To ensure the success of Universal Test and Treat (UTT) it is essential that untreated HIV-infected adults are identified and that there are no barriers to ART initiation. Since UTT implementation in June 2016 the Botswana Combination Prevention Project (BCPP) has offered fast-track ART initiation with enhanced counseling and ART at the first clinic visit. We evaluated the feasibility of identifying untreated adults in the community and the acceptability of fast-track ART initiation.
BCPP is a cluster randomized trial evaluating the impact of a combination prevention package on HIV incidence in 30 communities. This sub-analysis of the 15 intervention communities evaluates 1) the cohort of patients identified through enhanced BCPP testing and linkage activities between October 2013 and May 2016, and 2) all individuals initiating ART prior to the introduction of UTT (October 2013-May 2016) and following UTT (1 June-31 August 2016) when participants with a positive HIV-verification test were immediately referred for ART initiation.
BCPP assessedHIV status in 40,628 individuals; 9,586 (24%) were HIV-infected. Among the 9,406 with complete data, 2,354 (25%) were not on ART, 34% of whom had CD4≤200; 1,120 qualified for treatment by pre-UTT national guidelines (CD4≤350), of whom 76% initiated ART.Overall, prior to UTT 1,775 HIV-infected treatment eligible participants attended HIV-clinics in the 15 intervention communities, of whom 1,359 (77%) initiated ART. Median time to ART initiation was 35 days, with 46% (571 of the 1,253 with a known start date) starting within 30 days. Following introduction of UTT and fast-track ART initiation 896 participants attended a clinic visit and had a positive HIV-verification test; 85% (629/743 with a known start date) initiated on the same day as their verification test, 95% (709/743) initiated ART within a week of their initial clinic visit, and 99% (735/743) initiated within 30 days. Only 15 (1.8%) of individuals initiating fast-track ART had a baseline creatinine clearance <60mls/min necessitating a clinic recall, and 4 (0.5%) required a treatment switch.
Significant numbers of untreated HIV-infected individuals, many with advanced disease, were identified through intensified community testing.Fast track ART was acceptable and safe and led to increased rates of ART initiation and reduced times from initial clinic visit to treatment start, and could help ART programs in Africa reach the ambitious UNAIDS 90-90-90 targets.