New HIV infections can be prevented, million-people trial shows

A community-wide HIV-prevention strategy can reduce new infections, a new study has found.

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 SA and Zambia.

Findings 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 under way to explore the reasons for this finding."

The HPTN 071 (PopART) study involved more than a million people living in 21 communities in Zambia and SA, 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 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 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 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 SA was led by Nulda Beyers and Peter Bock, research clinicians at Desmond Tutu TB Centre (DTTC) in the department of paediatrics and child health at Stellenbosch University. The research team in Zambia was led by Helen Ayles, director of research at Zambart, Lusaka, in Zambia.

In both SA and Zambia, hundreds of community HIV care providers went house to house in 14 intervention communities over four years, with repeated offers of HIV counselling and testing. The DTTC also worked closely with the Western Cape department of health 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," said Bock.

The city of Cape Town welcomed the results.

"Valuable lessons have been 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 Cape Town's MMC for community services and health, Zahid Badroodien.

James Kruger, director of HIV/Aids, TB and STIs at the Western Cape department of health, 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 learnt 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.

"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 helped to get ARVs at clinics helped break down stigma. It was done in a very positive way."

- This article is written in partnership with the US-based HIV Prevention Trials Network