Day 2 of IAS2015, I attended a very full lunch poster discussion session entitled HIV Testing: The Gateway for Everything.

Sheri Lippman presented two posters. The first presented results from a cluster randomized controlled trial comparing the ‘one man can’ campaign in South Africa which aimed to engage men into testing through community mobilization. Community mobilization was found to be associated with higher testing uptake, though not equally for all CM domains. The main three domains which had the greatest impact were consciousness, concerns and collective action.

Sheri’s second presentation was on a pilot study examining feasibility and acceptability of self-testing in transgender women in San Francisco. 50 HIV-ve trans women were provided home HIV test kits and asked to utilized the tests once a month for three months, behavioral data was also collected at baseline and three months. 96% of study cohort had multiple recent partnerships and 80% had engaged in sex work, so as with other transgender communities, a pretty high risk population. Most found the test easy to use and would recommend to their friends (>90%), 68% would use the test again. The main reasons provided for not using again were around gaining access to counseling services that facility-based testing provided, and most participants had tested with a partner or a friend. A marketing strategy which provided two home-based tests aimed at testing with a partner could be an efficacious method for targeting this hard-to-reach population.

Laura Derksen from the London School of Economics presenting results from a cluster-randomized trial examining methods to reduce stigma in a community based setting in Malawi. 122 Malawi villages were targeting (60 intervention villages and 62 control) which reach two thirds of the target 15-49yrold population. In the control villages information was provided on the benefits of ARV including prolonging life and reversal of AIDS. While in the intervention villages, in addition to the control information, information regarding reduced likelihood of transmission in partnerships where the HIV+ve partner properly adhered to ARV was also propagated. The overall concept being that if they could reduce stigma, by showing that individuals who tested were in fact safer sexual partners then rates of testing would improve. The percent of the population having testing for HIV post-exposure was found to be  60% higher in the intervention arm compared to the control arm, and this was consistent for both genders.

Perhaps the most relevant to the Australian setting was a poster presented by David Katz, which examined self-testing as a method to increase overall testing frequency among high-risk MSM in Seattle. 230 HIV-ve MSM were randomized to have access to free HIV self-tests versus standard HIV testing for 15 months. The primary endpoint was the comparison of HIV testing frequency, secondary endpoints included non-inferiority in regards to behavioral markers of HIV risk acquisition. The mean number of test in the self-testing arm was 5.3 (4.7-6.0) compared to 3.6 (3.2-4.0) in the control arm, which was statistically significant (p<0.0001). Non-inferiority bounds were met for risk acquisition, which included difference in frequency of bacterial STI diagnosis at 15 months, likelihood of non-concordant anal intercourse at 3 months, and number of male non-concordant partners. However confidence intervals were wide for the secondary endpoints and the study not really adequately power to examine these associations.  

And finally the last two posters were presented by Sue Napierala Mavedzenge and Pius Tih Muffih respectively. Sue presented results of a feasibility study which examined the reliability of self-testing in both rural and urban settings in Zimbabwe. There was high sensitivity and specificity of interpreting self-test kits in both rural and urban settings, however slightly lower sensitivity in the rural setting, which was likely a result of lower literacy in this group. Some practical issues to encourage interpretation of the test (such as increased window size) were discussed.  Pius Tih Muffih provided the results of a very interesting study which examined integrating partner notification into Option B+ in Cameroon. Results looked promising with 823 women testing positive providing information on 840 partners of which 693 were notified, of whom 421 were tested for HIV and 139 new HIV+ve cases identified and linked to care. They had not observed any backlash in terms of violence to women as a result of the notification but this was highlighted as an issue which needs to be carefully monitored.

 Greetings from Day 1 of IAS 2015,

Treatment as prevention (TasP) and the UN proposed ambitious 5-year treatment target of 90% of HIV+ve individuals being diagnosed, 90% of those diagnosed on efficacious treatments and 90% of those treated virally suppressed equating to 73% of all HIV+ve individual’s being virally supressed was the topic of discussion at the pre-conference workshop UN 90-90-90 Target Workshop: Lessons from the field.

There were four sessions spanning the day. After an opening speech by Michel Sidibé, Session One starting with RCT evidence to support immediate versus standard of care (SOC) ARV population-based roll out interventions and it’s utility to achieve the 90:90:90 target (SEARCH, HTPN071 (POPART), ANRS12249 and the Botswana Combination Prevention Protocol(BCPP). There was also some evidence reported for the utility of financial based incentives (FIs) to encourage linkage to care (HPTN065) and some discussion of acceptability of immediate ARV in sero-discordant couples (HPTN052) though 1-year follow-up results of HPTN052 will be presented Monday 2:30pm. The take home messages of session one included:

