HIV data from sub-Saharan Africa gives reasons for hope

Organisation: Position: Deadline Date: Location:

Researchers and public health experts presented promising new data on the HIV epidemic and response in sub-Saharan Africa at the 22nd International AIDS Conference (AIDS 2018) today.

While a UNICEF study highlighted the ongoing toll of HIV among young people in the region, data from several African countries demonstrated how enhanced HIV prevention and treatment programmes can dramatically reduce the impact of the epidemic.

“Despite extraordinary progress, HIV remains a serious threat to the lives of millions of people in sub-Saharan Africa,” Linda-Gail Bekker, president of the International AIDS Society and international chair of AIDS 2018, said. “The data presented today underscore both the urgent need and the opportunity to invest in expanded HIV prevention and treatment programmes that can turn back the epidemic in Africa.”

Wednesday's press conference highlighted five abstracts being presented at AIDS 2018.

Note: Press summaries are based on abstracts; final data presented at the conference may change


Study projects heavy toll of HIV on young people in sub-Saharan Africa
An analysis conducted by UNICEF estimated that 9.6m young people aged 15-24 years will be newly infected with HIV in sub-Saharan Africa between 2017 and 2050. About two-thirds of those will be girls or young women, according to the study. The continued toll of HIV among young people reflects the rapidly growing youth population in the region, which is expected to increase by 85% by 2050, as well as the slow decline in HIV incidence in this group, which has fallen by some 3% per year since 2010.

Presenting the data, Aleya Khalifa of UNICEF noted that reducing the HIV burden among young people in sub-Saharan Africa will require better access to HIV prevention, sexual and reproductive health, and targeted testing services.

Abstract: Demographic transitions and the future of the HIV epidemic for children and adolescents
Session: New tools, old tricks: Innovative methods for understanding the epidemic (Hall 11B, Thursday, 26 July, 11:00-12:30)
(Abstract not yet available online)


Namibia surpasses target for viral suppression
A population-level study in Namibia (NAMPHIA) found that 77% of people living with HIV in the country are virally suppressed; that is, the HIV level in their blood has fallen to low levels. Viral suppression indicates that people living with HIV are on successful treatment, which not only improves their health, but also prevents transmission to others.

Presenter Bernard Haufiku, Namibian Minister of Health and Social Services, noted that Namibia surpassed the UNAIDS goal of achieving 73% viral suppression by 2020. Its success reflects a high-level commitment to HIV treatment: in 2015, Namibia implemented an Acceleration Plan that rapidly scaled up HIV testing and treatment services.

Abstract: Progress toward HIV epidemic control: Results from the Namibia Population-Based HIV Impact Assessment (PHIA)
Session: Pedal to the Metal: Accelerating the Cascade (Forum, Thursday, 26 July, 16:30-18:00)
(abstract not yet available online)


Randomised trial demonstrates impact of HIV ‘test-and-treat’ strategy
Data from SEARCH, a community-cluster randomised study in Uganda and Kenya, showed that enhanced testing and care initiatives for HIV and other diseases can result in significantly higher viral suppression and lower HIV mortality.

Communities in the study control group received testing and care for HIV-related hypertension and diabetes based on national guidelines. Communities in the intervention group received enhanced testing and care for the three diseases, including rapid-start treatment for all people living with HIV. After three years, communities receiving enhanced testing and care experienced higher viral suppression and lower HIV mortality, TB incidence and uncontrolled hypertension.

Presenting the data, Diane Havlir of the University of California San Francisco concluded that a multi-disease approach using streamlined care can rapidly achieve UNAIDS targets for HIV treatment and improve community health.

