Joseph Larmarange

Costs and economies of scale in repeated home-based HIV counselling and testing: Evidence from the ANRS 12249 treatment as prevention trial in South Africa

Joseph LARMARANGE — 2022-06-07T15:37:49Z

Costs and economies of scale in repeated home-based HIV counselling and testing: Evidence from the ANRS 12249 treatment as prevention trial in South Africa

Marwân-Al-Qays Bousmah , Collins Iwuji , Nonhlanhla Okesola , Joanna Orne‐gliemann , Deenan Pillay , François Dabis , Joseph Larmarange , Sylvie Boyer

Social Science and Medicine, 2022, 305, pp.115068. ⟨10.1016/j.socscimed.2022.115068⟩

Article dans une revue

hal-03701276

Authors

Marwân-al-Qays Bousmah, Collins Iwuji, Nonhlanhla Okesola, Joanna Orne-Gliemann, Deenan Pillay, François Dabis, Joseph Larmarange, Sylvie Boyer for the ANRS 12249 TasP Study Group

Abstract

Universal HIV testing is now recommended in generalised HIV epidemic settings. Although home-based HIV counselling and testing (HB-HCT) has been shown to be effective in achieving high levels of HIV status awareness, little is still known about the cost implications of universal and repeated HB-HCT. We estimated the costs of repeated HB-HCT and the scale economies that can be obtained when increasing the population coverage of the intervention. We used primary data from the ANRS 12249 Treatment as Prevention (TasP) trial in rural South Africa (2012–2016), whose testing component included six-monthly repeated HB-HCT. We relied on the dynamic system generalised method of moments (GMM) approach to produce unbiased short- and long-run estimates of economies of scale, using the number of contacts made by HIV counsellors for HB-HCT as the scale variable. We also estimated the mediating effect of the contact quality – measured as the proportion of HIV tests performed among all contacts eligible for an HIV test – on scale economies. The mean cost (standard deviation) of universal and repeated HB-HCT was $24.2 (13.7) per contact, $1694.3 (1527.8) per new HIV diagnosis, and $269.2 (279.0) per appropriate referral to HIV care. The GMM estimations revealed the presence of economies of scale, with a 1% increase in the number of contacts for HB-HCT leading to a 0.27% decrease in the mean cost. Our results also suggested a significant long-run relationship between mean cost and scale, with a 1% increase in the scale leading to a 0.36% decrease in mean cost in the long run. Overall, we showed that significant cost savings can be made from increasing population coverage. Nevertheless, there is a risk that this gain is made at the expense of quality: the higher the quality of HB-HCT activities, the lower the economies of scale.

Temporal trends of population viral suppression in the context of Universal Test and Treat: results from the ANRS 12249 TasP trial in rural South Africa

Joseph LARMARANGE — 2018-07-30T10:02:03Z

Oral communication presented at the 22^nd International AIDS Conference in Amsterdam the 24^th of July, 2018, in a abstract session entitled Forging new pathways towards HIV elimination.

Authors

Joseph Larmarange, Mamadou Hassimiou Diallo, Nuala McGrath, Collins Iwuji, Mélanie Plazy, Rodolphe Thiébaut, Frank Tanser, Till Bärninghausen, Joanna Orne-Gliemann, Deenan Pillay, François Dabis for the ANRS 12249 TasP Study Group

Abstract

Background: The universal test-and-treat strategy (UTT) aims to maximize the proportion of all people living with HIV (PLWHIV) on antiretroviral treatment (ART) and virally suppressed in a community, i.e. to reach population viral suppression (PVS). The ANRS 12249 TasP trial did not demonstrate an impact of universal ART on HIV incidence at population level (Lancet HIV 2017). Here, we investigated whether PVS improved during the course of the trial: differentially by arm, according to trial interventions or contextual changes.

