A universal testing and treatment intervention to improve HIV control: One-year results from intervention communities in Zambia in the HPTN 071 (PopART) cluster-randomised trial

Abstract

Background: The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets require that, by 2020, 90% of those living with HIV know their status, 90% of known HIV-positive individuals receive sustained antiretroviral therapy (ART), and 90% of individuals on ART have durable viral suppression. The HPTN 071 (PopART) trial is measuring the impact of a universal testing and treatment intervention on population-level HIV incidence in 21 urban communities in Zambia and South Africa. We report observational data from four communities in Zambia to assess progress towards the UNAIDS targets after 1 y of the PopART intervention.

Methods and findings: The PopART intervention comprises annual rounds of home-based HIV testing delivered by community HIV-care providers (CHiPs) who also support linkage to care, ART retention, and other services. Data from four communities in Zambia receiving the full intervention (including immediate ART for all individuals with HIV) were used to determine proportions of participants who knew their HIV status after the CHiP visit; proportions linking to care and initiating ART following referral; and overall proportions of HIV-infected individuals who knew their status (first 90 target) and the proportion of these on ART (second 90 target), pre- and post-intervention. We are not able to assess progress towards the third 90 target at this stage of the study. Overall, 121,130 adults (59,283 men and 61,847 women) were enumerated in 46,714 households during the first annual round (December 2013 to June 2015). Of the 45,399 (77%) men and 55,703 (90%) women consenting to the intervention, 80% of men and 85% of women knew their HIV status after the CHiP visit. Of 6,197 HIV-positive adults referred by CHiPs, 42% (95% CI: 40%-43%) initiated ART within 6 mo and 53% (95% CI: 52%-55%) within 12 mo. In the entire population, the estimated proportion of HIV-positive adults who knew their status increased from 52% to 78% for men and from 56% to 87% for women. The estimated proportion of known HIV-positive individuals on ART increased overall from 54% after the CHiP visit to 74% by the end of the round for men and from 53% to 73% for women. The estimated overall proportion of HIV-positive adults on ART, irrespective of whether they knew their status, increased from 44% to 61%, compared with the 81% target (the product of the first two 90 targets). Coverage was lower among young men and women than in older age groups. The main limitation of the study was the need for assumptions concerning knowledge of HIV status and ART coverage among adults not consenting to the intervention or HIV testing, although our conclusions were robust in sensitivity analyses.

Conclusions: In this analysis, acceptance of HIV testing among those consenting to the intervention was high, although linkage to care and ART initiation took longer than expected. Knowledge of HIV-positive status increased steeply after 1 y, almost attaining the first 90 target in women and approaching it in men. The second 90 target was more challenging, with approximately three-quarters of known HIV-positive individuals on ART by the end of the annual round. Achieving higher test uptake in men and more rapid linkage to care will be key objectives during the second annual round of the intervention.

Trial registration: ClinicalTrials.gov NCT01900977.

Fig 1. Overview of design of the HPTN 071 (PopART) trial.

ART, antiretroviral therapy; TB, tuberculosis.

Fig 2. Cascade of care from enumeration of household members through ART initiation during the first annual round of the PopART intervention.

ART, antiretroviral therapy.

Fig 3. Time from referral to linkage to care and ART initiation during the first annual round of the PopART intervention.

Survival curves showing cumulative proportions linking to care or initiating ART following referral by community HIV-care providers. ART, antiretroviral therapy.

Fig 4. Estimated coverage compared with the first two 90 targets in those consenting to the PopART intervention.

Dark blue bars show the estimated proportion of HIV+ adults who knew their status (first 90 target) and the estimated proportion of those who knew their HIV+ status who were on ART (second 90 target), pre-intervention. Red bars show the same estimated proportions, post-intervention. ART, antiretroviral therapy.

Fig 5. Estimated coverage compared with the first two 90 targets extrapolated to the total adult population.

The red line shows the 90% target for first two of the 90-90-90 targets. Dark blue bars show the estimated proportion of HIV+ adults who knew their status (first 90 target) and the estimated proportion of those who knew their HIV+ status who were on ART (second 90 target), pre-intervention. Red bars show the same estimated proportions, post-intervention. ART, antiretroviral therapy.

Fig 6. First two 90 target estimates by sex and age group in those consenting to the PopART intervention and extrapolated to the total adult population.

The red line shows the 90% target for first two of the 90-90-90 targets. The first 90 target is proportion of individuals with knowledge of HIV-positive status, and the second 90 target is proportion of known HIV-positive individuals on antiretroviral therapy. CHiP, community HIV-care provider.

Fig 7. Overall estimates of proportion of HIV+ adults on ART by age group and sex in those consenting to the PopART intervention and extrapolated to the total adult population.

The red line shows the cumulative 81% target based on first two of the 90-90-90 targets. ART, antiretroviral therapy; CHiP, community HIV-care provider.