Abstract (10514)
Background: The SEARCH Study (NCT01864683; first phase endpoint 2017) is a cluster randomized trial evaluating a “test and treat” HIV and multi-disease prevention strategy in rural Uganda and Kenya. We evaluated interim population-level HIV cascade coverage achieved over two years in the 16 SEARCH intervention communities.
Methods: We enumerated residents via baseline household census. HIV serostatus and plasma RNA were measured annually at multi-disease health campaigns followed by home-based testing for non-attendees. Streamlined ART (EFV/TDF/+FTC or 3TC), including patient-centered care and viral load counseling, was universally offered. At baseline, and after one and two years follow-up, we estimated (1) proportion of baseline HIV+ adult (≥15 years) stable (>6mo/past year) residents previously diagnosed; (2) of these, proportion ever on ART; (3) of these, proportion with viral suppression (RNA< 500 copies/ml). We estimated population viral suppression as a cascade product and via direct HIV RNA measurement, using inverse weights to adjust for missing measures.
Results: Of 77,773 baseline adult stable residents, 55% were women, 53% farmers, and 20% < 20 years. Baseline HIV prevalence was 9.9% (West Uganda: 6.3%; East Uganda: 3.3%; Kenya: 19.5%). We achieved high cascade coverage by follow up year 2 (Figure): (1) 97.4% (95%CI:97.3%,97.5%) were previously diagnosed; (2) 93.2% had received ART (95%CI:92.6%,93.9%); (3) 89.5% were suppressed (95%CI:88.6%,90.4%). Population viral suppression at year 2 was 81.3% (95%CI:80.3%,82.3%) based on the cascade product and 82.8% (95%CI:80.2%,85.3%) by adjusted direct measure. Coverage was high among men and mobile populations: 97.5% (95%CI:97.4%;97.7%;) of men and 97.1% (95%CI:96.8%,97.5%) of mobile populations tested at least once; among baseline HIV+, 80.3% (95%CI:78.4%,82.2%) of men and 81.7% (95%CI:78.3%,85.1%) of mobile populations had at least one suppressed RNA level.
Conclusions: Using a multi-disease community-based approach and patient-centered streamlined care, we increased population viral suppression from 45% to 81%, exceeding the UNAIDS 90-90-90 cascade target within 2 years in SEARCH intervention communities.

M Petersen, L Balzer, D Kwarsiima, N Sang, G Chamie, J Ayieko, J Kabami, A Owaraganise, T Liegler, F Mwangwa, K Kadede, V Jain, A Plenty, G Lavoy, D Black, E Bukusi, C Cohen, T Clark, E Charlebois, M Kamya, D Havlir, SEARCH Study Team


Botswana study shows effectiveness of combination HIV prevention approach
The Ya Tsie Botswana Prevention Project, a randomised study in rural and semi-urban communities, found that a package of interventions, including expanded HIV testing, linkage to care, earlier treatment and voluntary male circumcision, led to 30% reduction in HIV incidence. The study compared outcomes over 30 months from 15 communities receiving the interventions and 15 communities receiving the standard of care.

Moeketsi Joseph Makhema of the Botswana Harvard AIDS Institute Partnership presented the findings, noting that they provided strong real-world evidence for the efficacy of this approach in settings with high HIV prevalence and relatively high HIV treatment coverage, such as Botswana.

Abstract (13216)
Background: Antiretroviral therapy(ART) markedly reduces incidence in known HIV-discordant relationships. However, the impact of expanded access to HIV testing/counseling(HTC), ART, and male circumcision(MC) on community HIV incidence is unknown, particularly in settings with both high HIV prevalence and high baseline ART coverage such as Botswana.
Methods: The Ya Tsie Botswana Prevention Project was a pair-matched community-randomized trial that evaluated the impact of prevention interventions on HIV incidence in 30 rural/semi-urban communities throughout Botswana, from 2013-2018. Fifteen communities were randomized to receive community-wide HTC, linkage-to-care, earlier ART initiation, and enhanced MC services, and 15 communities received standard of care. Universal ART became standard of care in both arms mid-2016. A random sample of ~20% of households in each community was selected, and HIV-uninfected 16-64 year-old residents of these households enrolled in a longitudinal HIV incidence cohort (HIC) that underwent ~annual HTC. We compared HIV incidence by randomized arm over ~30 months. The pre-specified primary analysis used a permutation test of inverse variance weighted average of log- transformed incidence ratios from pair-specific, interval-censored Cox proportional hazards models (PHM); 95% CIs were obtained using standard pair-stratified Cox PHM for interval censored data. P-values are two-sided.
Results: Among 12,610 participants, at baseline 29% were HIV-infected, 72% of whom were already on ART (97% of individuals on ART had HIV-1 RNA< 400copies/mL). We enrolled 8,974 HIV-uninfected individuals in the HIC (4,487/arm), with median age 29 years (60% female). The median duration of follow-up was 29 months, and 95% of participants in each arm re-tested for HIV at >1 follow-up visit. 57 HIC participants in the intervention arm (annualized HIV incidence: 0.59%) and 90 in the control arm (annualized HIV incidence: 0.92%) acquired HIV. The HIV incidence ratio was 0.69 (P=0.09) in intervention vs. standard-of-care communities in the primary weighted-average Cox PHM. The pair-stratified Cox PHM produced 95%CI of 0.46-0.90 (incidence ratio=0.65, P=0.01).
Conclusions: We observed a 30% reduction in community HIV incidence with expanded HTC, linkage, ART, and MC campaigns. Importantly, our findings demonstrate that it is possible to reduce HIV incidence in high-HIV-prevalence settings that have already approached the ambitious UNAIDS 90-90-90 targets, by further increasing coverage.

