After a second wave of intensive household testing, a large study of the ‘test and treat’ strategy in Zambia is diagnosing more people with HIV, getting more people onto treatment and reducing the time between diagnosis and starting treatment, findings from the PopART study presented last month at the Conference on Retroviruses and Opportunistic Infections (CROI 2017) show.
PopART, also known as HPTN 071, is a large community-randomised trial being carried out in Zambia and KwaZulu-Natal, South Africa. The study by researchers at the London School of Hygiene and Tropical Medicine, Zambart, Lusaka, Desmond Tutu TB Centre, South Africa, FHI 360, Durham, North Carolina, and Imperial College London is comparing the impact on HIV incidence of household-based HIV testing and linkage to care by community HIV care providers (CHiPs), and immediate initiation of antiretroviral treatment delivered through routine health care services, to the standard of care.
PopART is an important test of the feasibility of offering testing and treatment at a very large scale, essential for achievement of the 90-90-90 target of 90% of people with HIV diagnosed, 90% of diagnosed people on treatment and 90% of those on treatment virally suppressed.
PopART investigators reported on progress towards achieving the 90-90-90 goals in the second round of the study in Zambia, from June 2015 to October 2016 in communities randomised to receive household visits. Each round of the study consists of visits to all households in the community to offer home-based HIV counselling and testing and, in round two, to make contact with everyone diagnosed with HIV in round one, to ensure that they had been linked to care and remain in HIV care.
After the first round of the study, 53% of people diagnosed with HIV in Zambia had started treatment within 12 months.
In Round Two, 45,616 households were visited, and 95% consented to take part in the study, comprising 110,755 adults (65% of men and 87% of women actually underwent testing). The higher frequency of testing among women was due to the fact that women were more likely to be contacted at home than men.
The researchers produced an estimate for the total number of adults living with HIV based on the prevalence of HIV among those who were tested (9.8% in men and 16.1% in women). They concluded that 6249 men and 10,341 women were living with HIV, and that 78% of men with HIV and 90% of women with HIV had been diagnosed.
Although men with HIV remained less likely to be diagnosed than women after Round Two, there was substantial improvement in the level of diagnosis in men. By the end of Round Two the proportion of men in all age bands diagnosed with HIV had risen above 70%, compared to less than 60% of those in the under-35 age bands being diagnosed after Round One. Men over 40 remained more likely to be aware of their HIV status after Round Two.
Among women the age difference in diagnosis evident after the first round had largely disappeared after Round Two. Almost 90% of women knew their HIV status in all age bands after Round Two.
After Round Two 78% of diagnosed men and 79% of women were estimated to be taking antiretroviral therapy (ART). Young men and women were less likely to be on treatment, but uptake of treatment improved in both women and men in Round Two. Among those who reported that they had started ART prior to the beginning of Round Two, 92% of men and 95% of women were still taking ART at the time they were contacted to take part in Round Two.
The speed at which people started treatment after having been referred for HIV care also improved in Round Two. Whereas it took study participants a median of nine and a half months to start treatment after referral in Round One, this interval was reduced to five months in Round Two. The investigators attribute this improvement to an increased focus among community HIV care providers on ensuring linkage to care, and improved co-ordination with clinics to ensure linkage.
The UNAIDS 90-90-90 targets aim to substantially decrease HIV transmission but it is unknown whether they can be achieved at scale in generalised epidemics. We report data from HPTN 071 (PopART), the largest programme to deliver universal testing and treatment at population level in Southern Africa, to determine how close we are to reaching the targets after two years of intervention.
The intervention comprises annual rounds of home-based HIV counselling and testing delivered by Community HIV Care Providers (CHiPs) who also support linkage to care, retention on ART and other HIV-related services. CHiP data from four communities in Zambia receiving the full PopART intervention (including universal ART irrespective of CD4 count), were used to determine proportions of adults who knew their HIV-positive (HIV+) status before and after the second annual round (R2: Jun 2015 – Sep 2016), and the proportions of known HIV+ adults who were on ART. Extrapolating from these data, we estimated overall proportions of HIV+ adults in these communities who knew their HIV+ status (first-90) and the proportion of these who were on ART (second-90) before and after R2.
By the end of August 2016, 45,616 households had been visited by CHiPs for the second annual round; 110,755 adult residents of these households (aged 18+) were enumerated, of whom 84,186 (76%) were contacted and consented to the intervention. Based on data from these participants, estimated total numbers of HIV+ adults in these four communities were 6,216 men and 10,341 women (Table), of whom 78% of men and 90% of women (86% overall) knew their HIV+ status following the R2 annual visit (first-90). Among these known HIV+ adults, 80% of men and 80% of women were estimated to be on ART by the end of R2 (second-90). For both targets, coverage was higher in those who had participated during R1 than in those who had not. Comparison of R1 and R2 estimates shows a continuing increase in coverage particularly for the second-90.
After two rounds of intervention, 86% of HIV+ adults were estimated to know their HIV+ status, close to the first-90. Of those known HIV+, an estimated 80% were on ART, approaching the second-90. Continuing efforts are needed to speed up linkage to care and ART initiation in order to reach the second-90. Lower coverage in the large number of clients who had not participated during R1 emphasises the need for annual re-visits in urban communities with high rates of mobility and migration.
Richard Hayes, Sian Floyd, Ab Schaap, Kwame Shanaube, Peter Bock, Sam Griffith, Nulda Beyers, Helen Ayles, Sarah Fidler