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SEARCH INTERVENTION REDUCES MORTALITY AT A POPULATION LEVEL IN MEN WITH LOW CD4 COUNT
Moses R. Kamya1, Maya L. Petersen2, Dalsone Kwariisima3, James Ayieko4, Norton Sang4, Jane Kabami3, Tamara D. Clark5, Edwin D. Charlebois5, Laura B. Balzer6, Craig R. Cohen5, Vivek Jain5, Elizabeth A. Bukusi4, Gabriel Chamie5, Diane V. Havlir5
1Makerere University, Kampala, Uganda,2University of California Berkeley, Berkeley, CA, USA,3Infectious Diseases Research Collaboration, Kampala, Uganda,4KEMRI-UCSF, Kisumu, Kenya,5University of California San Francisco, San Francisco, CA, USA,6University of Massachusetts Amherst, Amherst, MA, USA
HIV Test-and-Treat has the potential to reduce mortality of HIV+ persons with low CD4+ counts on a population level by rapidly initiating ART among 'late presenters' not previously in care and among persons disconnected from prior care. We evaluated the effect of streamlined ART delivery for HIV+ persons with CD4<350 cells/uL after population-wide HIV testing during the SEARCH study (NCT:01864603).
At baseline (2013-2014), HIV testing at multi-disease health fairs and in homes reached 91% of 143,870 adult stable residents in 32 communities in rural Kenya and Uganda. All HIV+ persons with CD4<350 were eligible for ART. In 16 intervention communities, ART was delivered via patient-centered streamlined care including supported linkage and rapid ART start. In 16 control communities, ART was delivered via country standard of care. Mortality was ascertained after 3 years via comprehensive outreach. We evaluated (1) identification of HIV+ persons with CD4<350 at baseline, (2) among these persons, the effect of streamlined care on ART start and mortality, and (3) gender differences in mortality. Comparisons between study arms used cluster-level TMLE; survival estimates used Kaplan-Meier; estimates of ART start among ART-naïve persons treated death as a competing risk.
Among 13,266 baseline HIV+ residents, 22% (N=2,956) had CD4<350. Of these, 33% (988/2,956) were new diagnoses and 10% (282/2,956) were diagnosed but ART-naive. HIV+ men (N=4,597) were twice as likely as HIV+ women (N=8,669) to have CD4<350 and untreated (18% vs. 9%, respectively). Among persons with CD4<350, streamlined care reduced mortality by 27% vs. control (RR=0.72; 95%CI:0.57, 0.93; p=0.02). Mortality was reduced substantially more among men (RR=0.60; 95%CI:0.43, 0.86; p=0.005) than women (RR=0.90; 95%CI:0.62, 1.31; p=0.56). Despite immediate ART eligibility in both arms, persons with CD4<350 started ART faster under streamlined care vs. control (76% vs. 43% by 12 months, respectively, p<0.001). Within each arm, time to ART start was similar between men and women. However, more men vs. women had baseline HIV RNA>100,000 copies/mL (29% vs. 19%, respectively), placing men at elevated risk of HIV progression/death.
After population-based HIV testing, SEARCH streamlined care accelerated ART start and reduced mortality at a population level among HIV+ persons with CD4<350, particularly among men. These interventions may play a key role in meeting the UNAIDS goal of eliminating AIDS deaths.