Balzer, International Team Lead Community-Based HIV Trial in East Africa

Top: Laura Balzer (seated at left) with colleagues from the SEARCH study.
Bottom left and right: Mobile health fairs in East Africa.

August 7, 2018

Assistant Professor of Biostatistics 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%, and improved control of hypertension by 26%. Within the intervention arm, annual HIV incidence decreased by 32%. Results from the study, led by investigators at the University of California, San Francisco, were presented at the 22nd International AIDS Conference (AIDS 2018) in Amsterdam on July 25th.

“SEARCH demonstrated that a multi-disease, patient-centered approach could dramatically reduce mortality and improve community health,” says 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 who remained 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.

Balzer played an essential role in both study design, which randomized communities instead of individuals, and statistical analyses for all adult health outcomes.

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% 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% higher hypertension control at three years.

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. Through repeated annual testing in intervention communities, more than 95 percent of the population received an HIV test. Those diagnosed through community health campaigns were more likely to start ART, and viral suppression increased dramatically in all communities. In intervention communities, population-level viral suppression was 79 percent, surpassing the 90-90-90 target of 73 percent. Control communities approached the target with 68 percent of community members living with HIV virally suppressed. The reduction in HIV infections over the course of the study was similar between intervention and control communities.

Investigators found that annual community health campaigns and streamlined care delivery also had a positive impact on the burden of diseases other than HIV. While men and youth have participated at lower rates in HIV testing and treatment programs in Sub-Saharan Africa, the SEARCH model resulted in 74 percent of men living with HIV in intervention communities achieving viral suppression by the end of the study.

“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 Balzer. “Finally, as HIV incidence declines, efficient and effect strategies are needed to identify and prevent infection among those remaining at high risk.”