Researchers report on 1-year findings of PopART study

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In a research article, Richard Hayes of the London School of Hygiene & Tropical Medicine, UK and colleagues report early findings from PopART – a clinical trial evaluating an intervention to achieve universal HIV testing and treatment – in Zambia.

The authors estimate that, after 1 year of the intervention, the proportion of people with HIV who knew their infection status had increased from 52% to 78% (men) and from 56% to 87% (women); and that the overall proportion of people with HIV receiving antiretroviral treatment (ART) had increased from 44% to 61%.

Despite progress against the HIV epidemic, some 2.1m people were newly infected with HIV in 2015, according to the most recent estimates from UNAIDS (the joint United Nations Programme on HIV/AIDS). In that year, more than 1m people died from HIV-related illnesses, mostly in low- and middle-income countries.

To accelerate progress against this disastrous toll of ill health and mortality, UNAIDS has set ambitious “90-90-90” targets: by 2020, 90% of people infected with HIV should know their status, with 90% of people diagnosed with HIV infection to be receiving ART and 90% of people receiving treatment to have viral suppression.

PopART and other large studies are aiming to evaluate programmes for universal testing and treatment towards these goals and to measure their effect on the number of new HIV infections.

PopART (also known as HPTN 071) is being implemented in 21 urban communities in Zambia and South Africa with a total population of around 1m. The new paper reports findings from the first year of the study in Zambia only. In PopART, community HIV care providers systematically visit people in their homes to offer HIV testing and counselling, with linkage to appropriate facility-based care and follow-up for people with HIV, tuberculosis and other diseases.

Hayes and colleagues report that, after 1 year, the estimated population proportion of those with HIV infection knowing their status was close to the UNAIDS target in women (87%); the lower proportion in men (78%) suggests that reaching men through home visits may be challenging. Although the estimated proportion of HIV-positive people on ART increased from 44% to 61%, this falls short of the 81% target (90% of 90%). The data also suggest that ART coverage was lower in younger adults with HIV. The trial is ongoing, and additional findings will be reported in future years.

Collins Iwuji and Marie-Louise Newell discuss the research in an accompanying perspective, concluding that “Overall, these results would suggest that it is unlikely that the rather optimistic forecasts…of an imminent end to the global HIV epidemic will be fulfilled. Substantial resources are needed to further scale up ART for all HIV-positive adults, and allocation of limited resources will need to be optimised on the basis of evidence of efficacy.”

Background: The 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 findings: The 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.
Conclusions: In 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.

Richard Hayes, Sian Floyd, Ab Schaap, Kwame Shanaube, Peter Bock, Kalpana Sabapathy, Sam Griffith, Deborah Donnell, Estelle Piwowar-Manning, Wafaa El-Sadr, Nulda Beyers, Helen Ayles, Sarah Fidle

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