MJ Makhema, K Wirth, M Pretorius Holme, T Gaolathe, M Mmalane, E Kadima, U Chakalisa, K Manyake, A Mbikiwa, S Simon, R Letlhogile, K Mukokomani, E van Widenfelt, S Moyo, K Bennett, J Leidner, R Lebelonyane, MG Alwano, K Powis, S Dryden-Peterson, C Kgathi, V Novitsky, J Moore, P Bachanas, W Abrams, L Block, S El-Halabi, T Marukutira, LA Mills, H Bussman, L Okui, O John, R Shapiro, V DeGruttola, Q Lei, R Wang, E Tchetgen Tchetgen, M Essex, S Lockman


First trial of ‘universal test and treat’ in a government health system shows benefits
The MaxART study in eSwatini (previously known as Swaziland) provided the world’s first data on the impact of “universal test and treat” (UTT) in a government-run national health system; UTT entails offering antiretroviral treatment to all HIV-positive individuals, regardless of CD4 count. The study evaluated data from 14 health facilities as they transitioned from the current standard of care to UTT.

Velephi Okello of the eSwatini Ministry of Health reported that adopting UTT led to improved health system performance. The likelihood of achieving viral suppression improved dramatically, with 79% of patients achieving viral suppression under UTT compared with just 4% under the current standard of care. Patients under UTT were also 60% more likely to be retained in care.

Abstract (13370)
Background: The World Health Organization recommends offering antiretroviral treatment (ART) to all HIV-positive individuals regardless of CD4 count or disease stage, known as “universal test and treat” (UTT). However, the health systems effects of UTT implementation are unknown. We investigated the effect of UTT on retention and viral suppression in the world"s first UTT implementation trial in a government-managed health system.
Methods: In this stepped-wedge randomized controlled trial, fourteen public sector health facilities in Swaziland were paired and randomly assigned to transition in four-month steps from implementing the current national standard of care (SoC) to providing ART under UTT. ART-naïve clients ≥ 18 years who were not pregnant or breastfeeding were eligible for enrollment. We used Cox proportional hazard models with censoring of follow-up at clinic transition to measure the effects of UTT on our two primary endpoints: retention and viral suppression after ART initiation. The trial is registered with (NCT02909218).
Results: Between September 2014 and August 2017, 3405 clients (62% women, median age 33 years (IQR:28-42)) were enrolled. Under SoC, 12-month retention and post ART initiation viral load suppression rates were 80% (95% CI): 77-83) and 4% (95% CI: 2-7), respectively, compared to 86% (95% CI: 83-88) and 79% (95% CI: 75-83) under UTT. 75% of clients were missing viral load at the 6-month time window following ART initiation; they were considered unsuppressed. Compared to SoC, UTT had a modest effect on retention (hazard ratio (HR) 1.60, 95% CI 1.15-2.21) and a large effect on viral suppression among those retained 6 months after ART initiation (HR: 14.51, 95% CI: 7.31-28.79) (Table 1). The UTT effect on the combined endpoint of retention and viral suppression was also substantial (HR 4.88, 95% CI 2.96-8.05).
Conclusions: Adopting UTT improves the performance of the health system in providing ART to people living with HIV. The observed improvement in retention and viral suppression, key indicators of ART success, provides an important co-benefit of UTT. Our results from this “real world” health systems trial strongly support the scale-up of UTT in Swaziland and countries with similar HIV epidemics and health systems.

S Khan, D Spiegelman, F Walsh, S Mazibuko, M Pasi, B Chai, R Reis, K Mlambo, W Delva, G Khumalo, M Zwane, Y Fleming, E Mafara, A Hettema, C Lejeune, T Bärnighausen, V Okello

AIDS 2018 abstract (10514) AIDS 2018 abstract (13216) AIDS 2018 abstract (13370)

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