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

Abstract

Importance: 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.

Objective: 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.

Design, setting, and participants: 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.

Main outcomes and measures: Primary outcome was viral suppression (plasma HIV RNA<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.

Results: 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).

Conclusions and relevance: 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.

Trial registration: clinicaltrials.gov Identifier: NCT01864683.

Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Figures

Figure 1.. Prior Diagnosis, ART, and Viral Suppression Among HIV-Positive Stable Residents of 16 SEARCH Intervention Communities in Rural Uganda and Kenya (Open Cohort)

ART indicates antiretroviral therapy; HIV, human immunodeficiency virus; SEARCH, Sustainable East Africa Research in Community Health Study. Stable residence was defined as living in the study community for 6 or more months in the past year. Viral suppression was defined as plasma HIV RNA measurement of less than 500 copies/mL. aEstimates adjusted for incomplete HIV serostatus and HIV RNA measurement (eTables 1-2 in Supplement 3).

Figure 2.. Prior Diagnosis, ART, Viral Suppression, Migration Out of the Community, and Death Among HIV-Positive Stable Residents of 16 SEARCH Intervention Communities in Rural Uganda and Kenya Who Were Diagnosed At or Before Baseline (Closed Cohort)a

ART indicates antiretroviral therapy; HIV, human immunodeficiency virus; SEARCH, Sustainable East Africa Research in Community Health Study. Stable residence was defined as living in the study community for 6 or more months in the past year. Viral suppression indicates residents who had less than 500 copies/mL of HIV RNA. Migration out of the study community indicates prior residents who were reported to no longer live in the community. aAdjusted to account for incomplete plasma HIV RNA measurement (eTable 4 in Supplement 3).