• Largely testing rates, linkage to care and viral suppression levels achieved in SEARCH, POPART, ANRS12249, and BCPP were all high, around the 80% mark, however the big question of the impact of early ARV on HIV incidence in all of these trials is yet to be determined. Results so far look promising.
• There still remain some pockets of the HIV+ve population which seem consistently hard to reach, primarily migratory young men in Africa. However while there were some gender disparities in linkage to care, once in care outcomes seemed similar for both genders. More social behavioural data from SEARCH, POPART and ANRS12249 to come.
• There was evidence to support that immediate ARV does not have detrimental impacts on adherence to treatment i.e. HIV+ve people who feel healthy still seem to be good at take their drugs
• The multi-disease approach undertaken by SEARCH, grouping testing for HIV with hypertension and diabetes was an encouraging approach
• Financial based incentives did not show significant improvements in linking known HIV+ve individuals into care in the US, however they did show some efficacy in specific sub-groups, suggesting possibly that FI should be a target rather than a broad roll out. Some discussion over the ethics of FIs and the difficulty in implemented these strategies was highlighted in the discussion

Session Two largely covered evidence from cohorts. Evidence in achieving the 90-90-90 targets was presented for HIV cohorts in rural Malawi, Swaziland, KwaZulu-Natal and Rwanda, and evidence from the new cohort AFRICOS was presented. Lessons from this session included:

• Results from rural Malawi where MSF task shifted ARV roll out from doctors to nurses which was later subsumed into the national program look very promising, 77% diagnosed, 84% on treatment and 91% of those virally suppressed. Again young men are those not linking to care.
• The Early Access to ART for All (EAA) Study in Swaziland provided evidence for scalability feasibility and acceptability of the 90-90-90 target approach. Results supported initiating ARV on the same day as testing to avoid LTFU. While this may be difficult to implement if GART for first line is part of the recommended national guidelines in most of the developing world it is not.  Further lessons from KwaZulu-Natal presented by Frank Tanser showed barriers to care were distance from treatment centres (even in non-centralised settings) and gender.
• The cascade of care in Rwanda looks close to the 90-90-90 target, with the epidemic now moving into older aged groups.

Session Three covered field implementation initiatives in China, Brazil, Thailand, and San Francisco. The ability for faith based organisations to engage people into care was also presented as well as some interesting results from a phylogenetic monitoring system that has been set up in British Colombia. Take home message from this post lunch, slightly jet-lagged session were:

• In many settings described in this session, patients still had a median CD4 at diagnosis of less than 350 so it’s not really a question of immediate or deferred ARV rather engaging people in testing and linking to care. HIV peer intervention testing and self-testing has found to have encouraging results in Brazil. While a mixed facility and community-based testing model has improved diagnosis and linkage rates in Thai MSM and Transgender populations.

• San Francisco has surpassed the 90-90-90 target and is now aiming for zero new infections. The RAPID program which enlisted individuals in immediate same-day ARV initiation looked promising. The difficulties in reaching that last 10% of the HIV+ve population in non-generalised epidemics was highlighted. How to reach specifically transgender populations was also discussed in question time, online outreach methods and linking ARV services with hormone therapy services were some of the suggestions.

• Finally a population-wide HIV resistance database in British Colombia has been used for phylogenetic monitoring of outbreaks in real time. Fascinating results but a real potential for huge legal ramifications (two Supreme Court appearances later, Art Poon and colleagues in British Colombia have managed to resist forced disclosure of individuals). What a shame we live in a world where criminalization of sex in HIV+ve individuals is still common place!

And finally the workshop ending with presentations from donors, PEPFAR and the Global fund, and agencies, CDC who highlighting the cascade in the US, and the WHO and IAPAC who discussed soon to be released guidelines. The main highlight of this session was the (unofficial) report by Gottfried Hirnschall that the new WHO ‘When to Start’ guidelines including PrEP recommendations will likely be released in September of this year. These will (unofficially) include ART initiation for all regardless of CD4 count, PrEP for individuals with substantial risk (to be defined…), Option B+ as the recommended SOC and some suggestions for dose reduction strategies.

So finally, my overall conclusions of the workshop are the 90-90-90 UN target seems a difficult target but potentially achievable in some settings. Primarily generalised epidemics where the health system can support such targets with UNAIDs strengthening the provision of ART and donors getting on board, or non-generalised epidemics where innovation methods are employ and large amounts of resources can be mobilised in support of such efforts.  It will, however, be a specific challenge in other setting where either there isn’t a national health system to support such a roll out or there isn’t the resources to achieve these target where the epidemic remains localised in particularly hard-to-reach populations. As suggested by one of the attendees, perhaps there should be a fourth 90, 90% of countries achieving the 90-90-90 UN target by the year 2020?

For details of the workshop see http://www.treatmentaspreventionworkshop.org, for a live stream of the workshop see http://flash-vs.cfenet.ubc.ca/cfestream1.html