UNAIDS welcomes the results from the HPTN 071 (PopART) trial. The results showed a 30% decline in new HIV infections where HIV prevention, including home-based HIV counselling and testing, was provided, as well as referral to HIV care and treatment for people testing positive for HIV according to country guidelines. The study took place between 2013 and 2018 and included 21 urban communities in Zambia and South Africa, covering a total population of 1 million people, the largest study of its kind.

“UNAIDS congratulates the PopART team on this important study, which clearly demonstrates the critical impact of community-based HIV prevention, testing and linkage to treatment,” said Michel Sidibé, Executive Director of UNAIDS. “It reinforces UNAIDS’ call for more community health-care workers across Africa, the need for increased investment in HIV prevention and treatment, including new and better tools and systems to deliver them. It also shows the urgent need to reach men and young people.”

There were three arms in the study. Arms A and B delivered the PopART package of HIV prevention, which includes annual household-based HIV counselling and testing, linkage to care at the local health centre for people living with HIV, follow-up visits to people living with HIV to ensure that they were linked to care and to support adherence to treatment, promotion of voluntary medical male circumcision for men who tested HIV-negative, services to prevent mother-to-child transmission of HIV, referral for treatment of sexually transmitted infections, provisions of condoms in the community and screening and referral for tuberculosis.

Arm A offered immediate initiation of antiretroviral therapy to people testing positive for HIV irrespective of CD4 count. Arm B offered antiretroviral therapy only to people who were eligible in accordance with the country guidelines—this was a CD4 count of 350 at the beginning of the trial, which moved to 500 and in 2016 treatment was offered to all people living with HIV, as in arm A. Arm C had no household intervention, but people did have access to HIV testing and treatment services in accordance with the country guidelines.

Both arms A and B reached the 90–90–90* targets overall. In arm B, HIV incidence declined by 30% compared to the basic standard of care offered by the countries involved in the study. In arm A incidence declined by just 7%, which, although not statistically significant, is surprising; ongoing transmission was also at a considerable rate (1.5%) in arm A. Further analysis is under way to help explain why the decline in incidence was not higher in arm A despite high viral suppression (viral suppression was 72% in arm A, 68% in arm B and 60% in arm C).

Subgroup analysis also showed that in both arm A and arm B antiretroviral therapy coverage was high in women older than 25 years and in men older than 40 years, but men and younger people had a much lower coverage. It also showed that men and younger people were much less likely to be virally suppressed. This emphasizes the importance of ensuring that 90–90–90 is reached at the country level but also that each population group reaches 90–90–90.

The impact of community-based access to testing, treatment and primary prevention in the trial is evident and supports UNAIDS’ focus on strengthening community platforms. UNAIDS promotes this work through the 90–90–90 initiative, the Fast-Track cities initiative and the Global HIV Prevention Coalition, a coalition convened by UNAIDS and the United Nations Population Fund to accelerate access to combination HIV prevention in settings with high HIV incidence. The work of the coalition includes a particular focus on young women and their male partners—groups that were found to require better access to services in the PopART trial.

UNAIDS underscores that there is still no single HIV prevention method that is fully protective against HIV. To end the AIDS epidemic, UNAIDS strongly recommends a combination of HIV prevention options. These include ensuring that all people living with HIV have immediate access to antiretroviral therapy, the correct and consistent use of male or female condoms, starting having sex at an older age, having fewer partners, voluntary medical male circumcision, and the use of pre-exposure prophylaxis for people at higher risk of HIV infection.

The results of the PopART trial were presented at the Conference on Retroviruses and Opportunistic Infections, taking place in Seattle, United States of America from 4-7 March 2019.

* By 2020, 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads.