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SEARCH study exceeds 90-90-90 targets after 2 years of 'test and treat' for HIV in rural East Africa
Keith Alcorn, 2016-07-20 21:50:00
A large study that
embeds 'test and treat' for HIV within a larger multi-disease prevention
campaign in rural Kenya and Uganda has achieved 82% viral suppression after two
years, and already exceeded UNAIDS targets for viral suppression after one
year of activity, investigators from the SEARCH study reported today at the 21st
International AIDS Conference (AIDS 2016) in Durban, South Africa.
The UNAIDS 90-90-90 targets (90% of people diagnosed with HIV, 90% of diagnosed people on treatment and 90% of treated people virally suppressed) equate to viral suppression in the entire population of people living with HIV of 73%. The SEARCH study achieved viral suppression of 77% after its first year of activity, and 82% after its second year, Dr Maya Petersen
of University of California Berkeley School of Public Health reported.
The SEARCH study
was designed to test whether offering HIV testing within a larger community
screening programme for non-communicable diseases such as diabetes would
increase demand for testing, whether a streamlined linkage to care model
improves treatment initiation, and whether the sequence of enhanced linkage and
person-centred treatment improves retention and viral suppression. The primary outcome
being measured in the study is whether the entire package leads to a reduction
in HIV infections in the communities where it is offered.
The study has randomised
32 communities, each with around 10,000 inhabitants, to receive either the
intervention or standard of care. The intervention consists of:
- A multi-disease prevention
campaign that includes testing for HIV, diabetes and hypertension, with a
two-week health fair and household testing in each community.
- Linkage to care of anyone who
- Immediate ART, regardless of
more about the SEARCH study interventions here).
Dr Maya Petersen presented interim results of the study,
looking at the proportions of people on treatment and virally suppressed after
one and two years.
collected at baseline and after twelve and 24 months of follow-up. Participants
were tested for HIV and viral load was checked for those found to be infected.
ART consisted of a standardised regimen of efavirenz with tenofovir and
emtricitabine or lamivudine. The intervention adopted a patient-centred
approach to care. Viral load counselling was offered to all patients.
At baseline and
again after one and two years, the investigators estimated the proportion of
all patients with HIV who were diagnosed; the proportion of diagnosed patients
receiving ART; and the percentage of ART-treated patients with viral
suppression (defined as a viral load below 500 copies/ml). The investigators
also calculated the proportion of all HIV-infected patients with virological
The baseline study
population consisted of approximately 78,000 individuals with stable
accommodation. The majority (55%) were women, 53% were farmers and one-third
were aged 24 years and under. Baseline HIV prevalence was 10%, but this differed
by region (West Uganda: 6%; East Uganda: 3%; Kenya: 20%).
At baseline, 70%
of people with HIV had been previously diagnosed, 80% had ever taken ART and
86% of those ART-treated patients were virally suppressed. Overall, 45% of all
patients with HIV had a viral load below 500 copies/ml.
By the end of year
1, 96% of people with HIV had been diagnosed, 91% had taken ART and 89% were
By the end of year
2 the intervention exceeded UNAIDS 90-90-90 targets. By this time, 97% of
HIV-infected patients were diagnosed; 94% had received ART and 90% were virally
suppressed. In addition, 82% of all people with HIV had a viral load below 500
was also successful at reaching populations with traditionally sub-optimal levels
of engagement in care: 97% of men and 97% of mobile populations had been tested
for HIV at least once by month 24. Whereas
men were much less likely to know their HIV status at baseline, the gender gap
in knowledge of HIV status was virtually eliminated by the end of year 2 and equalized
at the end of year 2.
A gap in HIV
diagnosis, treatment initiation and viral suppression persisted throughout the
follow-up period between younger people aged 15-24 and older people. Only 53%
of under-25s knew their HIV status at baseline compared to 72% of the older age
group, and after two years 90% of under-25s knew their status compared to 98%
of the older age group. Treatment initiation (89% vs 94%) and viral suppression
(83% vs 90%) remained lower after two years in under-25s, and this difference
translated into an overall level of viral suppression among the under-25
population of 67%, compared to 84% in the older age group.
conclude that use of a multi-disease community-based approach with streamlined
patient care, increased the proportion of all HIV-infected patients with viral
suppression from 45% at baseline to 81% within two years, thus exceeding UNAIDS
elements of the intervention appear to have the greatest impact in achieving
the overall goal of viral suppression, Maya Petersen told aidsmap that the team believed that it was the strong community
involvement and patient-centred nature of the care provided, rather than any
individual element, that had produced the high levels of linkage to care,
treatment initiation and viral suppression.
“This is a truly a
community-based study; the idea to include non-communicable disease screening integrated
with HIV care came from the community, and it also serves to reduce stigma,”
she said. Study investigators characterise the model of care being offered as “walking
with the patient every step of the way along their journey,” and say that
practices such as flexible clinic hours have contributed to the high level of
engagement seen in the study.
The scale of the
study – nearly 78,000 people – and the range of communities involved in two
countries make the results of the SEARCH study among the most significant
contributions to the emerging body of evidence supporting the implementation of
`test and treat` programmes in lower-income settings. Results showing the
effect of the intervention on the study’s primary outcome, HIV incidence, are
due in 2017.