HIV Psychiatry

Journal Article Annotations
2017, 2nd Quarter

HIV Psychiatry

Annotations by John Grimaldi MD and Mary Ann Cohen MD, FAPM
July 2017

  1. Association of implementation of a universal testing and treatment intervention with HIV diagnosis, receipt of antiretroviral therapy, and viral suppression in East Africa

Also of interest:

PUBLICATION #1 — HIV Psychiatry
Association of implementation of a universal testing and treatment intervention with HIV diagnosis, receipt of antiretroviral therapy, and viral suppression in East Africa
Petersen M, Balzer L, Kwarsiima D, et al


The finding: The Sustainable East Africa Research in Community Health Study (SEARCH) is an ongoing randomized trial comparing an innovative HIV test-and-treat strategy in rural Kenya and Uganda against country-specific standard of care for HIV on outcomes. Using observational data from SEARCH, this study reports interim results of proportions of HIV-positive individuals in the test-and-treat intervention who had received a diagnosis, individuals treated with antiretroviral treatment (ART), and treated individuals with HIV viral suppression at baseline and after 1 and 2 years. Compared to baseline, the rate of population-level viral suppression after 2 years, the primary outcome, rose from 44.7% to 80.2%, representing an increase of 35.5%. After 2 years, secondary outcomes were as follows: the rate of HIV-positive individuals who had been previously diagnosed was 95.9%; HIV-positive individuals who had received ART was 93.4%; and individuals who had been treated who had achieved HIV viral suppression was 89.5%. At both baseline as well as at 2 years, viral suppression was lower for males than for females and lowest for youth (aged 15-24 years). This study demonstrated that “WHO guidelines to treat individuals regardless of CD4 count can be successfully implemented.” In addition, an innovative test-and-treat strategy in rural East Africa was successful in achieving the UNAIDS 90-90-90 goal of 73% viral suppression in a relatively short time.

Strength and weaknesses: The study comprised a large number of individuals, 77,774 adults enrolled at baseline, a high proportion of women, and geographic areas that are currently far below UNAIDS 90-90-90 targets. The intervention was multi-faceted and included innovative testing strategies and streamlined engagement and treatment techniques. Given the observational nature of the analysis, the intervention effect on the positive outcome cannot be determined until the trial has been completed. The primary analyses included individuals who remained in the target communities for the full duration of the study period. These residents may represent a relatively easy group to reach and therefore do not account for other populations more likely to negatively impact treatment as prevention goals. The study does not provide insight about how to reach, engage and retain in care migrants in and out of the community. The study also is not designed to evaluate the impact of a successful test-and-treat outcome on population level HIV incidence.

Relevance: The study findings are highly relevant across all geographic areas, from developed to those with limited resources. Sweden is the only country to have achieved 90-90-90 cascade goals and there are significant questions about whether the same can be achieved in rural areas with a higher disease burden. For example, in the US only 40% of individuals diagnosed with HIV are retained in care and only 30% achieve viral suppression. HIV prevalence is highest in the Southeastern US where a higher proportion lives in rural areas. The outreach and treatment strategies offer important insights about scalable ideas applicable to all settings. The model was patient-centered with an emphasis on reducing structural barriers, improving patient education, enhancing clinician-patient relationships and adapting services to reflect patient preferences and expectations. For example, testing occurred at community health fairs offering multidisease screening to reduce stigma and entry into care was immediate and occurred at point of testing. Additionally, the study highlighted the need for improved models for testing, linkage to and retention in care for youth and males.