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Implementation of Universal HIV Testing and Treatment to Reduce HIV Incidence in Botswana: the Ya Tsie Study

  • Treatment as Prevention (SH Vermund, Section Editor)
  • Published:
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Abstract

Purpose of Review

Antiretroviral treatment (ART) can dramatically reduce the risk of HIV transmission, but the feasibility of scaling up HIV testing, linkage and treatment to very high population levels, and its impact on population HIV incidence, were unknown. We review key findings from a community-randomized trial in which we evaluated the impact of “universal test and treat” (UTT) on population HIV incidence in Botswana, a resource-constrained country with both high HIV prevalence and high ART coverage before study inception.

Recent Findings

We conducted a community-randomized trial (the “Ya Tsie” trial or Botswana Combination Prevention Project (BCPP)) in 30 villages in Botswana from 2013 to 2018, with the goal of determining whether a combination of prevention interventions—with a focus on universal HIV testing and treatment—would reduce population-level HIV incidence. The intervention included universal HIV testing (home-based and mobile), active linkage to HIV care and treatment with patient tracing for persons not linking, universal ART coverage, rapid ART start (at the first clinic visit), and enhanced male circumcision services. Botswana had very high HIV diagnosis, treatment, and viral suppression levels (approaching the UNAIDS “90-90-90” targets) prior to intervention roll-out. By study end, we were able to exceed the overall 95-95-95 coverage target of 86%: an estimated 88% of all persons living with HIV were on ART and had viral suppression in the Ya Tsie intervention arm. In addition, annual HIV incidence was 30% lower in the intervention arm as compared with the control arm over a 29-month follow-up period.

Summary

With universal HIV testing and relatively simple linkage activities, it was possible to achieve one of the highest reported population levels of HIV diagnosis, linkage to care, and viral suppression globally and to reduce population HIV incidence by about one-third over a short period of time (< 3 years). We were able to significantly increase population viral suppression and to decrease HIV incidence even in a resource-constrained setting with pre-existing very high testing and treatment coverage. Universal community-based HIV testing and tracing of individuals through the HIV care cascade were key intervention components.

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Funding

The Botswana Combination Prevention Project/Ya Tsie Trial was supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of cooperative agreements U01 GH000447, U2G GH001911, U2G GH000073, U2G GH002027, and U2G GH000419. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official positions of the funding agencies.

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Authors and Affiliations

  1. Brigham and Women’s Hospital, PBB-A4, 15 Francis Street, Boston, MA, 02115, USA

    Shahin Lockman

  2. Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Shahin Lockman, Molly Pretorius Holme, Joseph Makhema, Kathleen E. Wirth & M. Essex

  3. Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana

    Shahin Lockman, Joseph Makhema & M. Essex

  4. Centers for Disease Control and Prevention, Atlanta, GA, USA

    Pamela Bachanas & Janet Moore

  5. Ministry of Health and Wellness, Gaborone, Botswana

    Refeletswe Lebelonyane

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  1. Shahin Lockman
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Correspondence to Shahin Lockman.

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The authors declare that they have no conflicts of interest.

Human and Animal Rights

All reported studies with human subjects performed by the authors have complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines). The Botswana Combination Prevention Project (NCT01965470) was approved by IRBs at the U.S. Centers for Disease Control and Prevention and the Botswana Ministry of Health and Wellness.

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Lockman, S., Holme, M.P., Makhema, J. et al. Implementation of Universal HIV Testing and Treatment to Reduce HIV Incidence in Botswana: the Ya Tsie Study. Curr HIV/AIDS Rep 17, 478–486 (2020). https://doi.org/10.1007/s11904-020-00523-0

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