatment cascade and progress towards 90‐90‐90 in sub‐Saharan Africa – a systematic review and meta‐analysis

et al. 2020

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Introduction Heterogeneity of sociodemographics and risk behaviours across the HIV treatment cascade could influence the public health impact of universal ART in sub‐Saharan Africa if those not virologically suppressed are more likely to be part of a risk group contributing to onward infections. Sociodemographic and risk heterogeneity across the treatment cascade has not yet been comprehensively described or quantified and we seek to systematically review and synthesize research on this topic among adults in Africa. Methods We conducted a systematic review of peer‐reviewed literature in Embase and MEDLINE databases as well as grey literature sources published in English between 2014 and 2018. We included studies that included people living with HIV (PLHIV) aged ≥15 years, and reported a 90‐90‐90 outcome: awareness of HIV‐positive status, ART use among those diagnosed or viral suppression among those on ART. We summarized measures of association between sociodemographics, within each outcome, and as a composite measure of population‐wide viral suppression. Results and discussion From 3533 screened titles, we extracted data from 92 studies (50 peer‐reviewed, 42 grey sources). Of included studies, 32 reported on awareness, 53 on ART use, 32 on viral suppression and 23 on population‐wide viral suppression. The majority of studies were conducted in South Africa, Uganda, and Malawi and reported data for age and gender. When stratified, PLHIV ages 15 to 24 years had lower median achievement of the treatment cascade (60‐49‐81), as compared to PLHIV ≥25 years (70‐63‐91). Men also had lower median achievement of the treatment cascade (66‐72‐85), compared to women (79‐76‐89). For population‐wide viral suppression, women aged ≥45 years had achieved the 73% target, while the lowest medians were among 15‐ to 24‐year‐old men (37%) and women (49%). Conclusions Considerable heterogeneity exists by age and gender for achieving the HIV 90‐90‐90 treatment goals. These results may inform delivery of HIV testing and treatment in sub‐Saharan Africa, as targeting youth and men could be a strategic way to maximize the population‐level impact of ART.

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Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial

Abstract: Introduction

Cited by 198 publications

References 51 publications

What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?

What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?

ART adherence and viral suppression are high among most non‐pregnant individuals with early‐stage, asymptomatic HIV infection: an observational study from Uganda and South Africa

Evidence of sociodemographic heterogeneity across the HIV treatment cascade and progress towards 90‐90‐90 in sub‐Saharan Africa – a systematic review and meta‐analysis

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