There is life with HIV

"Treatment as Prevention (TASP)": Large study fails to show a positive impact on reducing new HIV infections

François Dabis
François Dabis at AIDS 2016. Photo by International AIDS Society / Abhi Indrarajan

The first major research study of "test and treat" as a public health intervention to report its final results, found that the strategy has failed to reduce new HIV infections in communities where it was provided.

speaking to21st International AIDS Conference (AIDS 2016)in Durban, South Africa on Friday, François Dabis the University of Bordeaux said that the collection of data for the study ANRS 12249 was completed only a month ago. So your team has not been able to delve into the data to explain the findings.

But it is already clear that many individuals diagnosed with HIV are not linked to medical care or took many months to do it. Only 49% of people diagnosed entered treatment.

The study was much more successful in terms of bringing HIV testing to people who needed it - 92% of people with HIV know their status. And the treatment was highly effective in those who adhered to it consistently, with 93% reaching undetectable viral load. These results were obtained in a poor rural area of ​​KwaZulu-Natal, South Africa.

So in terms of goals, the study 90-90-90 got 92-49-93. The crucial weakness in the intermediate phase may explain the lack of impact on new HIV infections. But the reasons for the bad joint for care need to be decompressed.

Aim of the study with TASP (Treatment to Prevention - Treatment as Prevention)

The aim of this study ANRS 12249 to know the effectiveness of HIV treatment as prevention (TASP) as population-level intervention in an African community deeply burdened by HIV.

Whereas studies as HPTN052 and Partner examined the HIV treatment impact on individuals and couples, this is the first of five large randomized studies to examine the impact of the measure adopted on a large scale in the population with TASP intervention or "treatment as prevention" universal in African countries. " The aim of this study was to determine whether the approach would be able to enable "the" delivering treatment and that would be "acceptable to local communities", but its main purpose was to reduce the number of new infections.

Therefore the primary outcome was the incidence of HIV, as measured in the general population.

HIV testThe study, which was conducted in Hlabisa sub-district of KwaZulu-Natal. Located three hours drive from Durban, three in ten people (30%) who live there, living with HIV - the highest prevalence in South Africa and one of the highest in the world. Previous observational studies in the field have shown that neighborhoods where more people with HIV were on antiretroviral therapy (ART), the number of new infections was lower. However, this approach could be applied effectively to "scale" and even better results? (Translator's Note: I see it with worried eyes, for there to a drug dictatorship is just one more step, and an interesting step for certain "sectors of our societies so well balanced")

Study design and interventions at home for TASP

This study was a randomized controlled clusters, wherein the randomization units were geographies(Clusters * A term in Computer designates industries clusters on a hard disk (HD) or a group of 4 or more machines in synchronicity, working as redundant servers of the same content - I decided to leave the cluster and just set the title elucidation) Of about a thousand each resident. There was 22 these clusters in the study area. They were divided into two groups, 11 11 intervention clusters and control clusters.

Every six months the whole population (in both groups) was offered, based on a home in collection system, HIV testing and counseling. The Directors involved were trained to go door to door, offering HIV testing at home people. Family members over the age of 16 years were offered rapid testing and counseling individually in a more private space within the home.

This approach, already used successfully in the region, helps to overcome some of the barriers of access to testing services (translator's note: I kept an electronic relationship with an activist in Angola and she told me that there was a line to the capital of Angola Luanda, was honored with a verse that went something like this:

Luanda, Luanda

City that all leads.

"From day no water. "

At night no light "-

Unfortunately I lost touch with her, it was via ICQ (there are times ...) and to this day, I wonder if she died from complications of AIDS or for "political complications", given the fact that the political stability of Africa and its mapeamento- batched, which in no respect ethnic and natural limitations, such as a river or a mountain, could serve purposes other than the "subaltern" ... Just to illustrate this website is automatically translated into 58 languages ​​by GTranslate that does not charge me anything there now well, well, about three years - for a time was not so and I have a good level of visitation beyond the countries where they speak Portuguese and, interestingly, even in nations that speak Portuguese in Africa, this is the continent - more needed - and at least the visit - it is clear that there is a major structural problem and not to take the conversation too far, watch a show "Africa's political and see how they are" graceful "the border lines" drawn "on that map. For me it is a blend ...). You can reach individuals who are more difficult to reach through other approaches, including adolescents living in rural areas and those with limited access to formal health system (Translator's Note: [...]).

Later, people diagnosed with HIV in immediate intervention cluster received the ready supply of early antiretroviral therapy, HIV treatment, regardless of symptoms or CD4 cell count. Individuals diagnosed in well control cluster received treatment based on lines of the national guidelines and directives of South Africa.

If you do not believe that the site Soropositivo.org is translated into 58 Languages, click this link and see in another tab of your browser

When the study began in 2012, there was a clear difference between the intervention and treatment of domestic approach with regard to national guidelines, they pray (...) as one day prayed in Brazil (and I am a victim of this in the midst of thousands ) treatment was recommended only for those with a cell count below CD4 350 cells / mm3. However this level was changed in January 2015 500 to cells / mm3 (Click this link and see what says a large study called START - opens in another tab). These guidelines are about to change again to recommend treatment for all - as in the intervention arm.

