1
|
Makurumidze R, Decroo T, Jacobs BKM, Rusakaniko S, Van Damme W, Lynen L, Gils T. Attrition one year after starting antiretroviral therapy before and after the programmatic implementation of HIV "Treat All" in Sub-Saharan Africa: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:558. [PMID: 37641003 PMCID: PMC10463759 DOI: 10.1186/s12879-023-08551-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Evidence on the real-world effects of "Treat All" on attrition has not been systematically reviewed. We aimed to review existing literature to compare attrition 12 months after antiretroviral therapy (ART) initiation, before and after "Treat All" was implemented in Sub-Saharan Africa and describe predictors of attrition. METHODS We searched Embase, Google Scholar, PubMed, and Web of Science in July 2020 and created alerts up to the end of June 2023. We also searched for preprints and conference abstracts. Two co-authors screened and selected the articles. Risk of bias was assessed using the modified Newcastle-Ottawa Scale. We extracted and tabulated data on study characteristics, attrition 12 months after ART initiation, and predictors of attrition. We calculated a pooled risk ratio for attrition using random-effects meta-analysis. RESULTS Eight articles and one conference abstract (nine studies) out of 8179 screened records were included in the meta-analysis. The random-effects adjusted pooled risk ratio (RR) comparing attrition before and after "Treat All" 12 months after ART initiation was not significant [RR = 1.07 (95% Confidence interval (CI): 0.91-1.24)], with 92% heterogeneity (I2). Being a pregnant or breastfeeding woman, starting ART with advanced HIV, and starting ART within the same week were reported as risk factors for attrition both before and after "Treat All". CONCLUSIONS We found no significant difference in attrition before and after "Treat All" one year after ART initiation. While "Treat All" is being implemented widely, differentiated approaches to enhance retention should be prioritised for those subgroups at risk of attrition. PROSPERO NUMBER CRD42020191582 .
Collapse
Affiliation(s)
- Richard Makurumidze
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium.
- Faculty of Medicine and Health Sciences, Department of Primary Health Care Sciences, University of Zimbabwe, Harare, Zimbabwe.
- Faculty of Medicine & Pharmacy, Gerontology, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Tom Decroo
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
- Research Foundation of Flanders, Brussels, Belgium
| | - Bart K M Jacobs
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
| | - Simbarashe Rusakaniko
- Faculty of Medicine and Health Sciences, Department of Primary Health Care Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Wim Van Damme
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
- Faculty of Medicine & Pharmacy, Gerontology, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Lutgarde Lynen
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
| | - Tinne Gils
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| |
Collapse
|
2
|
Wu X, Wu G, Ma P, Wang R, Li L, Sun Y, Xu J, Li Y, Zhang T, Li Q, Yang Y, Wang L, Xin X, Qiao Y, Fang B, Lu Z, Zhou X, Chen Y, Liu Q, Fu G, Wei H, Huang X, Su B, Wang H, Zou H. Immediate and long-term outcomes after treat-all among people living with HIV in China: an interrupted time series analysis. Infect Dis Poverty 2023; 12:73. [PMID: 37580822 PMCID: PMC10424386 DOI: 10.1186/s40249-023-01119-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/12/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND In 2003, China implemented free antiretroviral therapy (ART) for people living with HIV (PLHIV), establishing an eligibility threshold of CD4 < 200 cells/μl. Subsequently, the entry criteria were revised in 2012 (eligibility threshold: CD4 ≤ 350 cells/μl), 2014 (CD4 ≤ 500 cells/μl), and 2016 (treat-all). However, the impact of treat-all policy on HIV care and treatment indicators in China is unknown. We aimed to elucidate the immediate and long-term impact of the implementation of treat-all policy in China. METHODS Anonymized programmatic data on ART initiation and collection in PLHIV who newly started ART were retrieved between 1 January 2015 and 31 December 2019, from two provincial and municipal Centers for Disease Control and Prevention and ten major infectious disease hospitals specialized in HIV care in China. We used Poisson and quasi-Poisson segmented regression models to estimate the immediate and long-term impact of treat-all on three key indicators: monthly proportion of 30-day ART initiation, mean CD4 counts (cells/μl) at ART initiation, and mean estimated time from infection to diagnosis (year). We built separate models according to gender, age, route