Tackling the challenges of decentralized HIV testing and care in Southern Africa - two interlinked cluster-randomized trials in rural Lesotho (The GET ON Project)
Alain Amstutz (Basel | CH)
Reaching high HIV testing coverage during home-based testing campaigns in sub-Saharan Africa, and engaging those newly diagnosed to long-term HIV care, remains challenging. This is particularly difficult in remote areas where access to health facilities is a major impediment. Two interlinked cluster-randomized trials, HOSENG (HOme-based SElf-testiNG) and VIBRA (VIllage-Based Refill of Antiretroviral therapy (ART)), explore innovative interventions to improve testing coverage and subsequent engagement in care in rural Lesotho, Southern Africa. Together, they constitute the GET ON (GETting tOwards Ninety) research project, that is designed to reach the UNAIDS 90-90-90 targets, and in line with the UNAIDS strategy to recruit more than 2 million community health workers in Africa.
The HOSENG trial (NCT03598686) measures the effect of secondary distribution of oral HIV self-tests during home-based testing on testing coverage within 120 days after the campaign. In intervention clusters (i.e. villages), self-tests are left for household members who are absent or decline testing. Distributed self-tests are then followed up by trained lay community health personnel known as village health workers (VHWs). A long-standing public sector cadre of VHW already exists in Lesotho with more than 4000 VHWs currently successfully operating in all districts.
The VIBRA trial (NCT03630549) assesses a new decentralized ART delivery model that builds on the VHW program and uses SMS technology. It enrolls individuals found HIV positive and not on ART during the HOSENG trial. In control clusters, participants are offered same-day ART initiation with follow-up at the clinic. In intervention clusters, participants are offered same-day ART with the possibility of further follow-up by the nearby trained VHW. Moreover, they may receive automatically generated coded SMS with adherence reminders or viral load results.
Overall recruitment will successful be closed on May 31, 2019. By September we will be able to present final results from the HOSENG trial and preliminary results from the VIBRA trial.
The HOSENG trial results will inform the feasibility and additive effect of secondary distribution of self-tests during home-based HIV testing in rural Africa. The VIBRA trial will be the first randomized trial assessing follow-up of patients by medical lay-workers directly after home-based same-day ART initiation.
The HepCare Project of the Swiss Hepatitis Strategy: With GP empowerment towards hepatitis C elimination
Philip Bruggmann (Zürich | CH)
Both, the Swiss Hepatitis Strategy and the first Global Health Sector Strategy on Viral Hepatitis aim to eliminate Hepatitis C (HCV) until 2030. The main gaps in the cascade of care are awareness, testing and linkage to care. General Practitioners (GP) play a critical role to fill these gaps, but are cannot prescribe HCV direct acting antivirals (DAA) due to a ‘FOPH limitatio’. This has a negative impact on the motivation of GP to test and refer for treatment.
HepCare aims to improve the cascade of care of HCV by directly involving GPs in HCV therapy. This is supposed to enhance the motivation of GPs for case finding and linkage to care. HepCare should relevantly contribute to the elimination of HCV in Switzerland.
The HepCare Project allows GPs to provide DAA treatment to their patients on their own. A network of specialist supports GPs with prescribing DAA. This optimally only needs a consultation of the patient file. Patients remain with their GPs resulting in a lowered threshold in the access to therapy, higher chance of adherence and less risk of stigmatisation. A special focus of HepCare is on GPs taking care of patients in opioid-agonist therapy. The project provides all necessary documents and support, like a checklist with all required parameters for the file consultation, a letter template for the specialist and different education materials for GPs and patients. All documents are available on the project website www.hepcare.ch. HepCare is one of the flagship project of the civil society initiated and run by the Swiss Hepatitis Strategy.
Current status of project:
First patients got treated in April 2019 within pilot projects with GP networks in the cantons of Zurich, Aargau, St. Gallen and Zug. The project roll out in other cantons will follow a pilot phase of 6 months. The project is financed by FOPH, cantonal health authorities and pharmaceutical industry.
The HepCare project brings HCV therapy from tertiary to primary care with the potential to raise awareness and motivation for HCV care among GPs and to facilitate access to care for patients. A successful nationwide execution of the project would bring Switzerland an important step closer towards elimination of hepatitis C.
Surveillance of sexually transmitted infections using innovative laboratory testing approaches in Kampala, Uganda
George Abongomera (Zürich | CH)
Introduction: Sexually transmitted infections (STIs) are among the most common infectious diseases. Syphilis infection continues to be an important global health problem in Uganda and other sub-Saharan African countries; whereas screening for STIs such as gonorrhea and chlamydia remains a concern due to challenges in the implementation of testing. This project set out to improve diagnosis and treatment of three key STIs in a sustainable manner, using innovative laboratory testing approaches.
Objectives: The project had four key objectives; 1) to screen 800 pregnant women during antenatal care for syphilis using Immunochromatographic Strip (ICS) tests 2) to screen 400 asymptomatic individuals at high risk for acquisition of STIs for chlamydia and gonorrhea using GeneXpert® cartridges 3) to diagnose at least 50-100 STIs and link 20 partners to care and 4) to hold 3 Continuous Medical Education (CME).
Results: 2040 pregnant women were screened for syphilis, 82 (4%) tested positive and all were linked to care and treatment. 456 asymptomatic individuals were screened for gonorrhea and chlamydia, of which 299 (66%) females. 37 (8%) tested positive for chlamydia and 28 (6%) for gonorrhea while 6 (1%)individuals had dual infection. In total, 147 STIs were diagnosed and 65 (44%) partners were treated as well. Six trainings were conducted among health care workers.
Conclusions: As a direct result, IDI has established a surveillance platform for STIs that is routinely used; STIs screening is now standard of care at the clinic. Beyond the objectives of the project itself, this project has also spurred further study ideas. Antimicrobial resistance testing of N. gonorrhea isolates is one of the priority areas for further studies with this partnership.