HIV testing and treatment coverage achieved after 4 years across 14 urban and peri-urban communities in Zambia and South Africa: An analysis of findings from the HPTN 071 (PopART) trial

Abstract

Background: In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the 90-90-90 targets: that 90% of people living with HIV know their HIV status, that 90% of those who know their HIV-positive status are on antiretroviral therapy (ART), and that 90% of those on treatment are virally suppressed. The aim was to reach these targets by 2020. We assessed the feasibility of achieving the first two targets, and the corresponding 81% ART coverage target, as part of the HIV Prevention Trials Network (HPTN) 071 Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART) community-randomized trial.

Methods and findings: The study population was individuals aged ≥15 years living in 14 urban and peri-urban "PopART intervention" communities in Zambia and South Africa (SA), with a total population of approximately 600,000 and approximately 15% adult HIV prevalence. Community HIV care providers (CHiPs) delivered the PopART intervention during 2014-2017. This was a combination HIV prevention package including universal home-based HIV testing, referral of HIV-positive individuals to government HIV clinic services that offered universal ART (Arm A) or ART according to national guidelines (Arm B), and revisits to HIV-positive individuals to support linkage to HIV care and retention on ART. The intervention was delivered in 3 "rounds," each about 15 months long, during which CHiPs visited all households and aimed to contact all individuals aged ≥15 years at least once. In Arm A in Round 3 (R3), 67% (41,332/61,402) of men and 86% (56,345/65,896) of women in Zambia and 56% (17,813/32,095) of men and 71% (24,461/34,514) of women in SA participated in the intervention, among 193,907 residents aged ≥15 years. Following participation, HIV status was known by 90% of men and women in Zambia and by 78% of men and 85% of women in SA. The median time from CHiP referral of HIV-positive individuals to ART initiation was approximately 3 months. By the end of R3, an estimated 95% of HIV-positive women and 85% of HIV-positive men knew their HIV status, and among these individuals, approximately 90% of women and approximately 85% of men were on ART. ART coverage among all HIV-positive individuals was approximately 85% in women and approximately 75% in men, up from about 45% at the start of the study. ART coverage was lowest among men aged 18 to 34 and women aged 15 to 24 years, and among mobile individuals/in-migrants. Findings from Arm B were similar. The main limitations to our study were that estimates of testing and treatment coverage among men relied on considerable extrapolation because, in each round, approximately one-third of men did not participate in the PopART intervention; that our findings are for a service delivery model that was relatively intensive; and that we did not have comparable data from the 7 "standard-of-care" (Arm C) communities.

Conclusions: Our study showed that very high HIV testing and treatment coverage can be achieved through persistent delivery of universal testing, facilitated linkage to HIV care, and universal treatment services. The ART coverage target of 81% was achieved overall, after 4 years of delivery of the PopART intervention, though important gaps remained among men and young people. Our findings are consistent with previously reported findings from southern and east Africa, extending their generalisability to urban settings with high rates of in-migration and mobility and to Zambia and SA.

Trial registration: ClinicalTrials.gov NCT01900977.

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

CD4, cluster of differentiation 4; ART, antiretroviral therapy.

Fig 2. Arm A: Participation in the PopART intervention, Zambian communities R1–R3, and SA communities R3, by sex and age group.

R1, Round 1; R2, Round 2; R3, Round 3; SA, South Africa.

Fig 3. Arm A: Knowledge of HIV status following participation in the PopART intervention, Zambian communities R1–R3, and SA communities R3, by sex and age group.

R1, Round 1; R2, Round 2; R3, Round 3; SA, South Africa.

Fig 4. Arm A: Self-report of HIV-positive status, new HIV-positive diagnosis, and total known to be HIV positive, as a percentage of individuals who participated in the intervention; and the percentage of known HIV-positive individuals who were newly diagnosed HIV positive.

Zambian communities R1–R3 and SA communities R3, by sex and age group. R1, Round 1; R2, Round 2; R3, Round 3; SA, South Africa.

Fig 5. Arm A: Estimates of coverage against the first and second 90 targets, by sex, country, and round (with extrapolation to the total population).

R1, Round 1; R2, Round 2; R3, Round 3.

Fig 6. Arm A: Estimates of coverage against the first 90 target, Zambian communities R1–R3, and SA communities R3, by sex and age group (with extrapolation to the total population).

R1, Round 1; R2, Round 2; R3, Round 3; SA, South Africa.

Fig 7. Arm A: Estimates of coverage against the second 90 target, Zambian communities R1–R3, and SA communities R3, by sex and age group (with extrapolation to the total population).

R1, Round 1; R2, Round 2; R3, Round 3; SA, South Africa.

Fig 8. Arm A: Time from CHiP referral to ART initiation among individuals referred to HIV care, by country and round of referral.

ART, antiretroviral therapy; CHiP, community HIV care provider; R1, Round 1; R2, Round 2; R3, Round 3; SA, South Africa.

Fig 9. Arm B: Estimates of coverage against the first and second 90 targets, by sex, country, and round (with extrapolation to the total population).

R1, Round 1; R2, Round 2; R3, Round 3.

Fig 10. Arm A and Arm B: ART coverage estimates, by trial arm, sex, country, and round (with extrapolation to the total population).

ART, antiretroviral therapy; R1, Round 1; R2, Round 2; R3, Round 3.