of transmission and region. RESULTS Monthly data on ART initiation and collection were available for 75,516 individuals [gender: 83.8% males; age: median 39 years, interquartile range (IQR): 28-53; region: 18.5% Northern China, 10.9% Northeastern China, 17.5% Southern China, 49.2% Southwestern China]. In the first month of treat-all, compared with the contemporaneous counterfactual, there was a significant increase in proportion of 30-day ART initiation [+ 12.6%, incidence rate ratio (IRR) = 1.126, 95% CI: 1.033-1.229; P = 0.007] and mean estimated time from infection to diagnosis (+ 7.0%, IRR = 1.070, 95% CI: 1.021-1.120; P = 0.004), while there was no significant change in mean CD4 at ART initiation (IRR = 0.990, 95% CI: 0.956-1.026; P = 0.585). By December 2019, the three outcomes were not significantly different from expected levels. In the stratified analysis, compared with the contemporaneous counterfactual, mean CD4 at ART initiation showed significant increases in Northern China (+ 3.3%, IRR = 1.033, 95% CI: 1.001-1.065; P = 0.041) and Northeastern China (+ 8.0%, IRR = 1.080, 95% CI: 1.003-1.164; P = 0.042) in the first month of treat-all; mean estimated time from infection to diagnosis showed significant increases in male (+ 5.6%, IRR = 1.056, 95% CI: 1.010-1.104; P = 0.016), female (+ 14.8%, IRR = 1.148, 95% CI: 1.062-1.240; P < 0.001), aged 26-35 (+ 5.3%, IRR = 1.053, 95% CI: 1.001-1.109; P = 0.048) and > 50 (+ 7.8%, IRR = 1.078, 95% CI: 1.000-1.161; P = 0.046), heterosexual transmission (+ 12.4%, IRR = 1.124, 95% CI: 1.042-1.213; P = 0.002) and Southwestern China (+ 12.9%, IRR = 1.129, 95% CI: 1.055-1.208; P < 0.001) in the first month of treat-all. CONCLUSIONS The implementation of treat-all policy in China was associated with a positive effect on HIV care and treatment outcomes. To advance the work of rapid ART, efforts should be made to streamline the testing and ART initiation process, provide comprehensive support services, and address the issue of uneven distribution of medical resources.
Collapse
Affiliation(s)
- Xinsheng Wu
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Guohui Wu
- Institute for AIDS/STD Control and Prevention, Chongqing Center for Disease Control and Prevention, Chongqing, People's Republic of China
| | - Ping Ma
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, People's Republic of China
- Tianjin Association of STD/AIDS Prevention and Control, Tianjin, People's Republic of China
| | - Rugang Wang
- Dalian Public Health Clinical Center, Dalian, People's Republic of China
| | - Linghua Li
- Infectious Disease Center, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yinghui Sun
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Junjie Xu
- Clinical Research Academy, Peking University Shenzhen Hospital, Peking University, Shenzhen, People's Republic of China
| | - Yuwei Li
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Tong Zhang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No.8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing, 100069, People's Republic of China
| | - Quanmin Li
- Infectious Disease Center, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yuecheng Yang
- Dehong Prefecture Center for Disease Control and Prevention, Dehong, People's Republic of China
| | - Lijing Wang
- Shijiazhuang Fifth Hospital, Shijiazhuang, People's Republic of China
| | - Xiaoli Xin
- No.6 People's Hospital of Shenyang, Shenyang, People's Republic of China
| | - Ying Qiao
- No.2 Hospital of Hohhot, Hohhot, People's Republic of China
| | - Bingxue Fang
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Zhen Lu
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Xinyi Zhou
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Yuanyi Chen
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Qi Liu
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Gengfeng Fu
- Department of STD/AIDS Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, People's Republic of China
| | - Hongxia Wei
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, 1-1 Zhongfu Road, Nanjing, 210036, Jiangsu, People's Republic of China.
| | - Xiaojie Huang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No.8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing, 100069, People's Republic of China.
| | - Bin Su
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No.8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing, 100069, People's Republic of China.
| | - Hui Wang
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern, University of Science and Technology, Bulan Road 29#, Longgang District, Shenzhen, 518112, Guangdong, People's Republic of China.
| | - Huachun Zou
- School of Public Health, Fudan University, 130 Dongan Road, Xuhui District, Shanghai, 200032, People's Republic of China.
- School of Public Health, Southwest Medical University, Luzhou, People's Republic of China.
- Kirby Institute, University of New South Wales, Sydney, Australia.
| |
Collapse
|
3
|
Murenzi G, Kim HY, Shi Q, Muhoza B, Munyaneza A, Kubwimana G, Remera E, Nsanzimana S, Yotebieng M, Nash D, Anastos K, Ross J. Association Between Time to Antiretroviral Therapy and Loss to Care Among Newly Diagnosed Rwandan People Living with Human Immunodeficiency Virus. AIDS Res Hum Retroviruses 2023; 39:253-261. [PMID: 36800896 PMCID: PMC10171964 DOI: 10.1089/aid.2022.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
Despite improved clinical outcomes of initiating antiretroviral therapy (ART) soon after diagnosis, conflicting evidence exists regarding the impact of same-day ART initiation on subsequent clinical outcomes. We aimed to characterize the associations of time to ART initiation with loss to care and viral suppression in a cohort of newly diagnosed people living with HIV (PLHIV) entering care after Rwanda implemented a national "Treat All" policy. We conducted a secondary analysis of routinely collected data of adult PLHIV enrolling in HIV care at 10 health facilities in Kigali, Rwanda. Time from enrollment to ART initiation was categorized as same day, 1-7 days, or >7 days. We examined associations between time to ART and loss to care (>120 days since last health facility visit) using Cox proportional hazards models, and between time to ART and viral suppression using logistic regression. Of 2,524 patients included in this analysis, 1,452 (57.5%) were women and the median age was 32 (interquartile range: 26-39). Loss to care was more frequent among patients who initiated ART on the same day (15.9%), compared with those initiating ART 1-7 days (12.3%) or >7 days (10.1%), p < .001. In multivariable analyses, same-day ART initiation was associated with a greater hazard of loss to care compared with initiating >7 days after enrollment (adjusted hazard ratio 1.39, 95% confidence interval: 1.04-1.85). A total of 1,698 (67.3%) had available data on viral load measured within 455 days after enrollment. Of these, 1,476 (87%) were virally suppressed. A higher proportion of patients initiating ART on the same day were virally suppressed (89%) compared with those initiating 1-7 days (84%) or >7 days (88%) after enrollment. This association was not statistically significant. Our findings suggest that ensuring adequate, early support for PLHIV initiating ART rapidly may be important to improve retention in care for newly diagnosed PLHIV in the era of Treat All.
Collapse
Affiliation(s)
- Gad Murenzi
- Rwanda Military Hospital, Kigali, Rwanda.,Research for Development (RD Rwanda), Kigali, Rwanda
| | | | - Qiuhu Shi
- New York Medical College, Valhalla, New York, USA
| | | | | | - Gallican Kubwimana
- Rwanda Military Hospital, Kigali, Rwanda.,Research for Development (RD Rwanda), Kigali, Rwanda
| | | | | | | | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA.,School of Public Health, City University of New York, New York, New York, USA
| | | | - Jonathan Ross
- Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|
4
|
Remera E, Nsanzimana S, Chammartin F, Semakula M, Rwibasira GN, Malamba SS, Riedel DJ, Tuyishime E, Condo JU, Ndimubanzi P, Sangwayire B, Forrest JI, Cantoreggi SL, Mills EJ, Bucher HC. Brief Report: Active HIV Case Finding in the City of Kigali, Rwanda: Assessment of Voluntary Assisted Partner Notification Modalities to Detect Undiagnosed HIV Infections. J Acquir Immune Defic Syndr 2022; 89:423-427. [PMID: 35202049 PMCID: PMC8860213 DOI: 10.1097/qai.0000000000002878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Voluntary assisted partner notification (VAPN) services that use contract, provider, or dual referral modalities may be efficient to identify individuals with undiagnosed HIV infection. We aimed to assess the relative effectiveness of VAPN modalities in identifying undiagnosed HIV infections. SETTING VAPN was piloted in 23 health facilities in Kigali, Rwanda. METHODS We identified individuals with a new HIV diagnosis before antiretroviral therapy initiation or individuals on antiretroviral therapy (index cases), who reported having had sexual partners with unknown HIV status, to assess the association between referral modalities and the odds of identifying HIV-positive partners using a Bayesian hierarchical logistic regression model. We adjusted our model for important