Dr Sarah Fidler, Reader in HIV at Imperial College, London,
presented details of the antiretroviral treatment coverage achieved in the first
phase of the PopART study, a pilot in seven communities, which recruited
participants from November 2013 to mid-2015.
PopART is a community-randomised trial comparing the impact of
three strategies for providing antiretroviral therapy on population incidence:
standard of care provision through the current health infrastructure with ART
initiation according to national guidelines; a combination prevention package
with ART initiation according to national guidelines, and a combination
prevention package with immediate ART initiation irrespective of CD4 cell
In these communities annual rounds of home-based HIV testing are
taking place, carried out by community HIV care providers (CHiPs). The CHiPS
refer people to local health care facilities and follow up with home visits to
ensure linkage to care, adherence to treatment and retention in care. Men who
test negative are referred for male medical circumcision and the programme
provides HIV education and condoms, as well as promoting the availability of
sexual health and TB services.
Dr Fidler presented results from Round 1 in the immediate ART
initiation communities. Home-based HIV testing diagnosed 12,840 adults in
Zambia and 3,300 adults in South Africa in Round 1. Around half of those who
underwent home-based testing were already aware of their HIV-positive status
and were taking antiretroviral treatment. After referral to care 58% had started
treatment within 12 months in South Africa and 53% in Zambia.
Dr Fidler said that “in our experience, time is the most important
factor in terms of reaching the second 90 goal.” The study had set a target of
80% initiation within three months of referral, but in all settings and in both
men and women, treatment initiation was slower than hoped for. Six months after
referral 42-44% of people in Zambia had started treatment but by one year
after referral 58% of people were taking antiretroviral treatment.
Overall, a combination of existing treatment according to national
guidelines and the Round 1 efforts to diagnose and link people to care, together
with immediate treatment initiation, led to treatment coverage of 71% of men
and 72% of women in Zambia, and 58% of men and 69% of women among those still resident
in the trial communities. The study interventions had a similar impact on
improving treatment coverage in men and in women in both Zambia and South
Africa, and reduced the total population of diagnosed but untreated people
living with HIV by 43%.
PopART investigators say that decongestion of clinics will be
necessary in order to cope with the volume of new patients. Increasing the
amount of drugs dispensed so that clinic visits can be reduced, delivery of ART
in the community through innovative mechanisms like adherence clubs and
differentiation between stable and higher-need patients are all needed in order
to reach the second 90 goal.
The scale of the task – and the need for innovative thinking on
how to manage the growing number of people in HIV care – was emphasised by
Professor Diane Havlir of the University of California, San Francisco, who reminded
a press conference just what the 90-90-90 target means in human and health
system terms. “We’re going to need to increase the number of people on
treatment by 16 million by 2020,” she said.