Methods: The TasP cluster-randomized trial (2012-2016) implemented six-monthly repeated home-based HIV counselling and testing (RHBCT) and referral of PLWHIV to local HIV clinics in 2×11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters vs. regardless of CD4 count in intervention clusters.
Test results, clinic visits, ART prescriptions, viral loads, CD4 counts, migrations and deaths were used to produce information on residency status, HIV status and HIV care status for each participant. PVS was computed daily and per cluster among all resident PLWHIV (≥16, including those not in care). We used a mixed linear model to explore the relation between PVS with calendar time, time since cluster opening, trial arm and interaction between arm and time since cluster opening, adjusting on sociodemographic changes at cluster level.

Results: 8,646 PLWHIV were observed. Between January 1^st, 2013 and January 1^st, 2016, PVS increased significantly in both arms (intervention: 29.0% to 46.2%, +17.2, p< 0.001; control: 32.4% to 44.6%, +12.2, p < 0.001), but difference in temporal variation (+5.0%) was not significant (p=0.175).
According to adjusted model (figure) this increase was mainly attributable to RHBCT (measured by time since cluster opening). They were also some effect due to contextual changes (measured by calendar time). The effect attributable to universal ART (interaction term) was limited.

Conclusions: Although suboptimal, the UTT strategy implemented in TasP trial improved PVS over time. As it was mainly due to RHBCT rather than universal ART, it did not induce differences between arms, explaining the null effect observed on cumulative incidence, the main trial finding. Changes in ART initiation guidelines alone are not enough to significantly increase PVS.

Video

Medias

Reference

Larmarange Joseph, Diallo Mamadou Hassimiou, McGrath Nuala, Iwuji Collins, Plazy Mélanie, Thiébaut Rodolphe, Tanser Frank, Bärnighausen Till, Orne-Gliemann Joanna, Pillay Deenan, Dabis François and ANRS 12249 TasP Study Group (2018) “Temporal trends of population viral suppression in the context of Universal Test and Treat: results from the ANRS 12249 TasP trial in rural South Africa” (communication orale TUAC0103), presented at the 22nd International AIDS Conference, Amsterdam. http://programme.aids2018.org/Programme/Session/105.

From individual care trajectories to HIV care cascade at population level in rural KwaZulu-Natal (South Africa): the impact of population dynamics

Joseph LARMARANGE — 2018-06-06T14:57:15Z

Oral communication presented May 31 2018 at Life History Research Society Conference in Paris.

Authors

Joseph Larmarange, Mamadou Hassimiou Diallo, Nuala McGrath, Collins Iwuji, Rodolphe Thiébaut, Frank Tanser, Till Bärninghausen, Deenan Pillay, François Dabis, Joanna Orne-Gliemann for the ANRS 12249 TasP Study Group

Abstract

Introduction

The universal test-and-treat strategy (UTT) was developed to maximize the proportion of all HIV-positive individuals on antiretroviral and virally suppressed, assuming that it leads to reduction in HIV incidence. The evolution over time of the cross-sectional population HIV care cascade is determined by longitudinal individual trajectories through the HIV care continuum and the underlying HIV population dynamics. This structural effect could dilute the impact observed at population level of a UTT strategy RT: either add impact on what (incidence) or delete sentence. The purpose of this paper is to quantify the contribution of each component of population change on the population HIV care cascade in the context of UTT.

Sample

We used prospective individual-level longitudinal data from the ANRS 12249 cluster-randomized trial which was implemented in rural KwaZulu-Natal, South Africa between 2012 and 2016 to test such an approach.

Methods

HIV tests results and information on clinic visits, ART prescription, viral load and CD4 count, migration and deaths were used to calculate residency status, HIV status and HIV care status for each individual on a daily basis. Position within the HIV care continuum was considered as a score ranging from 0 (undiagnosed) to 4 (virally suppressed). We compared the cascade score of each individual joining or leaving the HIV population with the average score of their cluster at the time of entry or exit. Then, we computed the contribution of each event on the average cascade score and the annualised total contribution of all events, considering 5 components of HIV population change: aging into the cohort, HIV seroconversions, in-migrations, out-migrations, and permanent exits (including deaths).

