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Community-wide HIV prevention strategy can reduce infections by 30%

Researchers have presented results from the HPTN 071 (PopART) study at the annual Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle. The study examined the impact of a package of HIV prevention interventions on community-level HIV incidence in urban and peri-urban communities in South Africa and Zambia. Findings from HPTN 071 (PopART) show delivery of an HIV prevention strategy that includes offering in-home HIV testing to everyone, with immediate referral to HIV care, and treatment for people living with HIV based on prevailing in-country guidelines, can substantially reduce new HIV infections.

“We saw a highly significant 30% decrease in new HIV infections with a prevention strategy where HIV treatment was started according to in-country guidelines,” said Richard Hayes, HPTN 071 protocol chair and professor of epidemiology and international health at the London School of Hygiene and Tropical Medicine. “We did not see a similar reduction in new HIV infections with another strategy where universal HIV treatment was offered from the beginning of the study. Additional analyses are underway to explore the reasons for this finding.”

The HPTN 071 (PopART) study involved more than 1m people living in 21 communities in Zambia and South Africa, making it the largest HIV prevention trial to date. The study measured the effects of two HIV combination prevention strategies offering HIV testing to people in their homes annually, with linkage to HIV care and treatment at the local health facility for those living with HIV.

“Overall, both strategies improved knowledge of HIV status and uptake of treatment,” said Dr Wafaa El-Sadr, HPTN co-principal investigator, and professor of epidemiology and medicine at Columbia University in New York. “These findings show that a combination prevention strategy similar to PopART may be an effective tool to slow the global HIV epidemic.”

HPTN 071 (PopART) researchers are currently examining the effects of the interventions on other study outcomes including herpes simplex virus-2 incidence, tuberculosis and HIV-related stigma. Work is also in progress to estimate the cost-effectiveness of the interventions.

“While the findings from the HPTN 071 (PopART) study are very encouraging,” said Dr Sarah Fidler, protocol co-chair and professor of medicine at Imperial College London. “Testing and treatment coverage fall short among young people and men necessitating the need for further research on how to fill these important gaps.”

The research team in South Africa was led by Dr Nulda Beyers and Dr Peter Bock, research clinicians, Desmond Tutu TB Centre (DTTC) in the department of paediatrics and child health at Stellenbosch University. The research team in Zambia was led by Dr Helen Ayles, director of research, Zambart, Lusaka, Zambia.

In both South Africa and Zambia, hundreds of community HIV care providers went house to house in 14 intervention communities over a period of four years, with repeated offers of HIV counselling and testing. The DTTC also worked closely with the Western Cape Health Department and the City of Cape Town Health Department in linking HIV positive study participants to antiretroviral treatment at clinics. The DTTC hopes the lessons learnt will help to inform and change both policy and practice.

“Results from the HPTN 071 (PopART) study strongly support the ongoing expansion of the community-based platforms for health service delivery. There remain extensive opportunities for improved delivery of community-based health care services and more effective partnerships with communities to strengthen primary care health services in high-burden settings. Lessons learnt from PopART can be used to inform these activities going forward,” said Bock.

The City of Cape Town welcomed the results.

“There have been a number of valuable lessons learnt from this study. Not only did we learn what capacity there exists within health facilities to increase the number of HIV tests conducted, but it also shed light on the difficulties clients face between diagnosis and accessing care. Most important were the lessons learnt around regular door to door HIV testing, which isn’t currently part of the public health service offering and how effective it could be in ensuring that more people know their HIV status,” said the City’s mayoral committee member for community services and health, Councillor Zahid Badroodien.

James Kruger, director: HIV AIDS STI & TB at the Western Cape Health Department, said: “It will hopefully give us indications on how to tailor-make our interventions to a particular local context. This will allow us to reset our provincial, district, sub-district and local planning in accordance with the outcomes and voices of the community. We have also learned many lessons on the deployment of community care workers and will use this to reconsider what a community health service package could be and how to add to our current community-based services package.”

Beatrice Morobe, a member of the Community Advisory Board, which formed a link between the communities, the clinics and the researchers, said the study had a meaningful impact on people in communities.

“It helped so many people. More people got tested for HIV and went to the clinics to get treatment. The way people were encouraged to get tested and then assisted to get ARVs at clinics if they were HIV positive helped to break down stigma. It was done in a very positive way. I’m so proud to have been part of this study.”

“The study team is deeply grateful to the South African and Zambian study participants, the implementing and community partners, research teams, Ministries and Departments of Health, study funders and sponsor, without whom this research would not have been possible,” said Dr Myron Cohen, co-principal investigator and director of the Institute for Global Health at the University of North Carolina in Chapel Hill.

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