SEARCH Human Immunodeficiency Virus (HIV) Streamlined Treatment Intervention Reduces Mortality at a Population Level in Men with Low CD4 Counts

Background: We tested the hypothesis that patient-centered, streamlined human immunodeficiency virus (HIV) care would achieve lower mortality than the standard treatment model for persons with HIV and CD4≤350/uL in the setting of population-wide HIV testing. Methods: In the SEARCH (Sustainable East Africa Research in Community Health) Study (NCT01864603), 32 communities in rural Uganda and Kenya were randomized to country-guided antiretroviral therapy (ART) versus streamlined ART care that included rapid ART start, visit spacing, flexible clinic hours, and welcoming environment. We assessed persons with HIV and CD4≤350/uL, ART eligible in both arms, and estimated the effect of streamlined care on ART initiation and mortality at 3 years. Comparisons between study arms used a cluster-level analysis with survival estimates from Kaplan-Meier; estimates of ART start among ART-naive persons treated death as a competing risk. Results: Among 13 266 adults with HIV, 2973 (22.4%) had CD4≤350/uL. Of these, 33% were new diagnoses, and 10% were diagnosed but ART-naive. Men with HIV were almost twice as likely as women with HIV to have CD4≤350/uL and be untreated (15% vs 8%, respectively). Streamlined care reduced mortality by 28% versus control (risk ratio [RR]=0.72; 95% confidence interval [CI]:. 56,. 93; P=.02). Despite eligibility in both arms, persons with CD4≤350/uL started ART faster under streamlined care versus control (76% vs 43% by 12 months, respectively; P<.001). Mortality was reduced substantially more among men (RR=0.61; 95% CI:. 43,. 86; P=.01) than among women (RR=0.90; 95% CI:. 62, 1.32; P=.58). Conclusions: After population-based HIV testing, streamlined care reduced population-level mortality among persons with HIV and CD4≤350/uL, particularly among men. Streamlined HIV care models may play a key role in global efforts to reduce AIDS deaths.