Botswana has achieved and surpassed UNAIDS’ 90-90-90 HIV testing and treatment target-a year before the 2020 deadline, a new study shows.
Preliminary data from the Ya Tsie study shows that Botswana has achieved an 88% viral suppression score among all HIV positive participants in an intervention that targeted 30 rural and peri-urban communities in the country. It has emerged that of all those who have been tested, 88% now have undetectable HIV-1 RNA (regardless of previous diagnosis or Antiretroviral therapy (ART) status). “This percentage exceeds the prevalence of viral suppression of 73% in the UNAIDS 90-90-90 targets and the 86% suppression achieved by “95-95-95,” and it is one of the highest reported levels of population viral suppression globally,” the new study led by researchers from Harvard T.H. Chan School of Public Health and the Botswana-Harvard AIDS Institute Partnership says.
Participants in 15 villages in the intervention group received HIV testing and counselling, linkage to care, ART (started at a higher CD4 count than in standard care), and increased access to male circumcision services. Expanded HIV testing, linkage to care, and ART coverage were associated with increased population viral suppression.
The report shows that the intervention was effective in increasing population viral suppression to very high levels (meaning that the virus becomes undetectable and can’t be transmitted while patients are taking effective treatment),
The report titled “Universal Testing, Expanded Treatment, and Incidence of HIV Infection in Botswana” shows that, although the percentage of men who underwent circumcision was greater in the intervention group than in the standard-care group “in our trial, it was lower than expected.”
“We were unable to directly determine which specific intervention or interventions were most important in reducing the incidence of HIV infection,” the researchers said. They added: “However, we identified large numbers of HIV-positive persons who were not receiving ART15 and successfully linked them to ART,16 with a notably shorter time to ART initiation in the intervention group than in the standard-care group (69 days vs. 367 days).”
Expanded ART eligibility, in the absence of effective HIV testing and linkage activities, would probably not yield as great a reduction in the incidence of HIV infection, the report says.
“The more rapid viral suppression observed after fast-track and dolutegravir-based ART initiation starting in June 2016 may also have contributed to the reduction in incidence,” the report says.
It says given the small number of men who underwent circumcision and the low prevalence of circumcision (approximately 50%) by trial end, it is unlikely that male circumcision contributed substantially.
“Our findings suggest that even in populations with high viral suppression, it is feasible to find persons who are not yet receiving ART (including many who have not yet received a diagnosis of HIV infection), and these persons are willing to start and adhere to universal ART,” the researchers said.
They further stated that “Because our interventions were delivered within community and programmatic settings by cadres of staff that are typical in African countries, the feasibility of implementation may be generalizable. As WHO guidance on HIV testing and treatment evolves, we think that key elements of the Ya Tsie interventions can be locally adapted.”
They said planned costing and cost-effectiveness analyses will be critical to inform policy formulation.
The researchers found that “In our trial, potential remaining sources of HIV transmission included non community residents, residents who were not receiving ART, noncitizens (who cannot access free ART), and persons who had acute HIV infection before they began to receive ART.”
Commenting on the study, senior author Shahin Lockman associate professor in the Department of Immunology and Infectious Diseases of the United States, said “Using approaches that are feasible in most settings, we achieved levels of HIV diagnosis, treatment, and viral suppression that are among the highest levels reported globally.”
According to Lockman, “These high rates of treatment coverage are a testimony to the long-standing commitment that Botswana has shown to tackling HIV. We also believe that our approaches and findings are highly relevant for other countries.”
Lock added that “Universal HIV testing and treatment can contribute substantially toward improving health and reducing the rate of new HIV infections in the community. This reduction, if sustained over time, will help us achieve the UNAIDS target of 90% reduction in the rate of new HIV infections by 2030.”
With the goal of ending the acquired immunodeficiency syndrome (AIDS) epidemic by 2030, the Joint United Nations Program on HIV and AIDS (UNAIDS) promotes “90-90-90” targets: namely, that by the year 2020, 90% of all HIV-positive persons will know their HIV status, 90% of those with a diagnosis of HIV infection will receive sustained ART, and 90% of persons receiving ART will have viral suppression.