Background: Effective interventions to reduce HIV incidence in sub-Saharan Africa are urgently needed. Mathematical
modelling and the HIV Prevention Trials Network (HPTN) 052 trial results suggest that universal HIV testing combined
with immediate antiretroviral treatment (ART) should substantially reduce incidence and may eliminate HIV as a public
health problem. We describe the rationale and design of a trial to evaluate this hypothesis.
Methods/Design: A rigorously-designed trial of universal testing and treatment (UTT) interventions is needed because:
i) it is unknown whether these interventions can be delivered to scale with adequate uptake; ii) there are many
uncertainties in the models such that the population-level impact of these interventions is unknown; and ii) there are
potential adverse effects including sexual risk disinhibition, HIV-related stigma, over-burdening of health systems, poor
adherence, toxicity, and drug resistance.
In the HPTN 071 (PopART) trial, 21 communities in Zambia and South Africa (total population 1.2 m) will be randomly
allocated to three arms. Arm A will receive the full PopART combination HIV prevention package including annual
home-based HIV testing, promotion of medical male circumcision for HIV-negative men, and offer of immediate ART
for those testing HIV-positive; Arm B will receive the full package except that ART initiation will follow current national
guidelines; Arm C will receive standard of care. A Population Cohort of 2,500 adults will be randomly selected in each
community and followed for 3 years to measure the primary outcome of HIV incidence. Based on model projections,
the trial will be well-powered to detect predicted effects on HIV incidence and secondary outcomes.
Discussion: Trial results, combined with modelling and cost data, will provide short-term and long-term estimates of
cost-effectiveness of UTT interventions. Importantly, the three-arm design will enable assessment of how much could
be achieved by optimal delivery of current policies and the costs and benefits of extending this to UTT.