Universal HIV Testing and Treatment (UTT) Integrated with Chronic Disease Screening and Treatment: the SEARCH study

Future HIV epidemic trajectories in South Africa and projected long-term consequences of reductions in general population HIV testing: a mathematical modelling study

BACKGROUND

After successful intensive interventions to rapidly increase HIV awareness, coverage of antiretroviral therapy (ART), and viral suppression, HIV programmes in eastern and southern Africa are considering scaling back of some interventions, such as widespread general population HIV testing. We aimed to model whether scaling back of general population HIV testing in South Africa could result in a resurgence of the HIV epidemic or substantial slowing of declines in HIV incidence, resulting in increased long-term ART.

METHODS

In this modelling study, we used the Thembisa 4.5 model (a deterministic compartmental model of HIV transmission in South Africa) to project the South African HIV epidemic to 2100 assuming the continuation of 2022 epidemiological conditions and HIV programme implementation. We assessed how implementing reductions in general population HIV testing services in 2025 (while maintaining antenatal, symptom-based, and risk-based testing modalities and other HIV prevention services at 2022 levels) would affect HIV incidence and prevalence among people aged 15-49 years, the year in which incidence would reach one per 1000 people aged 15-49 years (the threshold for virtual elimination of HIV), and associated costs, as well as numbers of additional new HIV infections and AIDS-related deaths. We also modelled the effects of delaying reductions in general population testing services by 5-year increments. Additionally, we modelled the potential effects of reductions in general population testing services in combination with increases or decreases in ART interruption rates (ie, the annual rate at which people who are on ART discontinue ART) and condom usage in 2025-35.

FINDINGS

If general population HIV testing services and the HIV risk environment of 2022 were maintained, we projected that HIV incidence would steadily decline from 4·95 (95% CI 4·40-5·34) per 1000 population in 2025 to 0·14 (0·05-0·31) per 1000 in 2100, and that the so-called virtual elimination threshold of less than one new infection per 1000 population per year would be reached in 2055 (95% CI 2051-2060). Scaling back of general population HIV testing services by 25%, 50%, or 75% in 2025 delayed time to reaching the virtual elimination threshold by 5, 13, or 35 years, respectively, whereas complete cessation of general population testing would result in the threshold not being attained by 2100. Although the incidence of HIV continued to fall when general HIV testing services were reduced, our modelling suggested that, with reductions of between 25% and 100%, between 396 000 (95% CI 299 000-474 000) and 2·50 million (1·97 million-2·98 million) additional HIV infections and between 115 000 (94 000-135 000) and 795 000 (670 000-926 000) additional AIDS-related deaths would occur between 2025 and 2075, depending on the extent of reduction in testing. Delaying reductions in general population HIV testing services for 5-25 years mitigated some of these effects. HIV testing accounted for only 5% of total programmatic costs at baseline; reducing testing moderately reduced short-term total annual costs, but increased annual costs after 25 years. Increases in ART interruption and reductions in condom usage were projected to slow the decline in incidence and increase the coverage of general HIV testing services required to control transmission but did not cause rapid resurgence in HIV infections.

INTERPRETATION

Our modelling suggests that scaling back of general population HIV testing would not result in a resurgence of HIV infections, but would delay attainment of incidence-reduction targets and result in long-term increases in HIV infections, AIDS-related deaths, and costs (via increased need for ART provision). HIV programmes need to balance short-term potential resource savings with long-term epidemic control objectives.

FUNDING

Bill & Melinda Gates Foundation.

Community-based HIV testing through a general health check event in a high HIV-prevalent multicultural area in Rotterdam, The Netherlands: a pilot study on feasibility and acceptance

BACKGROUND

HIV testing is crucial for finding the remaining cases in a declining HIV epidemic in The Netherlands; providing HIV testing in non-traditional settings may be warranted. We conducted a pilot study to determine the feasibility and acceptability of a community-based HIV testing (CBHT) approach with general health checks to improve HIV test uptake.

