{"id":1291,"date":"2017-06-09T16:15:52","date_gmt":"2017-06-09T15:15:52","guid":{"rendered":"https:\/\/blogs.bmj.com\/sti\/?p=1291"},"modified":"2017-11-01T15:24:31","modified_gmt":"2017-11-01T15:24:31","slug":"hptn-071-attempts-universal-home-based-hiv-testing-in-sub-saharan-africa-scaling-the-mountainous-challenge-of-unaids-90-90-90-target","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/sti\/2017\/06\/09\/hptn-071-attempts-universal-home-based-hiv-testing-in-sub-saharan-africa-scaling-the-mountainous-challenge-of-unaids-90-90-90-target\/","title":{"rendered":"HPTN 071 attempts universal home-based HIV testing in sub-Saharan Africa: scaling the mountainous challenge of UNAIDS 90-90-90 target"},"content":{"rendered":"<p>Estimates of 96% for the preventative efficacy of ART against HIV transmission, reported in 2011 by <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1105243#t=article\">Myron &amp; Cohen<\/a> (M&amp;C), appeared at last to place long-term containment of the epidemic in our hands.\u00a0 In the wake of this, <a href=\"http:\/\/www.unaids.org\/sites\/default\/files\/media_asset\/90-90-90_en.pdf\">UNAIDS: 90-90-90<\/a> proposed ambitious targets: 90% of those living with HIV to know their status; 90% of known HIV+ individuals to undergo ART initiation; 90% of ART initiated to achieve viral suppression.\u00a0 Yet \u2013 for all the promise of known ART efficacy \u2013 the question remains how easy it will be to realize these targets in practice, especially in those settings (e.g. sub-Saharan Africa) where the impact of the epidemic is at its most severe.<\/p>\n<p>Perhaps less easily than one might imagine, suggest <a href=\"http:\/\/journals.plos.org\/plosmedicine\/article?id=10.1371\/journal.pmed.1002292\">Hayes &amp; Fidler<\/a> (H&amp;F) \u2013 a first (one year in) report of results from HPTN-071.\u00a0 This is\u00a0a large cluster-randomized study of home-based HIV testing and treatment in 21 Zambian and S. African communities.\u00a0 The results derive specifically from four of the seven \u2018intervention\u2019 communities situated in Zambia.\u00a0 Of the c.100,000 consenting to the intervention, and visited by pairs of Community HIV Care Providers (CHiPs), <strong>77%<\/strong> of men and <strong>85%<\/strong> of women ended up knowing their status.\u00a0 (The rest were presumably not reached, or refused testing.) \u00a0The estimated proportion of known HIV positive individuals who then went on to initiate ART was <strong>42%<\/strong> within six months and <strong>53%<\/strong> within 12 months.\u00a0 Over the first year, the estimated overall percentage of HIV+ adults in the four communities who were on ART rose from <strong>44%<\/strong> to <strong>61%<\/strong>.\u00a0 Obviously, these results reflect only the first year of the intervention, and CHiPs will revisit participants.\u00a0 At this stage no estimate of the third UNAIDS target (viral suppression) is possible. \u00a0Nevertheless, the results reported by this paper give us a sense of the very considerable challenge that the achievement of the UNAIDS target represents in practice. \u00a0Among the difficulties, H&amp;F refer specifically to the difficulty of accessing male participants at their homes, and the very slow rates of initiation to ART.<\/p>\n<p>There are various ways of delivering testing.\u00a0 Home-based testing has been trialled in populations that would otherwise be very difficult to access \u2013 e.g. in indigenous Amazonia (<a href=\"http:\/\/sti.bmj.com\/content\/91\/2\/94\">Ribeiro &amp; Benzaken (STIs)<\/a> (R&amp;B); <a href=\"http:\/\/sti.bmj.com\/content\/90\/1\/14.short?utm_source=TrendMD&amp;utm_medium=cpc&amp;utm_campaign=Sex_Transm_Infect_TrendMD-0\">Benzaken &amp; Peeling (STIs)<\/a> (B&amp;P).\u00a0 In the case of HPTN-071, its attraction seems to be the possibility of most easily achieving quasi universal coverage.\u00a0 At 90-90-90, achieved rates of viral suppression would be 73%; at 80-80-80, they would only be 43% &#8211; and the preventive efficacy of ART would be correspondingly reduced.\u00a0 Yet even\u00a0the latter target\u00a0seems ambitious.\u00a0 So far as the testing is concerned, however,\u00a0the 90%\u00a0is within reach &#8211; at least in Zambia.\u00a0 The real challenge will be second (and probably also the third) stage of the cascade.\u00a0 Other studies indicate that HPTN-071 is not unique in seeing large fall out at this point (see <a href=\"http:\/\/sti.bmj.com\/content\/early\/2016\/11\/25\/sextrans-2016-052773\">Schwartz &amp; Baral (STIs)<\/a>).\u00a0 R&amp;B and B&amp;P\u00a0point\u00a0to\u00a0further problem\u00a0likely to arise\u00a0at the stage of rolling out\u00a0this kind of\u00a0preventative ART intervention \u2013 namely that of maintaining the quality of POCT testing (<a href=\"http:\/\/sti.bmj.com\/content\/90\/1\/14.short?utm_source=TrendMD&amp;utm_medium=cpc&amp;utm_campaign=Sex_Transm_Infect_TrendMD-0\">Benzaken &amp; Peeling (STIs)<\/a>).<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Estimates of 96% for the preventative efficacy of ART against HIV transmission, reported in 2011 by Myron &amp; Cohen (M&amp;C), appeared at last to place long-term containment of the epidemic in our hands.\u00a0 In the wake of this, UNAIDS: 90-90-90 proposed ambitious targets: 90% of those living with HIV to know their status; 90% of [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/sti\/2017\/06\/09\/hptn-071-attempts-universal-home-based-hiv-testing-in-sub-saharan-africa-scaling-the-mountainous-challenge-of-unaids-90-90-90-target\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":152,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1642,4367,4352],"tags":[],"class_list":["post-1291","post","type-post","status-publish","format-standard","hentry","category-hiv-testing","category-hiv-treatment-cascade","category-preventative-effect-of-art"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - 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