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.