Association of Implementation of a Universal Testing and Treatment Intervention With HIV Diagnosis, Receipt of Antiretroviral Therapy, and Viral Suppression in East Africa

Abstract

<div class="section"> <a class="named-anchor" id="ab-joi170049-1"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e589">Question</h5> <p id="d3576481e591">Was implementation of a human immunodeficiency virus (HIV) test-and-treat intervention in rural East Africa associated with increases in diagnosis, treatment, and viral suppression among individuals with HIV infection? </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170049-2"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e594">Findings</h5> <p id="d3576481e596">In this study that included 77 774 residents of the intervention communities of an ongoing cluster randomized trial, the proportion of HIV-positive individuals with HIV viral suppression increased from 44.7% at baseline to 80.2% after 2 years, along with increases in HIV diagnosis and initiation of antiretroviral therapy. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170049-3"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e599">Meaning</h5> <p id="d3576481e601">Implementation of a community-based testing and treatment intervention in East Africa was associated with increased proportion of HIV-positive individuals who achieved viral suppression, along with increased HIV diagnosis and initiation of antiretroviral therapy. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170049-4"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e605">Importance</h5> <p id="d3576481e607">Antiretroviral treatment (ART) is now recommended for all HIV-positive persons. UNAIDS has set global targets to diagnose 90% of HIV-positive individuals, treat 90% of diagnosed individuals with ART, and suppress viral replication among 90% of treated individuals, for a population-level target of 73% of all HIV-positive persons with HIV viral suppression. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170049-5"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e610">Objective</h5> <p id="d3576481e612">To describe changes in the proportions of HIV-positive individuals with HIV viral suppression, HIV-positive individuals who had received a diagnosis, diagnosed individuals treated with ART, and treated individuals with HIV viral suppression, following implementation of a community-based testing and treatment program in rural East Africa. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170049-6"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e615">Design, Setting, and Participants</h5> <p id="d3576481e617">Observational analysis based on interim data from 16 rural Kenyan (n = 6) and Ugandan (n = 10) intervention communities in the SEARCH Study, an ongoing cluster randomized trial. Community residents who were 15 years or older (N = 77 774) were followed up for 2 years (2013-2014 to 2015-2016). HIV serostatus and plasma HIV RNA level were measured annually at multidisease health campaigns followed by home-based testing for nonattendees. All HIV-positive individuals were offered ART using a streamlined delivery model designed to reduce structural barriers, improve patient-clinician relationships, and enhance patient knowledge and attitudes about HIV. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170049-7"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e620">Main Outcomes and Measures</h5> <p id="d3576481e622">Primary outcome was viral suppression (plasma HIV RNA&lt;500 copies/mL) among all HIV-positive individuals, assessed at baseline and after 1 and 2 years. Secondary outcomes included HIV diagnosis, ART among previously diagnosed individuals, and viral suppression among those who had initiated ART. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170049-8"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e625">Results</h5> <p id="d3576481e627">Among 77 774 residents (male, 45.3%; age 15-24 years, 35.1%), baseline HIV prevalence was 10.3% (7108 of 69 283 residents). The proportion of HIV-positive individuals with HIV viral suppression at baseline was 44.7% (95% CI, 43.5%-45.9%; 3464 of 7745 residents) and after 2 years of intervention was 80.2% (95% CI, 79.1%-81.2%; 5666 of 7068 residents), an increase of 35.5 percentage points (95% CI, 34.4-36.6). After 2 years, 95.9% of HIV-positive individuals had been previously diagnosed (95% CI, 95.3%-96.5%; 6780 of 7068 residents); 93.4% of those previously diagnosed had received ART (95% CI, 92.8%-94.0%; 6334 of 6780 residents); and 89.5% of those treated had achieved HIV viral suppression (95% CI, 88.6%-90.3%; 5666 of 6334 residents). </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170049-9"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e630">Conclusions and Relevance</h5> <p id="d3576481e632">Among individuals with HIV in rural Kenya and Uganda, implementation of community-based testing and treatment was associated with an increased proportion of HIV-positive adults who achieved viral suppression, along with increased HIV diagnosis and initiation of antiretroviral therapy. In these communities, the UNAIDS population-level viral suppression target was exceeded within 2 years after program implementation. </p> </div><div class="section"> <a class="named-anchor" id="ab-joi170049-10"> <!-- named anchor --> </a> <h5 class="section-title" id="d3576481e635">Trial Registration</h5> <p id="d3576481e637">clinicaltrials.gov Identifier: <a data-untrusted="" href="http://clinicaltrials.gov/show/NCT01864683" id="d3576481e639" target="xrefwindow">NCT01864683</a> </p> </div><p class="first" id="d3576481e643">This analysis examines intervention communities in rural Uganda and Kenya in an ongoing cluster randomized trial to assess the change in the proportions of HIV-positive residents diagnosed with HIV, treated with ART, and achieving HIV viral suppression. </p>