HIV Viral Suppression Tripled Among Men and Young Adults in Bukoba, Tanzania, 2014–2017

At a glance

• Known before: reaching and keeping viral load suppression (VLS) reduces illness and death from HIV and effectively prevents sexual transmission.
• Found here: in Bukoba, Tanzania, 2.5 years of new testing, linkage to care and retention on antiretroviral therapy (ART) services roughly doubled VLS among HIV-positive adults aged 18–49 (28.6% → 64.8%) and roughly tripled it among men (20.5% → 59.1%) and adults aged 18–29 (15.6% → 56.7%).
• What follows: in 2019 the services are being scaled up across Tanzania with support from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR).

VLS here means an HIV-1 RNA level below 1,000 on a viral load test.

The gap

By 2020, countries in sub-Saharan Africa aim for VLS in 90% of people on ART and 73% of everyone living with HIV.

Tanzania has 1.4 million people with HIV. In 2017, 49.6% of HIV-positive people aged 15–49 had reached VLS — but only 21.5% of men and 44.6% of women aged 25–29.

Bukoba Municipal Council, on the western shore of Lake Victoria, is a mixed urban and rural municipality of 150,000 people and the capital of Kagera Region, which has the fourth-highest HIV prevalence (6.8% among residents aged 15–49) of Tanzania's 31 regions.

What was tried

The Bukoba Combination Prevention Evaluation (BCPE) brought three kinds of service to all of Bukoba from October 2014 to March 2017, while national rules on who could start ART widened:

• HIV testing, offered routinely at 11 health facilities, in homes and at community venues. Every patient seeking outpatient care at the three faith-based and all eight government facilities (police and military excluded) was screened and offered a test if eligible, and testing was offered at every home in Bukoba at least once and at 79 places men frequent.
• Linkage case management, for people who tested positive and were referred to the participating facilities: peer-delivered help for up to 90 days — support and counseling at diagnosis, escorts at the clinic, phone calls and reminders, and follow-up counseling on disclosure, testing partners and family, and barriers to care.
• Defaulter tracing, at nine facilities offering ART, for patients who had gone more than 90 days without care: calls, home visits and escorts to bring them back and start or restart ART.

How it was measured

Two household surveys with identical methods — one before (November 2013–January 2014) and one after (June–September 2017) — checked prior HIV diagnosis, current ART use and VLS. In census areas chosen at random in proportion to the population of each of Bukoba's 14 wards, every household member aged 18–49 could be interviewed and tested; samples from HIV-positive people were tested for viral load at the national laboratory. Estimates were weighted to the census by sex, age group and area.

• Before: 4,795 of 6,532 residents (73%) took part.
• After: 5,067 of 6,844 (74%) took part.

In both surveys, proportionally fewer men than women were reached, interviewed and tested.

Participation in the surveys before and after the intervention, by sex. CDC, MMWR.

Where Bukoba started

In 2014, among an estimated 66,134 residents aged 18–49, 8.9% had HIV. Of the estimated 5,903 HIV-positive residents:

That left an estimated 3,107 residents who needed a diagnosis and 3,493 who needed HIV care (and ART if eligible) — the program's targets.

What the services did

Over the intervention BCPE carried out 133,695 HIV tests. 4,731 clients of all ages tested positive and needed care; 4,143 (88%) were newly diagnosed.

• Linkage: of 4,206 HIV-positive clients who got linkage case management, 3,918 (93%) enrolled in care, and 2,521 (64%) started ART within 3 months of diagnosis. That share grew as the rules widened: 52% under the CD4 below 350 rule, 70% under 500 or lower, and 89% under Test and Start.
• Tracing: of 820 patients who had stopped care and were traced, 604 (74%) came back and 573 (70%) started or restarted ART. Another 830 were lost to follow-up, 85% of them before Test and Start.
• Targets: for HIV-positive people aged 18–49, BCPE reached 109% of its diagnosis target and 100% of its enrollment target — at least 91% and 86% for every sex and age group.

After: suppression doubled, and tripled for some

By 2017, HIV prevalence among residents aged 18–49 was 8.4%. Among those with HIV, 76.2% had been diagnosed before, and 70.9% were using ART, 91.3% of whom were virally suppressed.

The sex and age gaps of 2014 (adjusted prevalence ratios 1.5–2.7) had nearly closed by 2017 (1.1–1.3). Apart from owning a cell phone or television (67.2% suppressed among owners, 46.7% among non-owners), no gaps by other social and economic traits appeared in 2017.

What it means

In 2.5 years of widening ART eligibility, with only 6 months of Test and Start, suppression roughly doubled overall and tripled among men and young adults — two groups known for low suppression in Tanzania and elsewhere. BCPE nearly reached the 73% target for women, people aged 40–49 and residents settled in their home for more than 2 years. Wide outpatient and community testing, combined with Test and Start and recommended linkage and tracing services, can raise suppression substantially and narrow the gaps by sex and age in a short time.

• Fewer new infections? Not measured, but possible, given the rise — including a threefold rise among people with HIV who had unprotected sex. In a community-randomized trial in Botswana, yearly new infections fell about 30% in intervention communities, with a smaller net increase in suppression than Bukoba's but a higher level.
• Other trials: a Test and Start trial in 16 rural communities of about 5,000 people each in Kenya and Uganda raised suppression by 35.5 points (44.7% → 80.2%) in 2 years, through community health campaigns and home testing — an approach that might work less well in a larger urban place like Bukoba. Bukoba's rise was similar: 36.2 points.
• Why 73% wasn't met: most (81%) of BCPE's HIV-positive clients enrolled before Test and Start, and many patients dropped out of care; despite repeated tracing, 706 were lost before Test and Start. That fits reports of low retention in care across sub-Saharan Africa before Test and Start. Reaching 73% or more may depend not only on testing and linkage but on a concerted effort to keep people in care and bring back those who left.
• A puzzle: beating the diagnosis target (109%) should have produced more than 76% previously diagnosed after the intervention. Two likely reasons: some people diagnosed and referred to Bukoba's facilities may not have lived there (Bukoba has the regional referral hospital and two health centers that serve other districts), and, with no such services in other districts, fewer previously diagnosed people may have moved into Bukoba than out. That movement may also explain lower suppression among residents who had lived in their home less than a year (57%) than more than 2 years (70%).

Limitations

• No comparison communities, so the effect of BCPE on suppression can't be estimated.
• Men were underrepresented in both surveys; despite weighting, bias may remain.
• Clients' residence wasn't recorded for testing and linkage.
• Self-report is not very sensitive, so prior diagnosis and ART use may be underestimated, even with suppression counted in.

Rolling it out

In 2017, Tanzania's Ministry of Health, Community Development, Gender, Elderly and Children approved BCPE's facility-based testing and linkage case management as new ways of delivering care. In 2018, four nongovernmental organizations put them into 208 facilities, and into community services, in 11 regions. In 2019, PEPFAR is supporting their scale-up nationwide, and recommends provider-initiated testing and peer-delivered linkage case management to help countries reach 73% or more suppression among everyone with HIV by the end of 2020.

Sources

Based on "Threefold Increases in Population HIV Viral Load Suppression Among Men and Young Adults — Bukoba Municipal Council, Tanzania, 2014–2017," by Duncan MacKellar and colleagues of CDC, ICAP at Columbia University and Tanzania's Ministry of Health, Morbidity and Mortality Weekly Report, CDC; a work of the United States government in the public domain. Methods and outcomes of the testing and linkage programs: Cham and others, PLoS One, 2019 and MacKellar and others, PLoS One, 2018. Supplementary figure: CDC Stacks.