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Can "test and treat" work in sub-Saharan Africa ?: Goats and soda: NPR



  Blood extraction for HIV test.
<img date-original = "https://media.npr.org/assets/img/2019/06/20/popart-blood-test-close-up-ikhwezi_custom-341
a2580300827acbd31e6583ee44945a8dff0bf-s1200.jpg" alt = "Download blood for HIV test even when there are no symptoms of AIDS The strategy repels the disease and has a second benefit – it has been shown to prevent the spread of HIV in sexual contacts, called" treatment as prevention "(TasP in medical

But in countries with low incomes, "test and treatment" is not the typical approach to prevention.

When they started, they did not "People do not think we can provide anti-retroviral therapy in sub-Saharan Africa at all," says study co-chair Richard Hayes of the London School of Hygiene and Health, and says that there is some doubt in the AIDS research community if the effort is successful. tropical medicine. "" There was a lot of skepticism. "Helen Ayles, from the same institution, and from the Zambart-based Zambian research organization, struck the same resistance. "People say you will never make communities test, and you will never get communities to start treatment earlier, and if you do, they will never stay on treatment." This attitude is partly due to past struggles to force people to follow a daily drug regime in both developed and developing countries – and local distrust in low-income countries when foreigners arrive to carry out a health mission.

Thus, ten years ago, researchers began planning a massive study of treatment as prevention in South Africa and Zambia. The team came from the London School of Hygiene and Tropical Medicine, the Imperial College, and several other US institutions, Zambia and South Africa.

The study provided a "test and treatment" to communities with a total of about 1 million people in South Africa and Zambia from 2013 to 2018. The $ 130 million project is called PopART (Effects of the Antiretroviral Therapy Population Reduction of HIV). 19659004] "The results are fantastic," says Ayles. "We have been able to show that you can reduce the prevalence of HIV by 30%, that's an amazing thing." of Washington, who did not participate in the study. "Making communities take intervention and support it is one of the great challenges of global health."

Details of the new experience were revealed at Seattle's Retroviruses and Opportunistic Infections Conference this spring and will soon be published. The findings are likely to be a major source of discussion at the World AIDS and HIV Conference in Mexico City in July.

The scale of the process was enormous. Researchers have started HIV testing every year in 14 communities of about 50,000 people in urban neighborhoods and cities in South Africa and Zambia. Public health workers go to people's homes, talk to them about HIV and HIV prevention, disseminate condoms, and offer on-site testing. Those who have given positive results have been offered free antiretroviral therapy. Another 300,000 people were in the control group that did not offer a "test and treatment".

The study is funded by the US Government and the International Impact Assessment Initiative with the support of the Bill and Melinda Gates Foundation (which also funded the NPR and this blog.)

In half of the 14 communities where the " and the treatment "was the protocol, anyone found to be HIV-positive received immediate treatment.The results of these communities were not as impressive: a 7% decrease in new HIV infections compared to the control group communities where the tests and the treatment was sometimes ra but not with the agreed approach of the PopART approach door

In the other half of the "test and treatment" communities for the first few years, treatment does not begin until the number of white blood cells (During the study, these communities have switched to immediate treatment when national guidelines have changed.)

In these seven "test and treatment" communities, whose total population was about 330 000, the incidence of new infections is 30% lower than in "

" We have shown that it is feasible and acceptable to carry out such intervention in cities in sub-Saharan Africa, "Hayes said.

A key element in the study is to send local healthcare workers to door-to-door talk about – and test for – HIV.

Study on Kim Cloete / PopART


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Kim Klote / PopART

A key element in the study was the sending of local door-to-door health workers to talk and test HIV.

Kim Klote / PopART Study

The new study leaves one major question: why the decline is only 7% in the group in which HIV-positive people have received treatment immediately, compared with 30% in other treated communities where treatment was initially delayed

) "My first reaction was that the statisticians misunderstood him," Hayes said. But four different statisticians repeated the analysis and received the same results. PopART researchers retrieve the data to try to understand the difference. Her designers believed that buying community funds would be key to people taking testing and treatment. So at the beginning of PopART, scientists asked community leaders to work on advisory boards to monitor the project and help researchers find and train 700-member community members to serve as health workers. The process, Hayes says, "was like the mobilization of an army."

The idea was that community health workers who understand the life and language of their patients can change the situation. "What PPART has shown is how important local health workers can be," says Maryam Shahmanesh, an associate professor at London University College and an expert on HIV prevention and sexual health. medical training, found a list of health workers while looking for a job in the local newspaper. It completed the monitoring of 112 workers in the program and went on community visits.

"It was an incredible experience for me," she says. – At first, people were not sure what was going on. Test centers already exist in some of the cities, but it was a door-to-door effort. "When people realized we were there to help them stop this terrible infection, they became so receptive," she says. "They saw that we were there for our own good."

Myron Cohen, a professor at the University of North Carolina, calls the new study "Roadmap". Cohen is the world's largest collaborator of researchers conducting clinical trials of AIDS interventions, including this. Cohen led the study, which in 2011 showed that intensive attention – frequent visits to the health center and counseling to reduce risk and use of condoms – and antiretroviral drugs can stop transmission between partners when it is known to be HIV -positive. ] PopART is based on Cohen's findings and other efforts, including a large study in South Africa. This study has shown that transmission of HIV is less common in communities where treatment is available compared to similar communities where this is not the case, suggesting that HIV transmission can be controlled at population level.

At the beginning of June, a Quashuo-Natal community study done by doctors without borders showed that engaging patient groups, local health workers and political leaders encouraged people to be tested and treated. The study has provided preliminary evidence that widespread information could reduce the prevalence of HIV in poor regions

U.N. identified the lifting of the threat to public health by HIV as a target for 2030. Cohen quickly says "yes," if adequate efforts are made – if any person infected with HIV can be found to start treatment and be convinced to remain in treatment. Popstar Co-President Richard Hayes hesitated before answering. "I think this can happen," he says finally. "But I think this will be a real challenge." Joan Silberner, a former health policy correspondent for NPR, is a freelance journalist living in London.


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