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Can tests and treatments be done in sub-Saharan Africa?: Goats and soda: NPR



  Blood sampling for testing for HIV.

  Blood collection for testing for HIV.

In high-income countries such as the US, the standard of care for HIV-infected people is to provide antiretroviral pills when the virus is present, even if there are no symptoms of AIDS. The strategy prevents the disease and has a second major advantage. It has been shown to prevent the spread of HIV during sexual encounters. It is called "treatment as prevention" (TasP in medical jargon) or "testing and treating".

However, in low-income countries, "testing and treating" is not the typical approach to prevention. There are no studies that prove this.

When they began, they stated that the AIDS research community was in doubt as to whether the effort would be successful. "People did not think we could offer antiretroviral therapy in sub-Saharan Africa," says study leader Richard Hayes of the London School of Hygiene and Tropical Medicine. "There was a lot of skepticism." Helen Ayles from the same institution and a Zambian research organization called Zambart encountered the same resistance. "People said that you will never bring a community to the test and never a community that wants to start treatment early, and if you do, they will never continue the treatment." This stance is in part due to past efforts to induce people in developed and developing countries to adhere to a daily drug regime – and to the mistrust of the population in low-income countries when foreigners arrive to conduct a health mission.

Ten years ago, researchers began planning a comprehensive study on prevention in South Africa and Zambia. The team came from the London School of Hygiene and Tropical Medicine, Imperial College and several other facilities in the US, Zambia and South Africa.

The study provided "Test and Treat" for communities with approximately 1 million people in South Africa and Zambia from 2013 to 2018. The $ 130 million project is called PopART (Population Effects of Antiretroviral Therapy to Reduce HIV Transmission ).

The results show that practice could play a crucial role in combating the AIDS epidemic. [19659004] "The results are fantastic," says Ayles. "We've been able to prove that you can reduce HIV incidence by 30 percent, which is an amazing thing."

"This is a landmark study," says Judith Wasserheit, longtime AIDS researcher and head of the Department of Global Health at the University of Washington, who was not involved in the research. "Getting communities to intervene and maintain an intervention is one of the great challenges of global health."

Details of the new study were announced at the conference on retroviruses and opportunistic infections in Seattle in the spring of this year and will be published shortly. The findings should be a major source of discussion at the global AIDS and HIV conference in Mexico City in July.

The scope of the experiment was immense. The researchers began annual HIV testing in 14 communities, each with approximately 50,000 inhabitants, in urban areas and cities in South Africa and Zambia. Community health workers went to the people's home, talked to them about HIV and HIV prevention, distributed condoms, and offered field tests. Those who tested positive received a free antiretroviral therapy. Another 300,000 people were in the control group, which offered no "test and treat".

The study was funded by the US Government and the International Initiative for Impact Assessment with the support of the Bill and Melinda Gates Foundation (that is

In half of the 14 communities where "testing and treating" was the protocol Immediate treatment was offered to anyone who turned out to be HIV-positive and the results of these communities were not as impressive: a 7% reduction in HIV infection compared to control arm communities where sometimes tests and treatments were available not with the concerted door-to-door reach of the PopART approach.

In the other half of the communities where "Test and Treat" took place, treatment in the first few years did not begin until the number of white ones Individuals' blood cells fell below a certain level (during the study, these communities were switched to immediate treatment when the national guidelines changed

In these seven "Test and Treat" communities, whose total population was approximately 330,000, the incidence of new infections was 30 percent lower than in the control group communities.

"We have shown that it is feasible and acceptable to carry out this type of intervention in cities in sub-Saharan Africa," says Hayes.

A key element of the study was the door-to-door deployment of local health worker door to talk about HIV – and to test it for HIV.

Kim Cloete / PopART Study


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Kim Cloete / PopART Study

A key element in the study was to send local health workers door to door to talk about HIV and test it for HIV.

Kim Cloete / PopART Study

The new study raises an important question: why was there a drop of 7 percent in the group treating HIV-positive individuals immediately, compared to 30 percent in other treated communities where treatment was originally delayed? has been? [19659004] "My first reaction was that the statisticians got it the wrong way around," says Hayes. Four different statisticians repeated the analysis and obtained the same results. The PopART researchers use the data to understand the difference.

Further findings can be drawn from the study. The designers felt that community buy-in was the key to getting people to accept tests and treatments. At the start of PopART, researchers asked community leaders to work on advisory boards to monitor the project and help researchers find and train more than 700 community members working in healthcare. The process, Hayes says, "was like mobilizing an army."

The idea was that these community health workers, who understood the lives and languages ​​of their patients, could make a difference. "What PopART has shown is how important local health workers can be," says Maryam Shahmanesh, associate professor at University College London and expert on HIV prevention and sexual health medical training, found a listing for health workers while looking for a job in sought her local newspaper. She supervised 112 members of the program and visited the community.

"It has been an amazing experience for me," she says. "At first, people were not sure what was going on." There were already test centers in some cities, but this was a door-to-door effort. "When people noticed that we were there to help them stop this terrible infection, they became so susceptible," she says. "They saw that we were there for their own good."

Myron Cohen, a professor at the University of North Carolina, calls the new study "a roadmap." Cohen is a major investigator in a worldwide collaboration of researchers conducting clinical trials on AIDS interventions, including these. Cohen led the study, which showed in 2011 that intense attention – frequent visits to the health center and counseling on risk reduction and condom use – and antiretroviral drugs can stop inter-partner transmission if they are known to be HIV-positive. [19659004] PopART builds on Cohen's findings and other endeavors, including a major study in South Africa. This study showed that HIV transmission is less common in communities where treatment is available than in similar communities where it is not, suggesting that HIV transmission could be controlled at the population level.

A single-community study was conducted in early June In KwaZulu-Natal, MSF has shown that involving patient populations, local health workers and political leaders encourages people to be tested and treated. The study provided preliminary evidence that widespread dissemination could reduce the spread of HIV in a poor area.

The United States has set itself the goal of eliminating the public health threat posed by HIV for the year 2030. Is this possible? Cohen says swiftly Yes, if adequate efforts are made – if every HIV-infected person can be found, treatment is started and they are convinced to continue treatment. PopART co-leader Richard Hayes hesitates before answering. "I think it can be done," he finally says. "But I think it will be a real challenge."

Joanna Silver, former NPR health policy correspondent, is a freelance journalist living in London.


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