A clinical study in a remote region of southwest Uganda has demonstrated the feasibility of using a health campaign to rapidly test a community for HIV and simultaneously offer prevention and diagnosis for a variety of other diseases in rural and resource-poor settings of sub-Saharan Africa.
At the XIX International AIDS Conference in Washington, D.C., the first results of this study, called the "Sustainable East Africa Research in Community Health (SEARCH) Collaboration," will be described by doctors at the University of California, San Francisco (UCSF), San Francisco General Hospital and Trauma Center (SFGH) and Makerere University in Kampala, Uganda. The talk is scheduled for Monday, July 23, 2012.
The motivation for this work was the success of a comprehensive approach to addressing HIV/AIDS that was pioneered in San Francisco beginning in 2010. The strategy, known as "test and treat," involves universal testing, linkage to care and early treatment. Mounting evidence shows that this approach keeps people healthier longer and reduces the spread of HIV within the community.
The SEARCH study seeks to build on this approach and use "test and treat" as a platform for broader community health intervention in sub-Saharan Africa.
In the study, some 4,343 people were offered HIV testing, and 189 of them tested positive. Nearly half were new diagnoses -- meaning that the other half were tested even though they knew they had the disease --and their CD4+ cell counts, on average, were in the mid-400s--indicating they were in the early stages of disease, before a decline towards AIDS. Often regional health centers in Uganda don't identify new cases until a much more advanced stage of the disease.
The team also tested people for malaria, tuberculosis, diabetes and hypertension and offered counseling, treatment and prevention methods to address those conditions.
"Seventy-four percent of the adults in the community were tested for HIV, and we found a high burden of both communicable and non-communicable diseases," said Gabriel Chamie, MD, MPH, an assistant professor in the UCSF School of Medicine who will be presenting this work in Washington, D.C. "This is a proof of principle that you can test people in high volume, link them to care and address other diseases as well."
How the Campaign Worked
Addressing several diseases at once was a strategy meant to both maximize public health spending and to also address some of the stigma surrounding HIV testing by contextualizing it among other common diseases.
"We're really focusing on community health—not just HIV," said Diane Havlir, MD chief of the UCSF Division of HIV/AIDS at SFGH and co-director of the SEARCH Collaboration. "If we are going to bring everyone together and test for HIV, why wouldn't we test for hypertension, diabetes, TB, malaria and address those diseases, as well."
In the campaign, the SEARCH team first met with community leaders and discussed the needs of the local populations. They visited three sites over the course of five days and each day screened close to 1,000 people who moved through different stations where they were given counseling, testing, and treatment where appropriate.
People who tested positive for HIV had the opportunity to meet the providers from the regional clinic who would care for them moving forward, and they were given an appointment for follow-up care within 3 months of testing. A sub-group with far advanced HIV was also offered immediate therapy.
If people tested positive for TB, malaria, diabetes or hypertension, they were likewise given counseling, linked to care, and offered the appropriate treatment. Children were treated for worms, a common problem in the region, and given vitamin A tablets (vitamin A deficiency is a common problem in parts of Africa that leads to blindness). The medical team also handed out insecticide-treated bed nets, which are known to dramatically reduce the spread of malaria.
The challenge SEARCH was designed to test was whether this could all be done in a safe, efficient, low-cost way that minimizes disruptions to people's lives. It was designed in part to make things easier for people in rural sub-Saharan Africa who may live far from centralized clinics.
People in such settings often forego testing and are not diagnosed until their disease is much more advanced, making them sicker and harder to treat and contributing to the spread of HIV in the months and years before they are diagnosed. The same problem is true with other diseases. People in rural Africa with hypertension often go years without having any symptoms, for instance, and in general, for many chronic diseases it is cheaper and easier to treat someone who is diagnosed early.
Rather than asking people to come to the clinic, the SEARCH study brought the clinic to them.