Universal HIV Test-and-Treat Strategy Faces Challenges

Although there was excellent acceptance in repeated HIV screenings at home, a new study found that entry into the health care system for people diagnosed as HIV seropositive was still a challenge for people in rural populations.

The goal of the study was to examine the effectiveness of the universal test-and-treat strategy in reducing HIV transmission in strongly affected populations. The strategy involved voluntary testing followed by the immediate administration of antiretroviral therapy in patients who are seropositive.

ANRS 122249 TasP is 1 of 5 international randomized trials. It was conducted in South Africa in the Hlabisa sub-district of the rural region of KwaZulu-Natal, which has one of the highest prevalence of HIV infection in the world.

In the ANRS 122249 TasP trial, researchers evaluated 22 geographic zones that each contained approximately 1280 individuals age 16 or older. Each cluster was randomized into 2 equal groups: the intervention group and a control group.

Between March 2012 and April 2016, there were 13,239 individuals included in the intervention arm and 14,916 in the control arm. Every 6-months participants were offered rapid HIV screening at home.

Those in the intervention arm who were diagnosed as seropositive were offered immediate antiretroviral therapy, no matter their CD4 count. In the control arm, treatment was initiated according to the indications recommended by the South African Ministry of Health (originally a CD4 count <350 mm3; since January 2015 a CD4 count <500 mm3).

Each cluster that contained participants who were seropositive were sent mobile treatment centers to help facilitate access to care, or they could use local health services at any time. The results of the study, presented at the international AIDS 2016 conference in South Africa, found that at home HIV screening was very well accepted, since HIV diagnosis was identified at least once for 88% of the contacted individuals.

In participants diagnosed as HIV seropositive, 37.5% went to a treatment center in the 6 months after screening. Furthermore, 91% of people in the intervention arm began antiretroviral therapy just 3 months after the start of management by a health care center, and 52% of individuals in the control arm.

When all available data sources, including mobile and fixed treatment centers, were taken into account, researchers estimated that only 4 out of 10 seropositive patients who lived in that region had an undetectable viral load. However, UNAIDS estimates that in order to meet its target to end the HIV epidemic by 2030, 7 out of 10 seropositive individuals must have an undetectable viral load by 2020 (90-90-90 target).

There were 495 individuals who became seropositive during the trial. In the intervention arm, the annual incidence of HIV infection was 2.13% (2.13 people infected out of 100 in a year), and 2.27% in the control group (adjusted relative risk: 0.96 [0.83 to 1.10]).

Authors noted that despite clear advantages of the strategy, such as the excellent acceptance of repeated screening at home and a very good response to antiretroviral therapy among seropositive people who decide to start it, seropositive patients are still met with the challenge of entering into the health care system.

“Innovative research on the health care system and communities must be conducted to reach the targets of the universal test and treat strategy, if we hope one day to control the epidemic,” said principal investigators Deenan Pillay and François Dabis.