1. From trials to programmes: Lessons learned from four trials of Universal Testing and Treatment (UTT) in Sub-Saharan Africa 24th July 2018
Estimates of coverage against the 90:90:90 UNAIDS targets: Comparison of methods and findings
Kalpana Sabapathy
London School of Hygiene and Tropical Medicine,
HPTN 071 (PopART) trial
On behalf of the Universal Test and Treat Trials Consortium (UT3C)

2. Overview of presentation
Methods
UNAIDS targets
Measuring impact of trial interventions on coverage over time
Intervention communities of 4 UTT community randomised trials
Baseline pre-intervention, and after ~2 years of intervention
Findings
Compare and contrast outcomes
Limitations and strengths of coverage estimates
Conclusions

3. UNAIDS targets
73% VS among all PLWH
1st
2nd
3rd
Aimed at achieving high coverage at population level
Cross-sectional measure of coverage
‘Snapshot in time’
Population-wide
Universal Test & Treat Trials
Coverage has to be high to achieve the ultimate goal of population level HIV-incidence reduction
targets a way to measure the impact of UTT interventions on coverage over time

4. “…% of all people…” All people living in a community
All people living with HIV (PLWH)
90% PLWH diagnosed and know status
90% diagnosed PLWH on ART
90% diagnosed PLWH on ART & virally suppressed

5. All adults living in the
community
Ideally…
Identify all households and household members
Reality of delivering intervention…
Meet face to face
Agree to participate in intervention
Multiple time-points!
Population flux
Deaths
Out-migration
In-migration

6. Identifying the target population of adults
BCPP
15 communities*
PopART
4 communities**
SEARCH
16 communities
TasP
5 communities***
Population enumeration – baseline
Community-wide enumeration of HHs
Population enumeration – ~2y
Baseline enumeration data which mapped all households updated using Google maps to estimate population growth
Annual community-wide re-enumeration of HH and individuals during intervention delivery
Updated data for in- and out-migration and deaths using community-wide re-enumeration at y3
Six monthly community-wide re-enumeration of HH and individuals during intervention delivery
(Community wide enumeration was done at end of study in 3 of the intervention communities – data not shown today )
* BCPP – coverage estimates were restricted to Botswana citizens; primary by-arm coverage estimates will be derived from prospective cohort and end of study surveys in both arms ** PopART – coverage estimates shown are from 4 Arm A, full UTT intervention communities in Zambia pending data from SA ***TasP – 6 other intervention communities with ≤ 2y follow-up are not included here

7. Adults reached by intervention
Total population
BCPP
PopART
SEARCH
TasP
Proportion of adult residents reached by the intervention among all estimated eligible adult residents in community
– baseline
66%
(38,000/
58,000)
80%
(101,102/
125,912)*
92%
(73,310/
79,818)
86%
(4,024/
4,681)
Proportion of adult residents reached by the intervention among all estimated eligible adult residents in community
– ~2y
>100%!
(61,645 observed/
58,000 estimated at baseline
69%
(88,098/
127,438)*
77%
(73,952/
95,599)
95%
(4,587/4,828)
* PopART age eligibility changed from ≥18y at baseline to ≥15y by 2y

8. Extrapolating to total adult population
BCPP
PopART
SEARCH
TasP
Key assumption for extrapolation to total population
HIV status and steps of cascade among those not met during intervention delivery is the same as among those who were met prior to intervention
using age and sex standardisation
HIV status and steps of cascade* among those not met during intervention delivery is the same as among those who were met prior to intervention
- after stratifying on a number of key characteristics
- after controlling for a number of key characteristics
Estimates are focused on those identified by the intervention as HIV-positive.
Not extrapolated to total population in data shown here.
Statistical methods
Baseline HIV prevalence standardised according to age and gender distribution by community in Botswana Census 2011
Stratum specific estimates (based on key characteristics) summarised into summary estimate
Targeted maximum likelihood estimation with Super Learner
Sensitivity analysis (not presented here) include imputation of HIV status among those with no observed HIV-status information using mathematical modelling
*data on viral suppression not currently available

9. First-90 All people living in a community
All people living with HIV (PLWH)
90% PLWH diagnosed and know status

10. Approaches for identifying 1st 90: Knowledge of HIV-positive status and HIV-status
BCPP
PopART
SEARCH
TasP
Blood sample (independent of uptake of HIV rapid testing) No
Yes – dried blood spots for ELISA
HIV rapid diagnostic testing
Yes
Public health record of receiving HIV care
Self-report of HIV+ve status
Yes – with documentation
Self-report of HIV-ve status
Yes, if documented test result in last 3 months
Yes, if reported testing in last 3m
Data from baseline intervention delivery for estimates at latter time-point

11. Second -90 All people living in a community
All people living with HIV (PLWH)
90% PLWH diagnosed and know status
90% diagnosed PLWH on ART

12. Approaches for identifying 2nd 90 ART among those with knowledge of HIV-positive status
BCPP
PopART
SEARCH
TasP
Public health record of receiving ART
Yes No
Yes – from both trial & government run clinics
Self-reported ART
Yes - with documentation
Yes - (with documentation)
Self-reported HIV+ve
Yes, with documentation
Data from baseline intervention delivery for estimates at latter time-points

13. Third -90 All people living in a community
All people living with HIV (PLWH)
90% PLWH diagnosed and know status
90% diagnosed PLWH on ART
90% diagnosed PLWH on ART & virally suppressed

14. Approaches for identifying 3rd 90: Viral suppression among those on ART
BCPP (<400c/ml)
PopART
SEARCH (<500c/ml)
TasP (<400c/ml)
Blood sample No
Yes
Public health record of viral load done for HIV care monitoring
Yes – from both trial & government run clinics
Public health record of receiving ART
Self-reported ART
Yes - with documentation
*PopART data on viral suppression not currently available

15. Outcomes achieved after ~2 years of trial interventions

16. BCPP
68% VS % %
n = 11207
N = 13705
n = 9610
N = 11207
n = 8796
N = 9050*
n = 13705
N = 15093
n = 13051
N = 13705
n = 11803
N = 12087*
*Known to have started ART and alive at end of second intervention round of delivery and VL result available

17. PopART 45% ART coverage n = 9648 N = 17686 n = 7805 N = 9648 n = 14929

18. SEARCH
42% VS % %
n = 3484
N = 4149
n = 7988
N = 8408
n = 7287
N = 7988
n = 6392
N = 7287
n = 5136
N = 8305
n = 4149
N = 5316
These are interim results from intervention arm at baseline and y2. Full study results (y3, Intervention vs. Control) will be presented Wed 11 (WEAX01)

19. TasP 24% VS n =914 N = 1159 n=352 N = 914 n=275 N = 352 n=1268

20. Conclusions
Challenging to get accurate representation of coverage and estimate at population level to measure the impact of interventions
Key unknown “behind the scenes” is population flux
Estimates from all trials indicate high coverage is achievable
targets not originally part of the aims of the trial but useful way of summarising coverage

21. Thanks and Acknowledgements
BCCP
PopART
SEARCH
TasP
Pam Bachanas
Sian Floyd
Laura Balzer
Collins Iwuji
Kara Bennett
Richard Hayes
Diane Havlir
Joseph Larmarange
Lisa Block
Maya Petersen
Joanna Orne- Gliemann
Shahin Lockman
Study participants and community members
Funding organizations, sponsors, Ministries of Health,
collaborating partners and all study staff
Richard Hayes and Francois Dabis for leading the UT3C