- High viral suppression obtained in 3 studies in HIV infected people belonging to communities in high-burden settings, which range from 68% to 88%, is not enough to reduce HIV incidence.
- The smallest difference in viral suppression between intervention and control groups produces the largest effect on HIV incidence.
- Unreachable people and the testing gap are factors limiting intervention effectiveness.
Increasing viral suppression in HIV infected people is possible by universal intervention or routine care, but to reach the goal of Joint United Nations Program on HIV/AIDS of ending the AIDS epidemic by 2030, more needs to be done.
An editorial reporting on 3 studies published in the New England Journal of Medicine focuses on the various effects on HIV incidence obtained by universal test-and-treat strategies in high-burden settings and on the challenges in achieving effective HIV prevention.
In those studies, the viral suppression obtained ranged from 68% to 88%. The smallest difference between intervention and control groups (5% in Ya Tsie study, Botswana) produced the largest effect on HIV incidence - 30% lower in the intervention community - although the difference was not statistically significant.
By contrast, the largest differences had the smallest effect. In the SEARCH study (Kenya and Uganda), the 11% higher prevalence of viral suppression in intervention communities resulted in 3-years cumulative HIV incidence similar to control communities. In the PopArt study (Zambia and South Africa), the group who underwent test prevention strategies plus antiretroviral therapy (ART) according to local guidelines, had viral suppression of 7% higher on average and an HIV incidence 30% lower than group under standard care. A the same time, there was no great effect on HIV incidence in the group with combination prevention programs with universal ART, which achieved a viral suppression 12% higher than standard care group.
Moreover, the effectiveness of intervention can be limited by the time between the HIV infection and a positive test because transmission is more efficient when the infection is recent.
High HIV incidence rates in the intervention communities despite intensive ART-coverage interventions suggest that more will need to be done, especially to affect hard-to-reach populations and the testing gap.