What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?
What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?
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DOI：
10.1002/jia2.25455
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发表时间：
2020-02-01
影响因子：
6
通讯作者：
Dabis, Francois
中科院分区：
文献类型：
--
作者：
Havlir, Diane;Lockman, Shahin;Dabis, Francois
在全球实现艾滋病毒流行控制将需要新的战略，以加快减少艾滋病毒发病率和死亡率。根据世界卫生组织指南和联合国艾滋病规划署90-90-90活动，在撒哈拉以南非洲(SSA)进行了四项随机人群试验(BCPP/Ya Tsie，HPTN071/PopART，Search，ANRS 12249/TasP)，对通用试验和治疗进行了评估。研究中的主要观察结果是：(1)通用测试(通过各种家庭和社区测试方法实施)在所有研究中实现了90%的覆盖率。(2)再加上与艾滋病毒护理、快速抗逆转录病毒治疗和以患者为中心的护理的强有力联系，UTT在SSA实现了报告的最高人群病毒抑制水平。在基线人群病毒载量较低和较高的区域，在人群水平的病毒抑制方面取得了显著进展；然而，所有次级人群的病毒抑制收益并不一致，在青年中较低。(3)在普遍检测和强有力的联系存在的情况下，UTT导致社区艾滋病毒发病率显著下降。然而，没有达到消除艾滋病毒的目标。在BCPP和HPTN 071中，与对照组(不进行普遍检测)相比，干预(包括普遍检测)中的艾滋病毒年化发病率大约低20%至30%。在Search(两个分支都进行了普遍测试)中，发病率在三年内下降了32%。(4)与SSA中的对照社区相比，UTT降低了23%的HIV相关死亡率，这是一项综合测量死亡率的研究。结论这些试验提供了强有力的证据，表明包括普遍检测在内的UTT提高了人群水平的病毒抑制，并比SSA的现状更快地降低了艾滋病毒的发病率和死亡率，应该作为一项公共卫生战略在次国家层面进行调整。然而，还需要更多，包括将新的预防干预措施纳入UTT，以实现联合国艾滋病规划署消除艾滋病毒的目标。
Introduction Achieving HIV epidemic control globally will require new strategies to accelerate reductions in HIV incidence and mortality. Universal test and treat (UTT) was evaluated in four randomized population-based trials (BCPP/Ya Tsie, HPTN 071/PopART, SEARCH, ANRS 12249/TasP) conducted in sub-Saharan Africa (SSA) during expanded antiretroviral treatment (ART) eligibility by World Health Organization guidelines and the UNAIDS 90-90-90 campaign.Discussion These three-year studies were conducted in Botswana, Zambia, Uganda, Kenya and South Africa in settings with baseline HIV prevalence from 4% to 30%. Key observations across studies were: (1) Universal testing (implemented via a variety of home and community-based testing approaches) achieved >90% coverage in all studies. (2) When coupled with robust linkage to HIV care, rapid ART start and patient-centred care, UTT achieved among the highest reported population levels of viral suppression in SSA. Significant gains in population-level viral suppression were made in regions with both low and high baseline population viral load; however, viral suppression gains were not uniform across all sub-populations and were lower among youth. (3) UTT resulted in marked reductions in community HIV incidence when universal testing and robust linkage were present. However, HIV elimination targets were not reached. In BCPP and HPTN 071, annualized HIV incidence was approximately 20% to 30% lower in the intervention (which included universal testing) compared to control arms (no universal testing). In SEARCH (where both arms had universal testing), incidence declined 32% over three years. (4) UTT reduced HIV associated mortality by 23% in the intervention versus control communities in SEARCH, a study in which mortality was comprehensively measured.Conclusions These trials provide strong evidence that UTT inclusive of universal testing increases population-level viral suppression and decreases HIV incidence and mortality faster than the status quo in SSA and should be adapted at a sub-country level as a public health strategy. However, more is needed, including integration of new prevention interventions into UTT, in order to reach UNAIDS HIV elimination targets.