Vaccine and Infectious Disease Division

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Community based strategies: the link to HIV viral suppression

Antiretroviral therapy (ART) has turned HIV/AIDS from a fatal diagnosis to a chronic disease. While these medications are extremely effective when taken as prescribed, there is still a chasm between drug availability and HIV+ and/or at risk persons. One reason is that ART is not a ‘take once and you’re done’ type of therapy. People are on the drugs for life and often must take more than one pill every day. While this might sound as easy as taking a multivitamin with your breakfast, for those in resource poor settings such as small towns in sub-Saharan Africa with no Bartell Drugs down the street, it can quickly become a daunting task, especially over the long-term. Therefore, part of the public health rubric for HIV includes providing community based follow-up and sometimes continuing education and care for HIV infected individuals. This type of care, known as linkage care, integrates counselling, home visits, clinic visits, and referral to continue the dialog between care provider and patient after HIV diagnosis.

In order to investigate different linkage methods for increasing ART usage and male circumcision in resource poor communities, VIDD Affiliate Investigator Dr. Ruanne Barnabas, Affiliate Investigator Dr. Connie Celum, and Member Dr. Jim Hughes tested home-based counseling and diagnostics of HIV infection in rural South Africa and Uganda. This randomized controlled trial compared three different linkage to care community based strategies: clinic counselling, counsellor home visits, and standard of care referral. Approximately 2,000 HIV+ women aged 16-49 years were included in the study. Participants were assigned 1:1:1 to each of the three linkage strategies. All three methods resulted in a similar prevalence of HIV viral suppression after nine months (~50%) in HIV seropositive individuals. Initial results demonstrated high coverage of viral testing (>90%) (Figure, left graph) and high uptake of ART (85%) 6 months after home-based HIV counseling and testing. Subsequent follow-up exhibited continued viral suppression in 80% of participants receiving ART after 9 months. Participants reported that the main barrier to ART uptake was bottlenecks in accessing care at busy clinics, including repeat visits prior to ART initiation.

Effect of linkage to care strategies

The second research question of the study was investigating different methods for promoting male circumcision in uncircumcised individuals. A total of 750 HIV- men were assigned 1:1:1 to clinic referral, text message reminders or counsellor follow-up. Male circumcision surgery was performed on two times more men when they received text message reminders or counsellor home visits than those who only got standard clinic referral care (Figure, right graph). As circumcision has been shown to decrease HIV infection risk ~60%, the simple and inexpensive method of text messaging could be a powerful tool in reducing HIV incidence in these populations.

Overall, the study highlights the importance of continuing patient education and follow-up care post HIV testing contemporaneously with ART for achieving low viral load in rural eastern and southern Africa.


Barnabas RV, van Rooyen H, Tumwesigye E, Brantley J, Baeten JM, van Heerden A, Turyamureeba B, Joseph P, Krows M, Thomas KK, Schaafsma TT, Hughes JP, Celum C. Uptake of antiretroviral therapy and male circumcision after community-based HIV testing and strategies for linkage to care versus standard clinic referral: a multisite, open-label, randomised controlled trial in South Africa and Uganda. Lancet HIV. 2016 May;3(5):e212-20.


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