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Interventions to improve the performance of HIV health systems for treatment-as-prevention in sub-Saharan Africa: the experimental evidence

Bärnighausen, Tilla,b; Tanser, Franka; Dabis, Françoisc; Newell, Marie-Louisea,d

Current Opinion in HIV and AIDS: March 2012 - Volume 7 - Issue 2 - p 140–150
doi: 10.1097/COH.0b013e32834fc1df
TEST AND TREAT: Edited by Ann Duerr

Purpose of review To reduce HIV incidence, treatment-as-prevention (TasP) requires high rates of HIV testing, and antiretroviral treatment (ART) uptake, retention, and adherence, which are currently not achieved in general populations in sub-Saharan Africa. We review the experimental evidence on interventions to increase these rates.

Recent findings In four rapid reviews, we found nine randomized controlled trials (RCTs) on HIV-testing uptake, two on ART uptake, one on ART retention, and 15 on ART adherence in sub-Saharan Africa. Only two RCTs on HIV testing investigated an intervention in general populations; the other examined interventions in selected groups (employees, or individuals attending public-sector facilities for services). One RCT demonstrated that nurse-managed ART led to the same retention rates as physician-managed ART, but failed to show how to increase retention to the rates required for successful TasP. Although the evidence on ART adherence is strongest – several RCTs demonstrate the effectiveness of cognitive and behavioural interventions – contradictory results in different settings suggest that the precise intervention content, or the context, are crucial for effectiveness.

Summary Future studies need to test the effectiveness of interventions to increase testing and treatment uptake, retention, and adherence under TasP, that is, ART for all HIV-infected individuals, independent of disease stage.

aAfrica Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, KwaZulu-Natal, South Africa

bDepartment of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA

cInserm U897, Bordeaux School of Public Health, ISPED, Université Bordeaux Segalen, Bordeaux, France

dCentre for Paediatric Epidemiology and Biostatistics, UCL Institute of Child Health, London, UK

Correspondence to Till Bärnighausen, Africa Centre for Health and Population Studies, University of KwaZulu-Natal, PO Box 198, Mtubatuba 3935, South Africa. Tel: +27 35 550 7617; e-mail:

© 2012 Lippincott Williams & Wilkins, Inc.