Results

While the average cascade score increased over time in all clusters, that increase was limited due to population dynamics, the total contribution of all population entries and exits being negative. Permanent exits and individuals already infected when reaching the age of 16 had a marginal effect. Although migrants had a lower position than the rest of the population, their overall impact on the cross-sectional population cascade remained limited as in- and out-migration compensated each other.

Conclusions

In a context of high HIV incidence, the continuous flow of newly infected individuals slows down the efforts to increase ART coverage and population viral suppression.

Reference

Larmarange Joseph, Diallo Mamadou Hassimiou, McGrath Nuala, Iwuji Collins, Thiébaut Rodolphe, Tanser Frank, Bärnighausen Till, Pillay Deenan, Dabis François, Orne-Gliemann Joanna and ANRS 12249 TasP Study Group (2018) “From inspanidual care trajectories to HIV care cascade at population level in rural KwaZulu-Natal (South Africa): the impact of population dynamics” (communication orale), presented at the Life History Research Society Conference, Paris.

Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial

Joseph LARMARANGE — 2018-03-19T17:08:52Z

Authors

Collins C Iwuji, Joanna Orne-Gliemann, Joseph Larmarange, Eric Balestre, Rodolphe Thiebaut, Frank Tanser, Nonhlanhla Okesola, Thembisa Makowa, Jaco Dreyer, Kobus Herbst, Nuala McGrath, Till Bärnighausen, Sylvie Boyer, Tulio De Oliveira, Claire Rekacewicz, Brigitte Bazin, Marie-Louise Newell, Deenan Pillay, François Dabis, for the ANRS 12249 TasP Study Group

Abstract

Background

Universal antiretroviral therapy (ART), as per the 2015 WHO recommendations, might reduce population HIV incidence. We investigated the effect of universal test and treat on HIV acquisition at population level in a high prevalence rural region of South Africa.

Methods

We did a phase 4, open-label, cluster randomised trial of 22 communities in rural KwaZulu-Natal, South Africa. We included individuals residing in the communities who were aged 16 years or older. The clusters were composed of aggregated local areas (neighbourhoods) that had been identified in a previous study in the Hlabisa subdistrict. The study statisticians randomly assigned clusters (1:1) with MapInfo Pro (version 11.0) to either the control or intervention communities, stratified on the basis of antenatal HIV prevalence. We offered residents repeated rapid HIV testing during home-based visits every 6 months for about 4 years in four clusters, 3 years in six clusters, and 2 years in 12 clusters (58 cluster-years) and referred HIV-positive participants to trial clinics for ART (fixed-dose combination of tenofovir, emtricitabine, and efavirenz) regardless of CD4 cell count (intervention) or according to national guidelines (initially ≤350 cells per μL and <500 cells per μL from January, 2015; control). Participants and investigators were not masked to treatment allocation. We used dried blood spots once every 6 months provided by participants who were HIV negative at baseline to estimate the primary outcome of HIV incidence with cluster-adjusted Poisson generalised estimated equations in the intention-to-treat population after 58 cluster-years of follow-up. This study is registered with ClinicalTrials.gov, number NCT01509508, and the South African National Clinical Trials Register, number DOH-27-0512-3974.

Findings

Between March 9, 2012, and June 30, 2016, we contacted 26 518 (93%) of 28 419 eligible individuals. Of 17 808 (67%) individuals with a first negative dried blood spot test, 14 223 (80%) had subsequent dried blood spot tests, of whom 503 seroconverted after follow-up of 22 891 person-years. Estimated HIV incidence was 2·11 per 100 person-years (95% CI 1·84–2·39) in the intervention group and 2·27 per 100 person-years (2·00–2·54) in the control group (adjusted hazard ratio 1·01, 95% CI 0·87–1·17; p=0·89). We documented one case of suicidal attempt in a woman following HIV seroconversion. 128 patients on ART had 189 life-threatening or grade 4 clinical events: 69 (4%) of 1652 in the control group and 59 (4%) of 1367 in the intervention group (p=0·83).

