Balzer and International Team Evaluate Community Health Approach to Universal HIV Testing and Treatment in Rural East Africa

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Laura Balzer, assistant professor of biostatistics, is among the authors of a new paper appearing in the “New England Journal of Medicine� that shares the results of a three-year research project, the Sustainable East Africa Research in Community Health (SEARCH) Study, to reduce HIV incidence and improve community health in rural Kenya and Uganda.

Led by investigators at the University of California, San Francisco, the SEARCH Study was designed to test whether population-based, multi-disease testing with immediate treatment and patient-centered care for all HIV-positive persons would accelerate HIV epidemic control by reducing new infections and deaths. For the intervention group, testing for a variety of health conditions was provided annually at mobile health fairs, followed by home-based testing for non-participants. Those found to have HIV, diabetes or hypertension received counseling, clinic appointments, and were offered rapid treatment initiation. Through the same model, the control group received universal testing at baseline, followed by referral, if appropriate, to the country standard-of-care for treatment. Balzer says, “At the start of the study, global and national HIV guidelines indicated treatment initiation for HIV-positive persons with CD4 counts (a measure of certain immune cells in the blood) under 350. Those guidelines rapidly evolved, and within one year, our control sites were offering antiretroviral therapy with near universal eligibility for all HIV-positive persons.�

Balzer served as lead statistician on the project, playing an essential role in the study’s cluster randomized trial design. The investigators randomly assigned 32 rural communities in Kenya and Uganda —including more than 150,000 adults — to either the intervention group or the control group. Balzer was also responsible for the statistical analyses of all adult health outcomes.

At baseline, over 90 percent of community residents received testing for HIV infection in both study arms. After three years, viral suppression among all HIV-positive persons was 15 percent higher in intervention communities than in control communities, and both arms exceeded estimates of viral suppression in most countries in Sub-Saharan Africa. Within the intervention communities, annual incidence of HIV infection declined by 32 percent between the first and third years. There were also significant other health benefits to the community in response to the intervention approach. Risk of death, risk of tuberculosis and death among people living with HIV and prevalence of uncontrolled hypertension in adults were all 20 percent lower in the intervention group. Balzer remarks, “It’s not just the guidelines – how we deliver care matters.�

SEARCH showed that in a remarkably short time period, a community health approach to “Universal Test and Treat� could rapidly reduce HIV incidence, deaths, tuberculosis and other chronic diseases in sub-Saharan Africa that line up with the United Nation’s Sustainable Development Goals. Important gaps remain though—younger adults were not able to achieve the same levels of viral suppression, and women are still being disproportionately infected with HIV.

The SEARCH team is currently evaluating their next steps toward eliminating HIV transmission and improving community health.