Getting people testing for HIV and into care in China
Landmark Lancet study shows the benefit of a simplified approach to HIV testing, diagnosis and linking to care for people living with HIV in a middle-income country.
A cluster randomised control trial found that a patient-centred approach to streamlined HIV testing and treatment resulted in improved clinical outcomes for people living with HIV in China.
The approach aims to streamline pathways to HIV treatment in the country, minimising the time and number of hospital or clinic visits between HIV testing and treatment initiation - a major reason why people do not remain in HIV care, and a major contributor to morbidity of people living with HIV in China.
Prior to streamlining, just 43% of patients who had received an initial positive result in some parts of China were later given a confirmatory diagnosis. On top of this, just 57% of people newly diagnosed received a CD4 test within six months of diagnosis. As national health guidelines still require a CD4 count to determine whether a person should start treatment, 80% of people newly identified as HIV-positive did not receive timely antiretroviral treatment.
As such, 478 patients were enrolled in the new trial across 12 hospitals in Guangxi Province in China. Half were randomly assigned the standard package of care offered by the existing health system – the control group – while the other half were given the ‘One4All’ intervention. The intervention is designed to bring the country’s HIV programmes up to speed with World Health Organization guidelines by accelerating diagnosis and staging and to provide immediate ART for eligible patients.
Patients in the test group received rapid, point-of-care HIV testing and immediate CD4 and viral load testing for those who were HIV-positive. Those patients immediately started on antiretroviral treatment, regardless of CD4 count.
The One4All intervention found that people were 20 times more likely to achieve testing completeness by 30 days. As a result, participants had a three times greater chance of starting antiretroviral treatment by 90 days, with a reduction in mortality of 56% at 12 months.
The authors note that this is the first study of a streamlined approach for testing and treatment in a randomised control from a middle-income country. Given the population growth rate in China – innovative interventions and policy changes such as the approach trialled in this study are needed to ensure Fast-Track targets are met.
In an accompanying commentary, Sten H Vermund from Yale University in the USA said, “The authors have captured the essence of what is now an overwhelming global consensus, that streamlining to enable early, easy screening and confirmatory HIV testing, CD4 cell counts, and viral loads, when combined with linkage to ART, can improve clinical outcomes. This is likely to reduce transmission to others, but whether sufficient coverage can be reached to make a difference remains to be seen.”