Comparison of knowledge of HIV status and treatment coverage between non-citizens and citizens: Botswana Combination Prevention Project (BCPP)

Introduction
Non-citizens often face barriers to HIV care and treatment. Quantifying knowledge of positive HIV status and antiretroviral therapy (ART) coverage among non-citizens in a high HIV-prevalence country like Botswana that is close to achieving UNAIDS “90-90-90” targets may expose important gaps in achieving universal HIV testing and treatment.
Methods
The Botswana Combination Prevention Project (BCPP) is a pair-matched cluster-randomized trial evaluating the impact of prevention interventions on HIV incidence in 30 rural or peri-urban communities. Community case finding and HIV testing were conducted in home and mobile venues in 15 intervention communities from October 2013-September 2017. In this secondary analysis, we compared HIV positivity, knowledge of positive HIV-status, and ART status among all citizens and non-citizens assessed at intake in the intervention communities.
Results
HIV status was assessed in 57,556 residents in the intervention communities; 4% (n = 2,463) were non-citizens. Five communities accounted for 81% of the total non-citizens assessed. A lower proportion of non-citizens were HIV-positive (15%; n = 369) compared to citizens (21%; n = 11,416) [p = 0.026]; however, a larger proportion of non-citizens did not know their HIV-positive status prior to BCPP testing (75%) as compared to citizens (15%) [p = 0.003]. Among residents with knowledge of their HIV-positive status before BCPP, 79% of the non-citizens (72/91) were on ART compared to 86% (8,267/9,652) of citizens (p = 0.137).
Conclusions
Although non-citizens were less likely to know their HIV-positive status compared to citizens, there were no differences in treatment uptake among non-citizens and citizens who knew their status. Designing interventions for non-citizens that provide HIV testing and treatment services commensurate to that of citizens as well as targeting communities with the largest number of non-citizens may help close a meaningful gap in the HIV care cascade and ensure ethical treatment for all HIV-positive persons.
Trial registration
ClinicalTrials.gov: NCT01965470 (Botswana Combination Prevention Project).

引言
非本国公民在艾滋病（HIV）诊疗与照护方面常面临诸多障碍。在博茨瓦纳这类艾滋病高发且接近达成联合国艾滋病规划署（UNAIDS）“90-90-90”目标的国家，量化非本国公民的HIV阳性知晓情况与抗反转录病毒治疗（antiretroviral therapy，ART）覆盖率，有助于揭示实现全民艾滋病检测与治疗目标过程中存在的关键短板。

方法
博茨瓦纳综合预防项目（Botswana Combination Prevention Project, BCPP）是一项配对整群随机对照试验，旨在评估预防干预措施对30个农村或城郊社区艾滋病发病率的影响。2013年10月至2017年9月期间，研究团队在15个干预组社区的居家及流动场所开展社区病例发现与艾滋病检测工作。本项二次分析中，我们对比了干预组社区入组评估的所有本国公民与非本国公民的HIV阳性率、HIV阳性知晓情况及抗反转录病毒治疗状态。

结果
干预组社区共对57556名居民开展了HIV状态评估，其中4%（n=2463）为非本国公民。仅5个社区即覆盖了全部入组非本国公民的81%。非本国公民的HIV阳性率（15%，n=369）低于本国公民（21%，n=11416），差异具有统计学意义（p=0.026）；但在参与博茨瓦纳综合预防项目检测前，75%的非本国公民并不知晓自己的HIV阳性结果，这一比例显著高于本国公民的15%（p=0.003）。在参与项目前已知晓自身HIV阳性结果的居民中，非本国公民的抗反转录病毒治疗启动率为79%（72/91），本国公民则为86%（8267/9652），两组差异无统计学意义（p=0.137）。

结论
尽管非本国公民知晓自身HIV阳性结果的比例低于本国公民，但在已知晓自身感染状态的人群中，两类群体的抗反转录病毒治疗启动率并无显著差异。针对非本国公民设计可提供与本国公民同等质量的艾滋病检测与治疗服务的干预方案，同时聚焦非本国公民聚集度最高的社区，有助于缩小艾滋病诊疗关怀链中的关键差距，保障所有HIV阳性者均能获得符合伦理规范的诊疗服务。

试验注册
ClinicalTrials.gov: NCT01965470（博茨瓦纳综合预防项目）。