Interpretation

The absence of a lowering of HIV incidence in universal test and treat clusters most likely resulted from poor linkage to care. Policy change to HIV universal test and treat without innovation to improve health access is unlikely to reduce HIV incidence.

Funding

ANRS, GiZ, and 3ie.

Reference

Iwuji Collins C, Orne-Gliemann Joanna, Larmarange Joseph, Balestre Eric, Thiebaut Rodolphe, Tanser Frank, Okesola Nonhlanhla, Makowa Thembisa, Dreyer Jaco, Herbst Kobus, McGrath Nuala, Bärnighausen Till, Boyer Sylvie, De Oliveira Tulio, Rekacewicz Claire, Bazin Brigitte, Newell Marie-Louise, Pillay Deenan and Dabis François (2018) “Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial”, The Lancet HIV, 5 (3) (March 1), p. e116-e125. DOI : 10.1016/S2352-3018(17)30205-9. http://www.sciencedirect.com/science/article/pii/S2352301817302059.

“It is better to die” : experiences of traditional health practitioners within the HIV treatment as prevention trial communities in rural South Africa (ANRS 12249 TasP trial)

Joseph LARMARANGE — 2016-08-17T14:08:01Z

Article published in an AIDS Care special issue : « Test and Treat » trials in Africa

Authors

Mosa Moshabela, Thembelihle Zuma, Joanna Orne-Gliemann, Collins Iwuji, Joseph Larmarange, Nuala McGrath & on behalf of the ANRS 12249 TasP Study Group

Abstract

The ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomized trial in rural South Africa uses a “test and treat” approach. Home-based testing services and antiretroviral treatment initiation satellite clinics were implemented in every cluster as part of the trial. A social science research agenda was nested within TasP with the aim of understanding the social, economic and contextual factors that affect individuals, households, communities and health systems with respect to TasP. Considering the rural nature of the trial setting, we sought to understand community perceptions and experiences of the TasP Trial interventions as seen through the eyes of traditional health practitioners (THPs). A qualitative study design was adopted using four repeat focus group discussions conducted with nine THPs, combined with community walks and photo-voice techniques, over a period of 18 months. A descriptive, interpretive and explanatory approach to analysis was adopted. Findings indicate that THPs engaged with the home-based testing services and HIV clinics established for TasP. Specifically, home-based testing services were perceived as relatively successful in increasing access to HIV testing. A major gap observed by THPs was linkage to HIV clinics. Most of their clients, and some of the THPs themselves, found it difficult to use HIV clinics due to fear of labelling, stigma and discrimination, and the ensuing personal implications of unsolicited disclosure. On the one hand, a growing number of patients diagnosed with HIV have found sanctuary with THPs as alternatives to clinics. On the other hand, THPs in turn have been struggling to channel patients suspected of HIV into clinics through referrals. Therefore, acceptability of the TasP test and treat approach by THPs is a major boost to the intervention, but further success can be achieved through strengthened ties with communities to combat stigma and effectively link patients into HIV care, including partnerships with THPs themselves.

Reference

Moshabela Mosa, Zuma Thembelihle, Orne-Gliemann Joanna, Iwuji Collins, Larmarange Joseph, McGrath Nuala and Group on behalf of the ANRS 12249 TasP Study (2016) ““It is better to die”: experiences of traditional health practitioners within the HIV treatment as prevention trial communities in rural South Africa (ANRS 12249 TasP trial)”, AIDS Care, 28 (sup3) (June 2), p. 24-32. DOI : 10.1080/09540121.2016.1181296. http://dx.doi.org/10.1080/09540121.2016.1181296.

