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

HIV July 2016 patients people Treatment as Prevention (TASP)
François Dabis
François Dabis at AIDS 2016. Photo by International AIDS Society / Abhi Indrarajan

The first large “test and treat” research study as a public health intervention to report its final results found that the strategy failed to reduce new infections by HIV in the communities where it was provided.

Talking to 21st International AIDS Conference (AIDS 2016) in Durban, South Africa on Friday, François Dabis of the University of Bordeaux said that the data collection for the ANRS 12249 study was only completed a month ago. So your team has not yet been able to dig deeper to explain the findings.

But it is already clear that many individuals diagnosed with HIV were not tied to medical care or took many months to do so. Only 49% of people diagnosed went into treatment.

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

Pills spilling out of a pill bottle on wooden tableBurning woman has condoms in mind

Therefore in terms of goals, the 90-90-90 study obtained 92-49-93. The crucial weakness in the middle stage may explain the lack of impact on new HIV infections. But the reasons for poor articulation for care will need to be unpacked.

Purpose of the Study as TasP (Treatment as Prevention)

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

Considering that studies such as HPTN052 and Partner examined the impact of HIV treatment on individuals and couples, this is the first of five large randomized studies to examine the impact of a large-scale measure on the population with the TasP intervention or "treatment as Prevention" universal in African countries ". The aim of this study was to verify whether the approach would be able to "deliver" the treatment and whether this would be "acceptable to local communities," but its primary goal was to reduce the number of new infections.

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

HIV testThe study, which was conducted in the Hlabisa sub-district of KwaZulu-Natal. Located three hours by car from Durban, three out of ten people (30%) who live there live with HIV - the highest prevalence in South Africa and one of the highest in the world. Previous observational studies in the area had shown that neighborhoods where most people with HIV were on antiretroviral therapies (ART), the number of new infections was lower. However, could this approach be applied effectively on a “large scale” and improve results even further? (Translator's note: I see this with worried eyes, because for a drug dictatorship this is just another step, and an interesting step for certain “sectors of our well-balanced societies”)

Study design and home-based interventions for TasP

This was a randomized controlled grouping study, in which the randomization units were geographic areas (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 one thousand residents each. There were 22 of these clusters in the studied area. They were divided into two groups, 11 intervention clusters and 11 control clusters.

Every six months the entire population (in both groups) was offered, based on a system of home collection, HIV testing and counseling. The Counselors involved were trained to go door-to-door, offering HIV testing at people's homes. Family members over the age of 16 years were offered quick testing and counseling individually in a space of greater privacy within the home.

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

Luanda, Luanda

City that all leads.

"From day no water. "

At night lack light "-

Unfortunately, I lost touch with her, who was via ICQ (a long time ago…) and, to this day, I wonder if she died of AIDS complications or “political complications”, given that Africa's political stability and its mapping- lot, which in no way respects ethnicities and natural limitations, such as a river or a mountain, could serve other purposes than the “underlings”… Just to illustrate this site is automatically translated into 58 languages ​​by GTranslate that doesn't charge me anything for now , well, well, about three years - for a while it wasn't like that and I have a good level of visitation beyond the Portuguese speaking countries and interestingly even in the Portuguese speaking countries in Africa this it is the continent - most in need - and least visited - it is clear that there is a major structural problem and, not to take the conversation too far, look at a 'political map of Africa and see how' graceful ' ”The boundary lines“ drawn ”on that map. For me it is a subdivision…). It can reach individuals who are more difficult to reach through other approaches, including adolescents living in rural areas and those with limited access to the formal health system (Translator's Note: […]).

Subsequently, people diagnosed with HIV in immediate intervention clusters received an immediate offer to start ART, HIV treatment, regardless of symptoms or cell count. CD4. The individuals in the control cluster thus diagnosed received treatment based on the lines and guidelines of South Africa's national guidelines.

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 intervention and home-based treatment with respect to national guidelines, which pray (…), as one day was prayed in Brazil (and I am a victim of this among thousands ) treatment was only recommended for those with a CD4 cell count below 350 cells / mm3. However this level was changed in January from 2015 to 500 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 to everyone - as in the intervention arm.

It is worth noting that the only difference between the intervention and control groups was in terms of eligibility for HIV treatment. Otherwise, there were few differences between the arms: door-to-door testing occurred in both; with relative proximity to clinical HIV treatment centers (within a walk of approximately 45 minutes of all households) were provided to both.

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

Results

There were 28,153 people in the study population at the start of the study. There were fewer men, 37%, than the women enrolled in the study. The majority of people affected were in the age range between 22 and 50 years, with an average age of 30.

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

The door-to-door testing program was able to provide HIV testing at least once to 88% of people contacted. And in each round of tests, more than 70% of contacts, 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 articulation for care with their own health proved to be poor:

  • Three months after diagnosis, 28% had sought a clinic to initiate ART.
  • Six months after diagnosis, 36% had sought a clinic to initiate ART.
  • Twelve months after diagnosis, 47% had sought a clinic to initiate ART.
¹

Results: NEW HIV INFECTIONS

In general, there were new 495 registered HIV infections, over 22,434 person-years (opens on another tab). This equates to an annual incidence of 2,21% (that is, each year, two people in a cluster of 100 had just acquired HIV) (Editor's Note: It seems a little, but it seems only if we reduce Brazil's population to one hundred million of people, every year, two million and two hundred thousand people would contract HIV per year and paste you multiply by five and see the size of the humanitarian crisis - Has anyone here read Dante's Inferno?)

Incidence rates did not differ between 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 over the course of the study," summarized François Dabis.

However, he pointed out two pieces of "good news" from the study. Firstly, there was a good acceptance of repeated HIV testing at home, with almost everyone being tested at least once. Second, the virological response to HIV treatment was excellent in those people who took ART with adequate adherence.

Explaining the results

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

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

During the discussion, Myron Cohen of the University of North Carolina suggested that delays in attachment to care could mean that individuals with disproportionately recent HIV infection contributed to subsequent transmission. In addition, it will be important to understand the impact of migration and sexual transmission when they reach outside the study area networks, which may contribute to new HIV infections. (NE: A smell of xenophobia…)

François Dabis said that although the study was formulated on the assumption of a TasP (Treatment as Prevention) effect after four years of follow-up, it may take longer to have an impact on the incidence, in light of the slowness of the articulation of care towards one's own health.

Other delegates suggested that intervention clusters may not have received a package of interventions that was sufficiently intense compared to control clusters. For example, a more intensive approach to helping people link to clinical care (counseling, awareness) as in the door-to-door clusters for initiating treatment for HIV infection, which could have impact, leading to more people being treated.

(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, presiding over the session, commented that it may take longer than finding technical solutions than dealing with the structural barriers to commitment to self-care that subsist on a level for which I can not get another adjective, if not deplorable .

Posted in: 23 July 2016

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 Impact on New HIV Infections | Review Pending
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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