Community-based interventions for HIV testing and treatment in rural East Africa nearly doubled rates of HIV viral suppression over two years, according to a study by UC San Francisco researchers.
The findings, published June 6, 2017, in the Journal of the American Medical Association, are an encouraging step forward in the global effort to eliminate AIDS.
The results are the latest from the Sustainable East Africa Research in Community Health (SEARCH) study, an ongoing cluster randomized trial in rural Kenya and Uganda that considers the effect of test-and-treat strategy on HIV, health and economic outcomes.
A Global Challenge
In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) issued the ambitious 90-90-90 target: by 2020, to diagnose at least 90 percent of HIV-positive persons, treat 90 percent of those diagnosed with antiretroviral therapy (ART), and achieve suppressed viral replication in 90 percent of those treated. That would mean an overall rate of 73 percent viral suppression in all HIV-positive individuals.
In service of this goal, the World Health Organization (WHO) in 2015 recommended all HIV-positive individuals initiate ART, regardless of CD4 (the immune cell destroyed by HIV) count. This direction was modeled after San Francisco’s groundbreaking policy for universal ART treatment in 2010.
Despite the availability of effective treatments, HIV-positive individuals can be challenging to reach. Lack of awareness of infection, limited access to care, and poor retention in care are common obstacles. Of 37 million living with HIV worldwide, 20 million live without treatment.
“One of the big challenges of HIV is nearly half of the infected don’t know it,” said Diane Havlir, MD, chief of the UCSF Division of HIV, Infectious Diseases and Global Medicine and principal investigator of SEARCH. “Beyond treatment initiation, we need to consider the full cascade of care – including testing, diagnosis and maintenance.”
An Alternative Approach
The SEARCH study aimed to do just that – develop a scalable strategy to diagnose, treat and achieve viral suppression of HIV – in sub-Saharan Africa, where most nations remain below the UNAIDS 90-90-90 target.
They combined the WHO universal treatment recommendation with community-based multi-disease testing (including HIV, hypertension and diabetes) and patient-centered care designed to reduce structural barriers, improve patient-clinician relationships, and improve patient knowledge and attitudes about HIV. For instance, study participants would receive transportation vouchers, appointment reminders and flexible hours.
Researchers tracked 77,774 participants, aged 15 to 24, from 16 rural Kenyan and Ugandan communities for two years. HIV tests were given annually at multi-disease health campaign events and in-home. All HIV-positive individuals were immediately linked to care and offered treatment.
The HIV prevalence in the study population at baseline was 10.3 percent, with only 64.9 percent of HIV-positive participants previously aware of their status and 44.7 percent having achieved viral suppression.
After two years of community-based HIV testing and treatment, 95.9 percent of HIV-positive individuals had been diagnosed, 93.4 percent of those had received ART, and 89.5 percent of those had achieved viral suppression.
Overall, HIV viral suppression among this population nearly doubled over two years, from 44.7 percent to 80.2 percent, surpassing the UNAIDS 90-90-90 target.
A Promising Future
The SEARCH study offers proof that the WHO recommendation to treat all HIV-positive persons can be successfully implemented, and that the UNAIDS 90-90-90 target can be achieved – even exceeded – within a relatively short time period, even in communities that face severe barriers to HIV care.
Specifically, the study suggests ways to overcome these barriers, such as integrating HIV testing into a multi-disease strategy and designing patient-centered care.
“Our goal is to end the (AIDS) epidemic,” said Havlir. “One way to do that (in East Africa) is to use a community health approach to identify and treat all persons who are HIV-infected, thus improving the overall health of the greater community.”
The other co-authors include first author Maya Petersen, MD, PhD, of UC Berkeley; Laura Balzer, PhD, Gabriel Chamie, MD, MPH, Teri Liegler, PhD, Vivek Jain, MD, MAS, Lillian Brown, MD, PhD, Douglas Black, BA, and Tamara Clark, MHS, of the Division of HIV, Infectious Diseases and Global Medicine in the UCSF Department of Medicine; Albert Plenty, MS and Edwin Charlebois, MPH, PhD, of the Center for AIDS Prevention Studies, UCSF Department of Medicine; Craig R. Cohen, MD, MPH, of the Department of Obstetrics, Gynecology and Reproductive Sciences, UCSF School of Medicine; and additional researchers from UC Berkeley, Harvard, the Infectious Diseases Research Collaboration in Uganda, Kenya Medical Research Institute, and Makerere University in Uganda.