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 outcomewas 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 andUganda, implementation of community-based testing and treatmentwas 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 populationlevel viral suppression targetwas exceeded within 2 years after programimplementation.