Abstract Body

This presentation discusses the four recently completed community randomized trials of “Universal Test and Treat” (UTT) in East and southern Africa and their implications. Three themes developed in parallel and led to these ambitious implementation studies: recognition of the centrality of viral load for HIV pathogenesis and HIV transmission; studies showing >90% effectiveness of “treatment for prevention”; and evolution of antiretroviral treatment guidelines that since 2015 recommend immediate treatment of all persons living with HIV.  Mathematical modeling in 2008 suggested UTT, with repeated and regular HIV testing, could eliminate HIV in an epidemic of South African severity (Granich et al, Lancet, 2009).  Political advocacy highlighted the concept of “Ending AIDS” while scientific debate culminated in four community randomized trials aiming to assess UTT with HIV incidence as the primary outcome in Botswana (BCPP); Kenya and Uganda (SEARCH); South Africa (TASP); and South Africa and Zambia (PopART), from 2012-2018.  Primary results of the four trials were published in Lancet HIV (TASP, 2018) and NEJM (2019) and additional analyses, including on cost-effectiveness, are underway.  All four trials achieved >90% knowledge of HIV serostatus but TASP yielded low linkage to treatment.  The other three trials met the UNAIDS 90:90:90 targets, achieving 74-88% population-level viral suppression. Treatment guidelines changed over the studies’ course, resulting in some erosion of differences between intervention and control communities.  BCCP and one of PopART’s two intervention arms showed 30% reduction in HIV incidence compared to control communities, while no significant differences were found in the other studies.  Despite the successful achievement of 90:90:90 targets, HIV incidence in intervention communities (6-22.3/1000/year) remained well above an arbitrary definition of HIV elimination of <1/1000/year.  Knowledge of HIV serostatus and early treatment are essential for individual and the public health, but UTT alone will not lead to HIV elimination. Priorities include expansion in scale and scope of HIV testing to reduce the diagnostic and treatment gap in generalized epidemic settings, addressing needs of key and underserved populations (including youth and men), and scale-up of highly effective interventions such as voluntary medical male circumcision and PrEP.  Greater focus on measuring HIV incidence and mortality is required to better understand epidemic trends in the face of combinations of preventive interventions.