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Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa

Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa
Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa

INTRODUCTION: The universal test-and-treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa. METHODS: The TasP cluster-randomized trial (2012 to 2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 × 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level. RESULTS: 8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited. CONCLUSIONS: PVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART-initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90-90-90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context-specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register).

antiretroviral therapy, HIV, population health, retention in care, South Africa, sustained viral suppression
1758-2652
e25402
Larmarange, Joseph
8dc0592c-788f-4521-a3cb-4ff6c6aa06a3
Diallo, Mamadou H.
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McGrath, Nuala
b75c0232-24ec-443f-93a9-69e9e12dc961
Iwuji, Collins
9172710f-6d53-4fc4-8948-2db34293c7ed
Plazy, Mélanie
895cf9c4-4a3a-4609-af0b-5433f9884ae5
Thiébaut, Rodolphe
2e2f7877-94ad-44f8-a3f5-4af25884ded6
Tanser, Frank
a7112c48-809b-4f7c-8662-eaef445891f4
Bärnighausen, Till
337d5ec4-e26e-40de-aa26-42e5c5c9b61e
Orne-Gliemann, Joanna
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Pillay, Deenan
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Dabis, François
90f9de2e-aaba-4392-97d6-18776521b99f
ANRS 12249 TasP Study Group
Larmarange, Joseph
8dc0592c-788f-4521-a3cb-4ff6c6aa06a3
Diallo, Mamadou H.
3ca12b5a-f5fc-4c19-9bd6-70c721d9ac1e
McGrath, Nuala
b75c0232-24ec-443f-93a9-69e9e12dc961
Iwuji, Collins
9172710f-6d53-4fc4-8948-2db34293c7ed
Plazy, Mélanie
895cf9c4-4a3a-4609-af0b-5433f9884ae5
Thiébaut, Rodolphe
2e2f7877-94ad-44f8-a3f5-4af25884ded6
Tanser, Frank
a7112c48-809b-4f7c-8662-eaef445891f4
Bärnighausen, Till
337d5ec4-e26e-40de-aa26-42e5c5c9b61e
Orne-Gliemann, Joanna
2124c323-6911-49d3-9e50-bddb35f521f8
Pillay, Deenan
9b4da6c6-2220-4c60-aaca-f0f1a37c2ca8
Dabis, François
90f9de2e-aaba-4392-97d6-18776521b99f

Larmarange, Joseph, Diallo, Mamadou H., McGrath, Nuala, Iwuji, Collins, Plazy, Mélanie, Thiébaut, Rodolphe, Tanser, Frank, Bärnighausen, Till, Orne-Gliemann, Joanna, Pillay, Deenan and Dabis, François , ANRS 12249 TasP Study Group (2019) Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa. Journal of the International AIDS Society, 22 (10), e25402. (doi:10.1002/jia2.25402).

Record type: Article

Abstract

INTRODUCTION: The universal test-and-treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa. METHODS: The TasP cluster-randomized trial (2012 to 2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 × 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level. RESULTS: 8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited. CONCLUSIONS: PVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART-initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90-90-90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context-specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register).

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Accepted/In Press date: 3 September 2019
e-pub ahead of print date: 22 October 2019
Published date: October 2019
Keywords: antiretroviral therapy, HIV, population health, retention in care, South Africa, sustained viral suppression

Identifiers

Local EPrints ID: 435418
URI: http://eprints.soton.ac.uk/id/eprint/435418
ISSN: 1758-2652
PURE UUID: 0595f0fa-e49c-4580-a993-3c806bacf186
ORCID for Nuala McGrath: ORCID iD orcid.org/0000-0002-1039-0159

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Date deposited: 06 Nov 2019 17:30
Last modified: 18 Feb 2021 17:21

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Contributors

Author: Joseph Larmarange
Author: Mamadou H. Diallo
Author: Nuala McGrath ORCID iD
Author: Collins Iwuji
Author: Mélanie Plazy
Author: Rodolphe Thiébaut
Author: Frank Tanser
Author: Till Bärnighausen
Author: Joanna Orne-Gliemann
Author: Deenan Pillay
Author: François Dabis
Corporate Author: ANRS 12249 TasP Study Group

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