Measuring the Impact of Test and Treat on the HIV Cascade: the Challenge of Mobility

Joseph LARMARANGE — 2016-03-06T12:55:52Z

Oral communication presented at CROI 2016 the 25^th of February, 2016 in Boston.

Authors

Joseph Larmarange, Collins Iwuji, Joanna Orne-Gliemann, Nuala McGrath, Mélanie Plazy, Kathy Baisley, Till Barnighäusen, François Dabis, Deenan Pillay for the ANRS 12249 TasP Study Group

Ressources

Abstract

Background

Universal test and treat (UTT) could substantially improve the HIV care cascade at population level (i.e. the proportion of all HIV-infected people being diagnosed, on ART and virally suppressed at a given date) and thus reduce HIV incidence. Several trials are currently exploring this hypothesis.

Due to demographic change, the study population of HIV-infected individuals is composed of people with various degrees of exposure to the trial interventions. This structural effect could potentially dilute the impact observed at population level of a UTT strategy. Here, we describe a dynamic cascade according to both calendar (population) and exposure (individual) time approaches, using preliminary data from the ANRS 12249 TasP cluster-randomized trial ongoing in rural KwaZulu-Natal (South Africa).

Methods

Analysis was conducted within a subgroup of 4 clusters with the longest follow-up time where five six-monthly rounds of home-based HIV testing had been conducted between March 2012 and July 2015. Resident members 16 years and above were offered rapid HIV testing and asked to provide dried blood spots (DBS) each time. Those ascertained HIV-positive were referred to local trial clinics for ART initiation and follow-up.

HIV tests results and information on clinic visits, ART prescription, viral load and CD4 count, migration and death were used to calculate residency status, HIV status and HIV care status for each individual on each calendar day. This calendar cascade was then compared to the exposure cascade, where each status was recalculated for individuals at any given date with exposure time defined as the duration since trial registration.

Results

According to calendar time, the overall cascade improved rapidly during the first 15 months of the trial (from 25 to 40% virally suppressed), but more slowly thereafter (Fig a). Although the target population size of HIV-infected people remained rather stable over time ( 665 individuals, Fig b), population turnover was high (Fig c). According to exposure time, with a decreasing sample size over time (Fig e), the cascade improved continuously between M0 and M30, from 20% to 50% virally suppressed (Fig. d).

Conclusions

Population mobility dilutes the observed impact of UTT interventions on the cascade at population level. These preliminary findings also suggest that the impact of a UTT approach could be maximized as long as there is a coordination to facilitate continued access to care when people move.

Reference

Larmarange Joseph, Iwuji Collins, Orne-Gliemann Joanna, McGrath Nuala, Plazy Mélanie, Baisley Kathy, Bärnighausen Till, Dabis François, Pillay Deenan and ANRS 12249 TasP Study Group (2016) “Measuring the Impact of Test and Treat on the HIV Cascade: the Challenge of Mobility” (communication orale), presented at the Conference on Retroviruses and Opportunistic Infections (CROI), Boston. http://www.croiwebcasts.org/console/player/29736.

Participation Dynamics in Population-Based Longitudinal HIV Surveillance in Rural South Africa

