A universal testing and treatment intervention to improve HIV control: One-year results from intervention communities in Zambia in the HPTN 071 (PopART) cluster-randomised trial.

Richard Hayes,Sarah Fidler,Sam Griffith,Nulda Beyers,Helen Ayles,Sian Floyd,Deborah Donnell,Estelle Piwowar-Manning,For The Hptn 071 (Popart) Study Team ,Peter Bock,Kalpana Sabapathy,Ab Schaap,Kwame Shanaube,Wafaa El-Sadr

doi:10.1371/journal.pmed.1002292

Abstract

BackgroundThe Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets require that, by 2020, 90% of those living with HIV know their status, 90% of known HIV-positive individuals receive sustained antiretroviral therapy (ART), and 90% of individuals on ART have durable viral suppression. The HPTN 071 (PopART) trial is measuring the impact of a universal testing and treatment intervention on population-level HIV incidence in 21 urban communities in Zambia and South Africa. We report observational data from four communities in Zambia to assess progress towards the UNAIDS targets after 1 y of the PopART intervention.Methods and findingsThe PopART intervention comprises annual rounds of home-based HIV testing delivered by community HIV-care providers (CHiPs) who also support linkage to care, ART retention, and other services. Data from four communities in Zambia receiving the full intervention (including immediate ART for all individuals with HIV) were used to determine proportions of participants who knew their HIV status after the CHiP visit; proportions linking to care and initiating ART following referral; and overall proportions of HIV-infected individuals who knew their status (first 90 target) and the proportion of these on ART (second 90 target), pre- and post-intervention. We are not able to assess progress towards the third 90 target at this stage of the study. Overall, 121,130 adults (59,283 men and 61,847 women) were enumerated in 46,714 households during the first annual round (December 2013 to June 2015). Of the 45,399 (77%) men and 55,703 (90%) women consenting to the intervention, 80% of men and 85% of women knew their HIV status after the CHiP visit. Of 6,197 HIV-positive adults referred by CHiPs, 42% (95% CI: 40%–43%) initiated ART within 6 mo and 53% (95% CI: 52%–55%) within 12 mo. In the entire population, the estimated proportion of HIV-positive adults who knew their status increased from 52% to 78% for men and from 56% to 87% for women. The estimated proportion of known HIV-positive individuals on ART increased overall from 54% after the CHiP visit to 74% by the end of the round for men and from 53% to 73% for women. The estimated overall proportion of HIV-positive adults on ART, irrespective of whether they knew their status, increased from 44% to 61%, compared with the 81% target (the product of the first two 90 targets). Coverage was lower among young men and women than in older age groups. The main limitation of the study was the need for assumptions concerning knowledge of HIV status and ART coverage among adults not consenting to the intervention or HIV testing, although our conclusions were robust in sensitivity analyses.ConclusionsIn this analysis, acceptance of HIV testing among those consenting to the intervention was high, although linkage to care and ART initiation took longer than expected. Knowledge of HIV-positive status increased steeply after 1 y, almost attaining the first 90 target in women and approaching it in men. The second 90 target was more challenging, with approximately three-quarters of known HIV-positive individuals on ART by the end of the annual round. Achieving higher test uptake in men and more rapid linkage to care will be key objectives during the second annual round of the intervention.Trial registrationClinicalTrials.gov NCT01900977

Highlights

While there have been some reductions globally in the incidence of new HIV infections, incidence and prevalence remain at unacceptably high levels in many parts of sub-Saharan Africa
Unless effective ways can Findings from Zambia after one year of the plan for the parent HPTN 071 (PopART) universal testing and treatment intervention be found of steeply reducing incidence, it will become increasingly difficult to sustain antiretroviral therapy (ART) services for all who need them
The indicators of intervention coverage used for the current analyses were determined at the start of the trial, but when the United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets were announced at a later stage (September 2014), our analyses were extended to provide estimates of coverage against these targets

Summary

Introduction

While there have been some reductions globally in the incidence of new HIV infections, incidence and prevalence remain at unacceptably high levels in many parts of sub-Saharan Africa. This is especially the case in southern Africa, where many regions are still experiencing severe generalised epidemics. Unless effective ways can Findings from Zambia after one year of the PopART universal testing and treatment intervention be found of steeply reducing incidence, it will become increasingly difficult to sustain ART services for all who need them. The HPTN 071 (PopART) trial is measuring the impact of a universal testing and treatment intervention on population-level HIV incidence in 21 urban communities in Zambia and South Africa. We report observational data from four communities in Zambia to assess progress towards the UNAIDS targets after 1 y of the PopART intervention

Methods

Results

Discussion

Conclusion