It is worth noting that the only difference between the intervention and control groups was under eligibility for HIV treatment. Otherwise, there were few differences among the arms: the port test port happened in them; with relative proximity of polyclinics treatment of HIV (within a walk of about 45 minutes of all households) were provided to both.

Although the researchers describe the strategy tested as a model of "universal test and treat" any difference that could have been observed between the control and intervention groups should only be due to changes in eligibility for treatment. Unlike some other tests and treatment studies, the control arm of the intervention does not include more intensive provision of HIV testing or additional changes to make medical services easier to use.

Results

There 28,153 individuals in the study population at baseline. There were fewer men, 37% of women enrolled in the study. Most of those affected were aged between the 22 and 50 years, with an average age of 30.

As expected, 31% of people were already living with HIV. As 34% of them were in the treatment of HIV.

The "door to door" test program was able to provide HIV test at least once 88% of people contacted. And in each round of testing, more than 70% of contacted, accepted the offer to repeat the test.

Antiretroviral Therapy
It's not always like that. There are schemes with three tablets a day, once a day. As an example the combination of lamivudine in one tablet, associated with atazanavir, a capsule and Norvir, a relatively small tablet once a day.

But when individuals were diagnosed, the joint to care for their own health proved to be poor:

  • Three months after the diagnosis, 28% had sought a clinic to start ART.
  • Six months after diagnosis, 36% had sought a clinic to start ART.
  • Twelve months after diagnosis, 47% had sought a clinic to start ART.

¹

Results: FOR NEW HIV INFECTIONS

Overall, there was 495 new HIV infections registered on 22,434 person-years(Open in another tab) tracking. This equates to an annual incidence of 2,21% (ie, each year, two people in a cluster of 100 newly acquired HIV) (Editor's note: It seems, but only seems; if we reduce the population of Brazil a hundred million people each year, two million two hundred thousand people contrairiam HIV per year and folder you multiply by five and see the size of the humanitarian crisis - Has anyone here ever read Dante's Inferno)?

The incidence rates did not differ between the intervention clusters (2,13%) and control clusters (2,27%) - this difference was not statistically significant.

"The universal testing and treatment strategy had no measurable effect on the incidence of HIV during the course of the study," summarized François Dabis.

However, he pointed out two pieces of "good news" of the study. First, there was good acceptance of repeated testings offer for HIV at home with almost everyone being tested at least once. Second, the virologic response to HIV treatment was excellent in those people who have taken ART with proper adhesion.

Explaining the results

The analysis presented today was preliminary (data collection was completed only a month ago). Dabis said further analysis will try to gain a better understanding of how the results differ between men and women and for people of different age groups.

Researchers will try to clarify the reasons why people do not bind to a care system (is their life !!!!) - The explanation would lie in the way health services are provided, individual factors or community stigmata? They seek to better understand the differences between the profile of the affected individuals and not affected by the interventions.

During the discussion, Myron Cohen of the University of North Carolina suggested that delays in linking care could mean that individuals with recent HIV infection disproportionately contributed to the subsequent transmission. In addition, it is important to understand the impact of migration and sexual transmission when arriving outside the limits of the network of the study area, which can contribute to new HIV infections. (NE: A smell of xenophobia ...)

François Dabis said that although the study was formulated on the assumption able to show a TASP effect (Treatment Prevention- the Treatment as Prevention) after four years of follow-up, it may be that it will take longer to have an impact on the incidence in the light of the slow pace of joint care of their own health.

Other delegates suggested that the intervention clusters may not have received a package of interventions that has been sufficiently intense, as compared to the control clusters. For example of a more intensive approach to help people commit themselves to clinical care (counseling, awareness) and in clusters based on door approach to door for early treatment of HIV infection, which could have had a greater impact, leading more people to treat.

(Here speaks again the editor: In vain the complete state of inefficiency in financing -just prevention campaigns as an example, given "concession" of television channel use was renewed and no one thought to write a contractual clause requiring the production, the support of the NGOs working with "it" since "it is this" educational videos and the obligation to sprinkle them throughout the display grid with a minimum ratio of 5% {I know it's little, but would already be something} of total programming "granted, which does little about the facts, and when it does, makes fudge and clumsy way generating unfortunately counterproductive effects! I'm Pissy")

Sheri Lippman of the University of California, chairing the session, said that may take longer than finding technical solutions than to deal with structural barriers to commitment to the care of himself that remain at a level for which I can not another adjective, but deplorable .

Published: 23 2016 July

Roger Pebody

Roger Pebody

Roger Pebody

Claudio Souza - Seropositive from 1994
Claudio Souza

Translated by Claudio original Souzado site Aidsmap Article 'Test and treat': large study fails to show an impact on new HIV infections| Pending review

 


Reference

Dabis F et al.The impact of universal test and treat on HIV incidence in a rural South African population: ANRS 12249 TASP trial, 2012-2016.21st International AIDS Conference, Durban, abstract FRAC0105LB, 2016.

View the abstract on the conference website.

Download the presentation slides from the conference website.

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