Dr Helen Ayles, project director introduces TREATS - a revolutionary study for TB and HIV testing

23 MARCH 2018

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In Zambia, where I have worked for the past 20 years, TB and HIV go hand-in-hand. From 2004 to 2011 I was one of the principal investigators of the ZAMSTAR study where we showed that by working in the community, going into TB patients’ homes and offering a combined package of TB and HIV diagnosis we could make a difference to TB at community level. Our problem was that the trial had borderline significance as we only directly covered about 6 percent of the population.

When we designed the HPTN 071 (PopART) study it was revolutionary. The intervention involved reaching out to the entire population -- visiting all homes in a community to provide a combination HIV prevention package, and linking to universal treatment for individuals living with HIV. With our previous experience in the ZAMSTAR study we could not ignore TB. And so PopART was designed with a community intervention that mirrored ZAMSTAR’s innovations, but modified according to the lessons we had learned. The scale of this intervention meant that we were testing every member of the population for HIV, as well as screening every member of the population for TB. It was true active case finding.

The TB side of the intervention was not popular with everyone. Many of the study team were much more familiar with working in HIV and so found the TB element of the study difficult to grasp. Our Community HIV Care Providers (CHiPs) also struggled as they were wholeheartedly focused on HIV --collecting sputum proved to be a new challenge. However we managed to win everyone round.

The TREATS project is so important as it will allow us, for the very first time, to measure the effect of a combination TB and HIV intervention delivered to the entire population in seven urban, high prevalence communities, and to compare this with seven matched communities that did not receive this intervention. It also allows us to measure several endpoints including: the incidence of TB infection in young people; the prevalence of active TB; TB notification and TB disease incidence in a random cohort of 18-44-year-olds. TREATS enable us to bring all this data together in order to understand the epidemiology of TB better.

Working in the field of TB is challenging. Our tools for diagnosing TB infection are limited -- this has hampered our understanding of the population dynamics of TB. And the tools necessary for large scale surveys, such as prevalence surveys, are expensive and difficult to use in this setting. The TREATS project will allow us to use the newest available tools to maximise additional scientific value. TB is also a feared and stigmatised disease.  A social science component built into the TREATS project will help us understand what worked well and what worked less well in the intervention, and ultimately to better understand stigma related to TB. This will enable us to design better TB services for the future. Mathematical and economic modelling will provide generalisable answers for how we can most effectively undertake these large scale interventions in the future.

For me personally, the TREATS project brings together 20 years of research into a combined strategy -- to end both TB and HIV at community level. It is a unique opportunity to assess an intervention on a massive scale. The TREATS consortium brings together a fantastic team of some of the best TB researchers and modellers, TB diagnostics companies and communications experts in TB. The study, I am sure, will involve many challenges. But it will also provide amazing data, and hopefully practical solutions to end TB.