METHODS

CBHT's main conditions were low-threshold, free-of-charge, general health check, and HIV education. We interviewed 6 community leaders, 25 residents, and 12 professionals/volunteers from local organizations to outline these main conditions. Walk-in test events were piloted at community organizations, providing HIV testing along with body mass index (BMI), blood pressure, blood glucose screening, and HIV education (October 2019 to February 2020). Demographics, HIV testing history, risk perception, and sexual contact were collected via questionnaires. To evaluate the pilots' feasibility and acceptance, we utilized the RE-AIM framework and predefined goals, incorporating quantitative data from the test events and qualitative input from participants, organizations, and staff.

RESULTS

A total of 140 individuals participated (74% women, 85% non-Western, median age 49 years old). The number of participants during the seven 4-h test events ranged from 10 to 31. We tested 134 participants for HIV, and one was found positive (positivity 0.75%). Almost 90% of the participants were never tested or > 1 year ago, and 90% perceived no HIV risk. One-third of the participants had one or more abnormal test results on BMI, blood pressure, or blood glucose. The pilot was well-rated and accepted by all parties. The staff had concerns about waiting time, language problems, and privacy. Participants hardly indicated these concerns.

CONCLUSIONS

This CBHT approach is feasible, acceptable, and well-suited for testing not (recently) tested individuals and detecting new cases. Besides reducing HIV-associated stigma and increasing HIV test acceptance, offering multiple health tests may be appropriate as we frequently observed multiple health problems. Whether this laborious approach is sustainable in the micro-elimination of HIV and should be deployed on a large scale is questionable. CBHT like ours may be suitable as a supplement to more sustainable and cost-effective methods, e.g., proactive HIV testing by general practitioners and partner notification.

The future of HIV testing in eastern and southern Africa: Broader scope, targeted services

In this Policy Forum, Anna Grimsrud and colleagues discuss the future of HIV testing in eastern and southern Africa, using insights gleaned from a 2021 expert consultation.

Exploring the extent of mental health practice: content and cluster analysis of techniques used in HIV testing and counselling sessions in Uganda

There is an urgent need for greater provision of mental health services to people living with HIV. HIV testing and counselling (HTC) sessions diagnose HIV and offer appropriate psychosocial support and behavioural messages to support people to link into HIV care. It is not known to what extent HTC currently addresses mental health. We examined transcriptions of 116 audio-recorded HTC sessions delivered in Uganda against a checklist of mental health techniques. Hierarchical cluster analysis explored co-occurrence of techniques. Core counselling skills were very commonly present, and co-occurred. Assessment techniques were not commonly seen. Specific therapy techniques to treat anxiety or depression were not present. HTC staff are a resource for delivering mental health care for people with HIV, owing to their strong fundamental counselling skills. However, training is needed in assessment and evidence-based therapies. Provision of fuller assessment and interventions may increase detection and signposting for mental health and alcohol use, both of which may affect linkage into care. HTC staff have fundamental skills that could also be developed to train and supervise other staff to provide much needed mental health support to people living with HIV. Future research should develop brief mental health interventions for delivery by HTC staff.

Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda

BACKGROUND

Hypertension treatment reduces morbidity and mortality yet has not been broadly implemented in many low-resource settings, including sub-Saharan Africa (SSA). We hypothesized that a patient-centered integrated chronic disease model that included hypertension treatment and leveraged the HIV care system would reduce mortality among adults with uncontrolled hypertension in rural Kenya and Uganda.

