Antiretroviral therapy (ART) and tuberculosis preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community-based care, can increase the uptake of ART and TPT to prevent TB in settings with a high burden of HIV-associated TB, particularly among men.
We developed a gender-stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15−59 in KwaZulu-Natal, South Africa. We drew model parameters from a community-based ART initiation and resupply trial in sub-Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community-based ART and TPT care programmes during 2018−2027, assuming that community-based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e. ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for 10 years. We projected the number of TB cases, deaths and disability-adjusted life years (DALYs) averted relative to standard, clinic-based care. We calculated programme costs and incremental cost-effectiveness ratios from the provider perspective.
If community-based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3%−34.1%) and TB mortality by 34.6% (range 24.8%–42.2%) after 10 years. Increasing both ART and TPT uptake through community-based ART with TPT care could reduce TB incidence by 29.7% (range 23.9%−36.0%) and TB mortality by 36.0% (range 26.9%−43.8%). Community-based ART with TPT care reduced gender disparities in TB mortality rates, with a projected 54 more deaths annually among men than women (range 11–103) after 10 years of community-based care versus 109 (range 41–182) in standard care. Over 10 years, the mean cost per DALY averted by community-based ART with TPT care was $846 USD (range $709–$1012).
By substantially increasing coverage of ART and TPT, community-based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV-associated TB and reduce TB gender disparities.
Adolescence is defined by significant socio-emotional changes and vulnerability. Adolescents and youth living with HIV (AYLHIV) experience worse clinical HIV outcomes—adherence, retention and viral load suppression—compared to adults [1]. Novel approaches to implement evidence-based interventions to address their unique needs and life-stage are needed.
Undetectable = Untransmittable (U = U) is important in the comprehensive care of AYLHIV [2, 3]. U = U is a community-driven, evidence-based movement embodying the message that a person living with HIV who has reached and sustained an undetectable viral load (<200 copies/ml) will not transmit HIV to a sexual partner [4, 5]. As AYLHIV navigate friendships, sexual and romantic relationships, and parenthood, U = U may be a powerful tool for safe relationships and motivation for maintaining viral suppression [6]. Limited U = U interventions exist for AYLHIV, especially in Eastern and Southern Africa, where nearly 80% of AYLHIV reside.
The experience of implementing this tool reveals the practicality and promise of a narrative, youth-friendly graphic novel tool on a topic like U = U.
The authors declare no competing interests.
CL, TR, ET, AT, MM and CAYA conceptualized the project. Data tools were designed by CL, TR and MM with inputs from CAYA, ET and AT. Data collection was facilitated by TR and MM. Data analysis was led by CL. The draft was jointly constructed by all authors and reviewed by all authors.
ET/AT were funded by the Fogarty International Center, National Institute on Mental Health, National Institutes of Health [K43TW011434] and UKRI GCRF Accelerating Achievement for Africa's Adolescents (Accelerate) Hub (ES/S008101/1).
The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.
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