Joseph LARMARANGE — 2015-04-21T07:03:13Z

Authors

Joseph Larmarange
Joël Mossong
Till Bärnighausen
Marie Louise Newell

Abstract

Population-based HIV surveillance is crucial to inform understanding of the HIV pandemic and evaluate HIV interventions, but little is known about longitudinal participation patterns in such settings. We investigated the dynamics of longitudinal participation patterns in a high HIV prevalence surveillance setting in rural South Africa between 2003 and 2012, taking into account demographic dynamics. At any given survey round, 22,708 to 30,495 persons were eligible. Although the yearly participation rates were relatively modest (26% to 46%), cumulative rates increased substantially with multiple recruitment opportunities: 68% of eligible persons participated at least once, 48% at least twice and 31% at least three times after five survey rounds. We identified two types of study fatigue: at the individual level, contact and consent rates decreased with multiple recruitment opportunities and, at the population level, these rates also decreased over calendar time, independently of multiple recruitment opportunities. Using sequence analysis and hierarchical clustering, we identified three broad individual participation profiles: consenters (20%), switchers (43%) and refusers (37%). Men were over represented among refusers, women among consenters, and temporary non-residents among switchers. The specific subgroup of persons who were systemically not contacted or refusers constitutes a challenge for population-based surveillance and interventions.

Citation

Larmarange Joseph, Mossong Joël, Bärnighausen Till and Newell Marie Louise (2015) “Participation Dynamics in Population-Based Longitudinal HIV Surveillance in Rural South Africa”, PLoS ONE, 10 (4), p. e0123345. DOI : 10.1371/journal.pone.0123345. http://dx.doi.org/10.1371/journal.pone.0123345.

Addressing social issues in a universal HIV test and treat intervention trial (ANRS 12249 TasP) in South Africa: methods for appraisal

Joseph LARMARANGE — 2015-03-21T12:21:37Z

Authors

Joanna Orne-Gliemann†, Joseph Larmarange†, Sylvie Boyer, Collins Iwuji, Nuala McGrath, Till Bärnighausen, Thembelile Zuma, Rosemary Dray-Spira, Bruno Spire, Tamsen Rochat, France Lert, John Imrie and for the ANRS 12249 TasP Group

† Equal contributors

Abstract

Background

The Universal HIV Test and Treat (UTT) strategy represents a challenge for science, but is also a challenge for individuals and societies. Are repeated offers of provider-initiated HIV testing and immediate antiretroviral therapy (ART) socially-acceptable and can these become normalized over time? Can UTT be implemented without potentially adding to individual and community stigma, or threatening individual rights? What are the social, cultural and economic implications of UTT for households and communities? And can UTT be implemented within capacity constraints and other threats to the overall provision of HIV services? The answers to these research questions will be critical for routine implementation of UTT strategies.

Methods/design

A social science research programme is nested within the ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomised trial in rural South Africa. The programme aims to inform understanding of the (i) social, economic and environmental factors affecting uptake of services at each step of the continuum of HIV prevention, treatment and care and (ii) the causal impacts of the TasP intervention package on social and economic factors at the individual, household, community and health system level. We describe a multidisciplinary, multi-level, mixed-method research protocol that includes individual, household, community and clinic surveys, and combines quantitative and qualitative methods.

Discussion

The UTT strategy is changing the overall approach to HIV prevention, treatment and care, and substantial social consequences may be anticipated, such as changes in social representations of HIV transmission, prevention, HIV testing and ART use, as well as changes in individual perceptions and behaviours in terms of uptake and frequency of HIV testing and ART initiation at high CD4. Triangulation of social science studies within the ANRS 12249 TasP trial will provide comprehensive insights into the acceptability and feasibility of the TasP intervention package at individual, community, patient and health system level, to complement the trial's clinical and epidemiological outcomes. It will also increase understanding of the causal impacts of UTT on social and economic outcomes, which will be critical for the long-term sustainability and routine UTT implementation.

Trial registration

Clinicaltrials.gov: NCT01509508 webcite; South African Trial Register: DOH-27-0512-3974.

Keywords

HIV infections; HIV testing; Community; HIV care; Antiretroviral treatment; Social; Behaviour; Cost; South Africa

Reference

Orne-Gliemann Joanna, Larmarange Joseph, Boyer Sylvie, Iwuji Collins, McGrath Nuala, Bärnighausen Till, Zuma Thembelihle, Dray-Spira Rosemary, Spire Bruno, Rochat Tamsen, Lert France, Imrie John and ANRS 12249 TasP Study Group (2015) “Addressing social issues in a universal HIV test and treat intervention trial (ANRS 12249 TasP) in South Africa: methods for appraisal”, BMC Public Health, 15 (1) (March 1), p. 209. DOI : 10.1186/s12889-015-1344-y. http://www.biomedcentral.com/1471-2458/15/209/abstract.

