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.

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).