The HIV Prevention Trials Network (HPTN) congratulates the participants and researchers taking part in two important HIV prevention trials announcing results this week at the AIDS 2018 conference – the Sustainable East Africa Research in Community Health (SEARCH) study and the Botswana Combination Prevention Project (BCPP) study. Both studies were cluster-randomized, community-based trials conducted in sub-Saharan Africa that measured the impact of enhanced HIV services and the offer of universal treatment on HIV incidence. These impressive studies have demonstrated that providing enhanced HIV testing and treatment services at the community level (with treatment provided through government facilities) can help to achieve the UNAIDS 90-90-90 targets and may also reduce the rate of new HIV infections in some settings.
SEARCH and BCPP are two of several large-scale universal testing and treatment (UTT) studies being conducted in sub-Saharan Africa. Another of these studies is HPTN 071 (PopART), for which results are expected in early 2019. Although HPTN 071 (PopART), SEARCH and BCPP are all investigating the impact of UTT on HIV incidence, there are key differences between the studies:
- Setting: SEARCH and BCPP were conducted in smaller, more rural communities (average community size of 10,450 and 5,785, respectively), whereas HPTN 071 (PopART) is being conducted in larger urban and peri-urban communities (average size 44,000). All three of the trials were conducted in different countries.
- Intervention: The intervention offered in SEARCH was centered around community services provided through periodic community health campaigns which offered HIV testing and multi-disease prevention and treatment, with services provided at the household level for those missed at the health campaigns. In contrast, the interventions in BCPP and HPTN 071 focused heavily on service provision to all community residents at the household (with treatment provided at local government clinics). An important difference between BCPP and HPTN 071 is that BCPP initially provided ART only to those with viral loads of 10,000 copies/mL or higher (or who were eligible according to the local treatment guidelines) whereas HPTN 071 included the offer of immediate treatment from the start in the communities where the full intervention was offered.
- Endpoint Assessment: The three studies differ in how they measured community incidence of HIV. HPTN 071 followed a randomly-selected cohort of approximately 2,000 adults aged 18-44 (each from a different household) in each community in the intervention and control arms over three years. SEARCH and BCPP also measured incidence over three years, but differently. In SEARCH, all adults 15 years and older were tested yearly in the intervention arm, and at baseline and after three years in the control arm. In BCPP, a cohort of adults aged 16-64 years, drawn from a randomly-selected sample of households in the intervention and control arms, was followed for annual testing over three years.
In view of these differences, HPTN 071 (PopART) is poised to answer additional important questions about UTT that were not addressed in SEARCH or BCPP:
- Can a combination prevention package, including UTT, lower HIV incidence in urban/peri-urban settings in sub-Saharan Africa - the kind of settings where 40 percent of the population now live?
- How does successful implementation of UTT in urban/peri-urban settings differ from rural settings in terms of strategy, cost and effectiveness?
- Can the UTT approach be delivered successfully across multiple settings in multiple countries at large scale in sub-Saharan Africa?
Given the mixed findings of the previous UTT trials, HPTN 071 (PopART) will also be of great importance in helping to clarify the impact of UTT on HIV incidence in different settings.
The final results of HPTN 071 (PopART) are expected in early 2019. Already-reported findings show that after three years, the PopART intervention has substantially increased the uptake of HIV testing and ART and has achieved the first two of the UNAIDS 90-90-90 targets that are part of the strategy to bring the global HIV epidemic under control.
About HPTN 071 (PopART)
HPTN 071, also known as PopART (Population Effects of Antiretroviral Therapy to reduce HIV Transmission), is investigating a combination prevention package that includes annual house-to-house HIV testing, linkage to care, support for antiretroviral therapy (ART) retention, ART for all those with HIV-infection and other HIV prevention services. HPTN 071 (PopART) is being conducted in 21 urban and peri-urban communities in Zambia and South Africa, and will provide additional evidence of the effectiveness of universal testing and treatment (UTT) in lowering the spread of HIV.
About SEARCH and BCPP
The SEARCH study took place in 32 communities in rural Uganda and Kenya where periodic community health campaigns offered communities testing for HIV and other diseases and provided streamlined, universal treatment to HIV-infected adults and children. HIV testing was provided at the homes of residents who were not reached during the local health campaigns. The BCPP study tested the rapid scale-up of HIV services -- including HIV testing, HIV treatment and male circumcision – in 30 villages in rural/peri-urban Botswana to slow down the rate of new HIV infections.
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