Comparative assessment of five trials of universal HIV testing and treatment in sub-Saharan Africa

Delphine Perriat, Laura Balzer, Richard Hayes, Shahin Lockman, Fiona Walsh, Helen Ayles, Sian Floyd, Diane Havlir, Moses Kamya, Refeletswe Lebelonyane, Lisa A Mills, Velephi Okello, Maya Petersen, Deenan Pillay, Kalpana Sabapathy, Kathleen Wirth, Joanna Orne-Gliemann, François Dabis, Universal Test and Treat Trials Consortium (UT3C), Delphine Perriat, Laura Balzer, Richard Hayes, Shahin Lockman, Fiona Walsh, Helen Ayles, Sian Floyd, Diane Havlir, Moses Kamya, Refeletswe Lebelonyane, Lisa A Mills, Velephi Okello, Maya Petersen, Deenan Pillay, Kalpana Sabapathy, Kathleen Wirth, Joanna Orne-Gliemann, François Dabis, Universal Test and Treat Trials Consortium (UT3C)

Abstract

Design: Universal voluntary HIV counselling and testing followed by prompt initiation of antiretroviral therapy (ART) for all those diagnosed HIV-infected (universal test and treat, UTT) is now a global health standard. However, its population-level impact, feasibility and cost remain unknown. Five community-based trials have been implemented in sub-Saharan Africa to measure the effects of various UTT strategies at population level: BCPP/YaTsie in Botswana, MaxART in Swaziland, HPTN 071 (PopART) in South Africa and Zambia, SEARCH in Uganda and Kenya and ANRS 12249 TasP in South Africa. This report describes and contrasts the contexts, research methodologies, intervention packages, themes explored, evolution of study designs and interventions related to each of these five UTT trials.

Methods: We conducted a comparative assessment of the five trials using data extracted from study protocols and collected during baseline studies, with additional input from study investigators. We organized differences and commonalities across the trials in five categories: trial contexts, research designs, intervention packages, trial themes and adaptations.

Results: All performed in the context of generalized HIV epidemics, the trials highly differ in their social, demographic, economic, political and health systems settings. They share the common aim of assessing the impact of UTT on the HIV epidemic but differ in methodological aspects such as study design and eligibility criteria for trial populations. In addition to universal ART initiation, the trials deliver a wide range of biomedical, behavioural and structural interventions as part of their UTT strategies. The five studies explore common issues, including the uptake rates of the trial services and individual health outcomes. All trials have adapted since their initiation to the evolving political, economic and public health contexts, including adopting the successive national recommendations for ART initiation.

Conclusions: We found substantial commonalities but also differences between the five UTT trials in their design, conduct and multidisciplinary outputs. As empirical literature on how UTT may improve efficiency and quality of HIV care at population level is still scarce, this article provides a foundation for more collaborative research on UTT and supports evidence-based decision making for HIV care in country and internationally.

Keywords: HIV; comparative assessment; protocols; randomized trials; sub-Saharan Africa; universal test and treat.

© 2018 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.

Figures

Figure 1
Figure 1
Evolution of the ART eligibility in the UTT trial areas from 1 January 2012 to 31 December 2016. WHO, World Health Organization; N, National recommendations; C, Control arm of the trial; I, intervention arm of the trial; A, Intervention arm A in the PopART trial; B, Intervention arm B in the PopART trial, *shift to universal antiretroviral therapy in the PopART communities in Zambia as part of a pilot for a national roll out.

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