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Home-based universal test-and-treat program cuts HIV incidence by 30%
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SEATTLE – A home-based universal test-and-treat program led to a 30% decline in new HIV infections in a study conducted in two African countries, according to research presented at CROI.
The intervention conducted in Zambia and South Africa included house-to-house voluntary HIV testing, referring people who tested positive to HIV treatment according to local guidelines, and offering HIV prevention measures to those who tested negative, researchers explained.
“Taken together with the findings of other studies, our results provide key evidence that the universal test-and-treat strategy can bring down the incidence of new HIV infections, even in settings with severe, generalized HIV epidemics, as in much of southern Africa, and help to bring the global epidemic under effective control as we try to achieve the end of AIDS,” Richard J. Hayes, DSc, MSc, FMedSci, professor of epidemiology and international health at the London School of Hygiene & Tropical Medicine, said during a news conference.
Hayes and colleagues reported results from the HPTNO7 (PopART) study, the largest HIV prevention trial ever conducted, they said. They included a random sample of 48,301 adults aged 18 to 44 years in the study — roughly 2,300 adults from each of 21 communities in Zambia and South Africa, according to an NIH press release.
The community-randomized trial took place from 2013 to 2018, with the 21 communities arranged in seven groups of three and randomly assigned to receive full PopART intervention, including universal ART (arm A); PopART intervention with ART per local guidelines (arm B); and standard of care (arm C).
The PopART prevention intervention included annual rounds of home-based HIV testing by community HIV-care providers, who supported linkage to care, ART adherence and other HIV services, Hayes and colleagues explained.
They collected data from study participants at baseline, then after 1 year, 2 years and 3 years. Viral load was measured at 2 years.
According to the findings, the baseline HIV prevalence was similar — between 21.1% and 22.4% — across all three treatment arms. They recorded 553 incident HIV infections in 39,733 person-years between 12 and 36 months (or 1.4 per 100 person-years).
According to Hayes and colleagues, arms A and B had adjusted HIV incidence rate ratios of 0.93 and 0.70, respectively, compared with arm C. The difference between arm A and arm C was not statistically significant. The researchers reported surprise that new HIV infections did not significantly decline in patients who were immediately offered ART throughout the study.
“Surprisingly we found a smaller, non-significant effect in arm A, where we had expected to see the greatest effect,” Hayes said. “We need to do a lot more analysis to try to explain this dissonant finding.”
He said migration and mobility, as well as sexual risk behavior, might have been higher in arm A compared with the other cohorts.
The researchers reported that viral suppression was achieved by 72.1% of participants in arm A, 67.9% in arm B and 62.5% in arm C.
“The results of the PopART study suggest that conducting population-wide, home-based HIV testing and offering treatment to those diagnosed with HIV could help control the epidemic in certain settings,” Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, said in a news release. “These findings indicate that a universal test-and-treat strategy could be an important addition to our toolbox of proven HIV prevention modalities.” – by Bruce Thiel
Reference:
Hayes RJ, et al. Abstract 92LB. Presented at: Conference on Retroviruses and Opportunistic Infections; March 4-7, 2019; Seattle.
Disclosure: Fauci and Hayes report no relevant financial disclosures.
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Susan P. Buchbinder, MD
PopART demonstrated that communitywide home-based testing, with linkage to local HIV services for those testing positive, can successfully drive down population-level HIV infection rates.
The study provided invaluable lessons in how to rapidly scale up treatment and linkage. The 30% reduction in incidence also points out that more than testing and treatment alone are needed to end the epidemic.
Pre-exposure prophylaxis, not part of the PopART project, could potentially further drive down population-level HIV infection rates.
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