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Population uptake of HIV testing, treatment, viral suppression, and male circumcision in Botswana: a cluster-randomized trial

Background— We sought to determine whether a community-based intervention to identify and rapidly treat persons living with HIV (PLWH) and support male circumcision (MC) could increase population levels of HIV diagnosis, treatment, viral suppression, and MC in Botswana. Methods— The Ya Tsie study was a pair-matched community-randomized trial conducted in 30 communities across Botswana from 2013–2018; 15 communities were randomized to receive HIV prevention and treatment interventions (including enhanced HIV testing, earlier antiretroviral treatment [ART], and strengthened MC services) and 15 received standard-of-care. We enrolled a cohort of residents aged 16–64 years from a random ~20% sample of households to assess baseline uptake of the following outcomes: (1) proportion known to be HIV-positive or tested HIV-negative in the preceding 12 months; (2) proportion of PLWH diagnosed and on ART; (3) proportion of PLWH on ART with viral suppression; and (4) proportion of HIV-negative men circumcised. In six communities all residents not previously enrolled in the longitudinal cohort completed an end-of-study survey to provide study-end coverage estimates. Differences in intervention uptake over time by arm were tested via paired student’s t-test. Findings— At baseline we enrolled 2,625 (n=805 PLWH; 403/402 in standard-of-care/ intervention communities) residents from the six communities also participating in the end-of-study survey. An additional 10,791 (n=2,691 PLWH; 1,338/1,353 in standard-of-care/intervention communities) residents completed an end-of-study survey in these communities. After accounting for baseline differences, at study-end, the proportion of PLWH who were diagnosed was significantly higher in the intervention arm (absolute increase of 9% to 93% [n=1,254 of