Feasibility and acceptability of an antiretroviral treatment as prevention (TasP) intervention in rural South Africa: results from the ANRS 12249 TasP cluster-randomised trial

Joseph LARMARANGE — 2014-07-16T14:03:22Z

Oral communication presented at the 20^th International AIDS Conference in Melbourne in July 2014 (session WEAC01 Maximizing the Preventive Benefits of Treatment: Evolving Views).

Authors

Collins Iwuji¹, Joanna Orne-Gliemann², Frank Tanser¹, Rodolphe Thiébaut², Joseph Larmarange³, Nonhlanhla Okesola¹, Marie-Louise Newell⁴, François Dabis²

Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
Bordeaux University, Institut de Santé Publique, Epidemiologie et Developpement, Bordeaux, France
Centre Population et Développement (CEPED UMR 196 Université Paris Descartes-Ined-IRD), Paris, France
University of Southampton, Faculty of Medicine, Faculty of Social and Human Sciences, Southampton, United Kingdom

Citation

Iwuji Collins, Orne-Gliemann Joanna, Tanser Frank, Thiébaut Rodolphe, Larmarange Joseph, Okesola Nonhlanhla, Newell Marie-Louise and Dabis François (2014) “Feasibility and acceptability of an antiretroviral treatment as prevention (TasP) intervention in rural South Africa: results from the ANRS 12249 TasP cluster-randomised trial” (communication orale n°WEAC0105LB), presented at the 20th International AIDS Conference, Melbourne. http://pag.aids2014.org/session.aspx?s=1118.

Abstract

http://pag.aids2014.org/Abstracts.aspx?SID=1118&AID=11354

Presentation

Feasibility and acceptability of an antiretroviral treatment as prevention (TasP) intervention ...
by IAC - the International AIDS Conference

https://www.youtube.com/watch?v=s9L...

Issues emerging from universal test and treat (UTT) intervention trials

Joseph LARMARANGE — 2013-07-05T09:19:42Z

Authors

John Imrie, Joseph Larmarange, Joanna Orne-Gliemann,Collins Iwuji, France Lert for the ANRS 12249 TasP Study Group.

Abstract

Universal repeat testing and early antiretroviral treatment (UTT) strategies to reduce onward sexual transmission are major social, as well as biomedical interventions. Several UTT trials are underway or being prepared. This paper discusses some emerging issues arguing extensive social science within UTT trials needs complementary enquiry to guide public health and operational decisions beyond the trials themselves.

The issues fall under three broad headings:

Social and behavioural consequences of large numbers of people knowing their HIV-status and potentially beginning treatment early. Will the impacts on sexual behaviour, disclosure and stigma all be positive? Harmful?
Normative changes at individual and community levels. What normative changes occur in communities exposed to prolonged, intense research around unspoken or socially taboo subjects? Does seeing more healthy people attending clinics alter community perceptions of disease and care? Can salient positive changes be identified and replicated?
Operational and ethical implications of transforming research interventions into routine care. Who should lead? Requirements for sustainability. Impacts of institutions ‘knowing' about individuals' HIV status and care uptake, especially in contexts of criminalisation and marginalised or vulnerable populations?

UTT strategies have potentially great social consequences that need to be explored alongside the actual trials, to guide and inform future decisions and policy.

Reference

Imrie John, Larmarange Joseph, Orne-Gliemann Joanna, Iwuji Collins, Lert France and ANRS 12249 TasP Study Group (2013) “Issues emerging from universal test and treat (UTT) intervention trials” (communication orale n°CS20#2), presented at the 2nd International Conference for the Social Sciences and Humanities in HIV, Paris.