Community health approach to HIV testing and treatment in rural Africa improves health on path to HIV epidemic control

community health campaign
Antiretroviral treatment (ART) improves the health of people living with HIV and also reduces transmission of the disease. With 1.8 million new HIV infections every year, it’s clear that the full benefits from effective treatment of all people living with HIV have yet to be realized. New approaches to universal testing and treatment have to overcome multiple barriers. It’s estimated that millions of people with HIV do not know their status. People who are diagnosed face a health care system that’s unresponsive to their specific needs and lacks patient-centered care. As a result, only 47% of people living with HIV have viral suppression, far short of the 73% UNAIDS target for 2020. The challenge now is to find people living with HIV who aren’t receiving care.

A new paper in the New England Journal of Medicine shares the results of a Sustainable East Africa Research in Community Health (SEARCH) trial in rural Kenya and Uganda. The SEARCH team tested the idea that universal HIV treatment and annual testing in a community-based, multi-disease, patient-centered approach would result in a lower number of new HIV infections and better community health. They conducted mobile, 2-week health campaigns under large tents in all communities during weekdays, evening and weekends. For people who didn’t attend, testing was performed at home or some other location of their choice. People found to have HIV, diabetes or hypertension received counseling and clinic appointments. One group received standard care, while people in the intervention communities got a more intensive treatment model to facilitate linkage to care and the community was tested annually.

After 3 years, cumulative HIV testing coverage in the intervention group was 98% for community residents and HIV viral suppression went from was 15% higher at 3 years than the control communities. Within the intervention communities, annual incidence of HIV infection in the intervention group declined by 32% between the first and third years. However, there wasn’t a significant difference seen in the rate of new HIV infections between the intervention and the control community arms. The most likely explanation is that the control communities had also received successful HIV testing intervention, and responded to changing guidelines that made almost all patients eligible for ART went into effect 1 year into the trial. The combination of these increased the overall level of viral suppression from 42% to 68% in the control group, reducing large differences between the groups in the number of people capable of transmitting HIV.

There were also significant other health benefits to the community in response to the intervention approach. Risk of death, risk of tuberculosis and death among people living with HIV and prevalence of uncontrolled hypertension in adults were all 20% lower in the intervention group. The amount of time it took to start someone on ART was shorter, and the rate of viral suppression was both higher than the control group and above the UNAIDS target of 73%. Researchers attribute this gain to the multi-disease care model and the patient-centered delivery of universal ART, which accelerated ART initiation among people who hadn’t been receiving treatment. The trial showed that the way in which care is delivered can affect clinical outcomes.

SEARCH showed that in a remarkably short time period, a community health approach to “test and treat” could rapidly reduce HIV incidence, deaths, tuberculosis and other chronic diseases in sub-Saharan Africa that line up with UN Sustainable Development Goals. Population level viral suppression achieved in SEARCH is much higher than that being achieved with the current roll-out of ART in Uganda and Kenya. Further gains beyond standard of care are expected with longer follow-up. Important gaps remain though—young women and men are not able to achieve the same levels of viral suppression on ART, and young women in particularly are still being disproportionately infected with HIV. The SEARCH team is currently evaluating the addition of pre-exposure prophylaxis (PrEP) to this population – knowing that universal test and treat is a necessary first step, but not enough to achieve HIV epidemic control. To truly overcome this epidemic, we will need new and innovative patient-centered prevention and treatment strategies to reach all populations.