Late breakers at treatment as prevention workshop: home-based testing, economic benefits of ART, and HIV services for men explored

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The late breaker session at the 2nd International Treatment as Prevention Workshop in Vancouver Wednesday offered some interesting insights relevant to HIV treatment scale up.

Home-based testing
Nathan Ford from Medicines Sans Frontieres (MSF or Doctors Without Borders) offered findings from a meta-analysis of home-based testing studies.  Their analysis found that home-based testing was an acceptable and effective way to increase testing.  Three-quarters of the adults in the households accepted testing and received their results.  Forty-seven percent of the testers were men, who are much less likely to present for testing at health care sites, so this testing intervention is one important mechanism to identify more HIV-infected men and link them to care.

HIV testing and IDUs in Bangkok
Liangping Ti from the British Columbia Centre for Excellence in HIV/AIDS  presented a study aimed at increasing the uptake of HIV testing among injection drug users (IDUs) in Bangkok, Thailand. The study utilized former and active drug users as peer researchers, interviewers and outreach workers for three different studies conducted over a four-year period.  In one of the studies, 66 percent of those who had not been tested for HIV reported they had not done so because they were not at risk, despite reporting high-risk sexual and/or drug-using behaviors during the interview process. Many of them reported they had been denied health care services at least once. The studies found a fairly high testing rate, higher than generally seen among IDUs in this region, which Ti attributed to the active tenofovir pre-exposure prophylaxis study that is ongoing in Bangkok, and the practice of some drug treatment centers in  the city to impose mandatory HIV testing on their clients. There was a high rate of acceptance of HIV testing in the community-based drop-in center for drug users where testing was delivered by peers.

Are HIV services failing men in Africa?
Steve Kanters from Simon Fraser University in Vancouver conducted a meta-analysis of the effect of gender on survival among enrollees in antiretroviral therapy (ART) programs and found significant increased mortality among men on treatment compared to men not on treatment.  Access to testing and linkage to ART for women through antenatal settings are key reasons for this difference, but they do not totally explain the survival difference.  Men still initiate treatment much later in disease progression.  According to Kanters, we need to find many ways to promote HIV testing among men including encouraging them to be tested with their partners in antenatal settings.  Rwanda has shown that this can work since men accompany women to antenatal care clinics in 87 percent of cases.  Home-based testing is another important mechanism to identify men. Using voluntary medical male circumcision clinics as testing centers and encouraging church-based testing could also help.

Economic benefits of ART in rural South Africa
Till Barnighausen from the Harvard School of Public Health reported on an analysis of the socioeconomic employment status of a population cohort in rural KwaZulu-Natal (KZN), South Africa, aimed at looking at the impact of ART on employment status.  This work was conducted with the Africa Centre for Health and Population Studies in KZN and looked at the employment history of people living with HIV between the ages of 18 and 59, compared to matched controls in the same community.  This is a community with high HIV prevalence, high unemployment, and poverty and labor migration. 

The study looked at the employment history of 2,166 adults who had initiated ART between 2004 and 2010 in ART clinics supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) attached to primary care clinics.

The researchers found a significant reduction in employment in the one to two years before ART was initiated.  Four years after ART initiation, there was substantial recovery of employment.  While employment didn’t rebound as quickly as health status, 89 percent of individuals regained employment and the vast majority were able to retain employment.  According to Barnighausen, the employment benefits of ART provide “a strong additional rationale for expanding treatment access.”  He also noted that the economic benefits of ART could be used as a tool to recruit working adults into HIV testing and treatment, particularly men who tend to seek care late in disease progression.

Cost effectiveness of combination prevention
Barnighausen also reported on a cost effectiveness analysis of different combinations of scaling up treatment as prevention along with voluntary medical male circumcision, versus scaling up treatment only under current guidelines in South Africa, which indicate starting therapy at CD4 counts greater than 350.

They found that the more ambitious the investment, the greater the impact on HIV incidence. However, the combination of high ART coverage at CD4 cell counts less than 350 and high medical male circumcision coverage provides about the same HIV incidence reduction as scale up of treatment according to current guidelines alone.  This combination is also considerably less expensive, requiring $5 billion less over the period from 2009 to 2020. The cost-effectiveness of male circumcision increases over time.  Nevertheless, massive scale up of all three scenarios meets cost-effectiveness criteria.

Home-based testing facilitates reduction in community viral load
Connie Celum from the University of Washington reported on a pilot study that found a decrease in community viral load six months after a program of home-based HIV testing and facilitated referral to care was initiated in a rural community in KwaZulu-Natal, South Africa.  Home-based HIV counseling and testing works as a platform to facilitate linkages to care. The study used lay counselors to perform the testing and offered point of care CD4 testing for HIV-infected persons in the household.

There was a decrease in community viral load six months after the program of home-based HIV testing and facilitated referral to care.  The workers also did tuberculosis and sexually transmitted infection (STI) symptom screening and included these results and CD4 count on a referral card presented to the individual.  The community workers also did a follow up visit to the homes of HIV infected persons.

Of 673 adults tested in 282 households, 201 were found to have HIV infection, with a median CD4 count of 425.  Ninety-five percent of those identified visited an HIV clinic within six months.  A quarter of them initiated ART during this period when South African national guidelines were changing from treatment initiation at a CD4 count less than 200 to a CD4 less than 350. Viral loads were taken at the initiation of treatment and then six months later.  There was a 50 percent reduction found in the community viral load after six months. This was viewed by the authors as conservative since many individuals had been on treatment for a short time.  Celum concluded that expanding ART to individuals under current guidelines could have a marked impact on HIV incidence.

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