METHODS AND FINDINGS

This is a secondary analysis of the SEARCH trial (NCT:01864603), in which 32 communities underwent baseline population-based multidisease testing, including hypertension screening, and were randomized to standard country-guided treatment or to a patient-centered integrated chronic care model including treatment for hypertension, diabetes, and HIV. Patient-centered care included on-site introduction to clinic staff at screening, nursing triage to expedite visits, reduced visit frequency, flexible clinic hours, and a welcoming clinic environment. The analytic population included nonpregnant adults (≥18 years) with baseline uncontrolled hypertension (blood pressure ≥140/90 mm Hg). The primary outcome was 3-year all-cause mortality with comprehensive population-level assessment. Secondary outcomes included hypertension control assessed at a population level at year 3 (defined per country guidelines as at least 1 blood pressure measure <140/90 mm Hg on 3 repeated measures). Between-arm comparisons used cluster-level targeted maximum likelihood estimation. Among 86,078 adults screened at study baseline (June 2013 to July 2014), 10,928 (13%) had uncontrolled hypertension. Median age was 53 years (25th to 75th percentile 40 to 66); 6,058 (55%) were female; 677 (6%) were HIV infected; and 477 (4%) had diabetes mellitus. Overall, 174 participants (3.2%) in the intervention group and 225 participants (4.1%) in the control group died during 3 years of follow-up (adjusted relative risk (aRR) 0.79, 95% confidence interval (CI) 0.64 to 0.97, p = 0.028). Among those with baseline grade 3 hypertension (≥180/110 mm Hg), 22 (4.9%) in the intervention group and 42 (7.9%) in the control group died during 3 years of follow-up (aRR 0.62, 95% CI 0.39 to 0.97, p = 0.038). Estimated population-level hypertension control at year 3 was 53% in intervention and 44% in control communities (aRR 1.22, 95% CI 1.12 to 1.33, p < 0.001). Study limitations include inability to identify specific causes of death and control conditions that exceeded current standard hypertension care.

CONCLUSIONS

In this cluster randomized comparison where both arms received population-level hypertension screening, implementation of a patient-centered hypertension care model was associated with a 21% reduction in all-cause mortality and a 22% improvement in hypertension control compared to standard care among adults with baseline uncontrolled hypertension. Patient-centered chronic care programs for HIV can be leveraged to reduce the overall burden of cardiovascular mortality in SSA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01864603.

Increasing the Uptake of HIV Testing among Men in Tanzania: A Novel Intervention for Bar Patrons

We investigated a novel community-based HIV testing and counseling (HTC) strategy by recruiting men from bars in northern Tanzania in order to identify new HIV infections. All bars in the town of Boma Ng'ombe were identified and male patrons were systematically invited to participate in a health study. HIV testing was offered to all enrolled participants. Outputs included HIV test yield, cost per diagnosis, and comparison of our observed test yield to that among male patients contemporaneously tested at five local facility-based HTC. We enrolled 366 participants and identified 17 new infections - providing a test yield of 5.3% (95% Confidence interval [CI] 3.3-8.4). The test yield among men contemporaneously tested at five local HTC centers was 2.1% (95% CI 1.6-2.8). The cost-per-diagnosis was $634. Our results suggest that recruiting male bar patrons for HIV testing is efficient for identifying new HIV infections. The scalability of this intervention warrants further evaluation.

NIH Workshop on HIV-Associated Comorbidities, Coinfections, and Complications: Summary and Recommendation for Future Research

BACKGROUND

With potent antiretroviral therapy and simplified regimens, people living with HIV (PWH) are achieving near-normal lifespans but not necessarily a normal health span or healthy aging. PWH have a higher than expected risk of developing a number of non-AIDS comorbidities, coinfections, and complications (CCC), often against a background of stigma, poverty, and isolation.

SETTING

To gain a better understanding of research needs for HIV-associated CCC, the NIH convened a 2-day workshop (HIV-associated CCC, or HIV ACTION).

METHODS

A cross-institute NIH planning committee identified 6 key research areas: epidemiology and population research, pathogenesis and basic science research, clinical research, implementation science research, syndemics research and international research in low and middle income countries. Investigators were selected to lead working groups (WGs) to assess the state-of-the-art and identify 3-5 priority areas in each field before the workshop. A 2-day program at the NIH was developed which included presentations by invited experts and WG members.

RESULTS

Over 400 participants attended the workshop. After general and individual WG discussions, the most pressing gaps, questions, or proposed action items were identified. Priority lists of pressing research issues were presented by cochairs of each WG. A detailed report is posted at the NHLBI website. This article reports the streamlined priority list and a summary of WG discussions to inform investigators of current priorities in the field.

CONCLUSION

Collaborative efforts of many disciplines are needed to improve the health and wellbeing of PWH. Several common themes emerged across WG representing potential priorities for investigators and recommendations for the NIH.