University of Massachusetts Amherst School of Public Health and Health Sciences assistant professor of biostatistics Dr. Laura Balzer is the lead statistician on a cluster randomized trial designed to prevent and treat HIV and other health conditions in East African communities. In a trial with over 350,000 adults and children in rural Kenya and Uganda, the Sustainable East Africa Research in Community Health (SEARCH) study resulted in 21 percent fewer HIV deaths, reduced tuberculosis by 59 percent, and improved control of hypertension by 26 percent. Within the intervention arm, annual HIV incidence decreased by 32 percent. Results from the study, led by investigators at the University of California, San Francisco, were recently presented at the 22nd International AIDS Conference (AIDS 2018) in Amsterdam.
“SEARCH demonstrated that a multi-disease, patient-centered approach could dramatically reduce mortality and improve community health,” says Dr. Balzer, who played an essential role in both study design, which randomized communities instead of individuals, and statistical analyses for all adult health outcomes.
[Photo: Dr. Laura Balzer]
In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched the “90-90-90” campaign, a call for 90 percent of people with HIV to know their status, 90 percent of all people diagnosed with HIV to receive antiretroviral therapy (ART), and 90 percent of people on ART to be virally suppressed. In line with the UN goals, SEARCH investigators designed a new approach that offered comprehensive health care, including immediate treatment for anyone diagnosed with HIV — to reduce new HIV infections and to improve community health.
HIV is endemic in rural Kenya and Uganda, where stigma and other barriers to HIV care resulted in large population groups remaining undiagnosed and untreated. The SEARCH team overcame these barriers by offering a multi-disease approach that provided testing for a variety of health conditions at mobile community health fairs and a patient-centered approach to care.
SEARCH investigators randomly assigned 32 rural communities in Kenya and Uganda — including over 150,000 adults — to either the intervention group, which received multi-disease testing at baseline and annually with universal treatment eligibility for all HIV-positive persons, or the control group, which received testing at baseline, followed by referral, if appropriate, to the country standard-of-care for treatment. Out-of-facility health fairs offered screening for HIV, hypertension, diabetes, and malaria, with community or home-based follow-up for non-participants. This testing model resulted in over 90 percent of the study population (>135,000 adults) being tested for HIV at baseline.
At the end of the three-year study, rates of deaths from any cause among people living with HIV in the intervention communities were 21 percent lower than control communities. People living with HIV in communities that received the intervention also experienced 59 percent fewer new TB cases during the third year of the study compared with the control communities. TB, a bacterial infection that affects the lungs, is a leading cause of death among people living with HIV across the globe and is particularly endemic in East Africa. The program also impacted non-communicable diseases with 26 percent higher hypertension control at three years.
Dr. Balzer says, “These results suggest that the SEARCH approach can successfully treat both HIV and non-communicable diseases at a population-level and in a community-based setting in rural East Africa. HIV incidence decreased because of the multi-disease community-based health fairs, and mortality decreased because of how we delivered care.”
The SEARCH study outcomes exceeded international HIV testing and treatment goals set by UNAIDS. “While the SEARCH approach provides one pathway to rapid and high population-level viral suppression, additional and innovative strategies are needed to engage youth (15-24 years) as well as mobile groups,” says Dr. Balzer. “Finally, as HIV incidence declines, efficient and effect strategies are needed to identify and prevent infection among those remaining at high risk.”