HIV Prevention Trials Network (HPTN) 071 (PopART) was a cluster-randomized trial to evaluate universal testing and treatment (UTT) strategies for HIV prevention. HPTN071 compared three arms: (A) combination prevention with UTT; (B) combination prevention with universal testing and antiretroviral therapy initiation according to local guidelines; and (C) standard of care (SOC). Interventions were implemented in entire randomized communities, with impacts on HIV incidence measured in “population cohorts,” that is the HPTN071 sample. Unexpectedly, a significantly lower incidence was not observed in arm A relative to SOC. Importantly, rates of participation in the HPTN071 sample differed among population subgroups, for example men were underrepresented.
To correct for underrepresented subgroups, PopART intervention effects are estimated in a population of interest, adults aged 18−44 in trial provinces, characterized with two nationally representative HIV-focused surveys. The HPTN071 sample is weighted to match the population of interest by demographics and HIV risk factors. Risk of HIV acquisition is compared across arms, both in the trial population (unweighted) and the population of interest (weighted). Both (1) the risk of HIV acquisition between 1 and 3 years and (2) the risk of HIV acquisition by 3 years are compared.
In the trial population, estimated risk in arm A is, counterintuitively, slightly higher than SOC (Year 1−3 Risk Difference [RD]: 0.10%; 95% CI: −1.15%, 1.25%). After weighting, risk in arm A is lower than SOC in the population of interest (RD: −0.34%; 95% CI: −2.04%, 0.96%). Weighting also strengthened the estimated effect in arm B relative to SOC (unweighted RD: −0.66%, 95% CI: −1.88%, 0.46%; weighted RD: −1.18%, 95% CI: −2.85%, 0.15%). Weighted year 3 risk difference estimates indicated even stronger possible intervention effects: A versus SOC −0.83% (95% CI: −2.94%, 0.99%), B versus SOC −1.86% (95% CI: −3.80%, −0.09%).
PopART interventions are estimated to be more protective in the population of interest than observed in the HPTN071 sample. These results partially explain the unexpected finding in arm A, providing further support for UTT strategies for HIV prevention. This analysis also highlights the importance of considering heterogeneous treatment effects among population subgroups when measuring the overall efficacy of HIV interventions.
Progress in reducing and eliminating vertical transmission of HIV in children has stagnated over recent years. Unfortunately, recent decisions in the global donor space are likely to lead to considerably lower funding available for HIV and other disease programmes in high-burden low- and middle-income settings. Understanding and implementing the most effective strategies to prevent, diagnose, treat and monitor HIV acquisition in children are critical to maximize available resources and provide the best care for children.
A set of tools to support the elimination of vertical transmission and end AIDS in children exists across the cascade of care for pregnant mothers and their children, including those for prevention, diagnosis, treatment, monitoring and service delivery. Each tool comes with its own challenges in implementation and scale-up; however, the effectiveness of many has been well-studied and documented. Ensuring all women living with HIV have consistent and secure access to optimized antiretroviral therapy will prevent the largest number of leaks in the cascade that can lead to vertical transmission events. Implementing effective infant diagnosis strategies, including same-day point-of-care testing and birth testing where feasible, will lead to earlier and faster identification of children living with HIV. Subsequently, rapid linkage to optimized treatment will save and improve the lives of children living with HIV. Finally, implementing accompanying monitoring modalities and country-specific service delivery approaches will improve implementation and the effectiveness of these tools as well as retention and commitment in care programmes by children as they become adolescents and adults.
Ending AIDS in children is possible. We have the tools to do so. However, now is the time for national, regional and global stakeholders to come together to prioritize children and ensure appropriate funding, implementation and equitable access are in place. Testing infants quickly and accurately for HIV is the first step to ensuring their lifelong health and wellbeing. As national and global public health structures shift, programmes need to act quickly—gains in paediatric HIV cannot be lost but must be accelerated. Doing so will require political will, financing, infrastructure, community-led initiatives, and commitment by and access to all to achieve those goals.
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：