factors identified through a Bayesian variable selection. RESULTS Between October 2018 and December 2019, 6336 index cases were recruited, leading to the testing of 7690 partners. HIV positivity rate was 7.1% (546/7690). We found no association between the different referral modalities and the odds of identifying HIV-positive partners. Notified partners of male individuals (adjusted odds ratio 1.84; 95% credible interval: 1.50 to 2.28) and index cases with a new HIV diagnosis (adjusted odds ratio 1.82; 95% credible interval: 1.45 to 2.30) were more likely to be infected with HIV. CONCLUSION All 3 VAPN modalities were comparable in identifying partners with HIV. Male individuals and newly diagnosed index cases were more likely to have partners with HIV. HIV-positive yield from index testing was higher than the national average and should be scaled up to reach the first UNAIDS-95 target by 2030.
Collapse
Affiliation(s)
- Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Faculty of Science, Basel- Switzerland
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Frédérique Chammartin
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Faculty of Science, Basel- Switzerland
| | - Muhammed Semakula
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
- I-BioStat, Hasselt University, Hasselt, Belgium
| | - Gallican N. Rwibasira
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | | | - David J. Riedel
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD
| | - Elysee Tuyishime
- African Center of Excellence in Data Science, University of Rwanda, Kigali, Rwanda
| | - Jeanine U. Condo
- School of Public Health, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Tulane University, New Orleans, LA
| | | | - Beata Sangwayire
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
| | - Jamie I. Forrest
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Sara L. Cantoreggi
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda
- University of Basel, Faculty of Science, Basel- Switzerland
| | - Edward J. Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Faculty of Science, Basel- Switzerland
| |
Collapse
|
5
|
Mayasi N, Situakibanza H, Mbula M, Longokolo M, Maes N, Bepouka B, Ossam JO, Moutschen M, Darcis G. Retention in care and predictors of attrition among HIV-infected patients who started antiretroviral therapy in Kinshasa, DRC, before and after the implementation of the 'treat-all' strategy. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000259. [PMID: 36962315 PMCID: PMC10022330 DOI: 10.1371/journal.pgph.0000259] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 02/13/2022] [Indexed: 11/18/2022]
Abstract
The retention of patients in care is a key pillar of the continuum of HIV care. It has been suggested that the implementation of a "treat-all" strategy may favor attrition (death or lost to follow-up, as opposed to retention), specifically in the subgroup of asymptomatic people living with HIV (PLWH) with high CD4 counts. Attrition in HIV care could mitigate the success of universal antiretroviral therapy (ART) in resource-limited settings. We performed a retrospective study of PLWH at least 15 years old initiating ART in 85 HIV care centers in Kinshasa, Democratic Republic of Congo (DRC), between 2010 and 2019, with the objective of measuring attrition and to define factors associated with it. Sociodemographic and clinical characteristics recorded at ART initiation included sex, age, weight, height, WHO HIV stage, pregnancy, baseline CD4 cell count, start date of ART, and baseline and last ART regimen. Attrition was defined as death or loss to follow-up (LTFU). LTFU was defined as "not presenting to an HIV care center for at least 180 days after the date of a last missed visit, without a notification of death or transfer". Kaplan-Meier curves were used to present attrition data, and mixed effects Cox regression models determined factors associated with attrition. The results compared were before and after the implementation of the "treat-all" strategy. A total of 15,762 PLWH were included in the study. Overall, retention in HIV care was 83% at twelve months and 77% after two years of follow-up. The risk of attrition increased with advanced HIV disease and the size of the HIV care center. Time to ART initiation greater than seven days after diagnosis and Cotrimoxazole prophylaxis was associated with a reduced risk of attrition. The implementation of the "treat-all" strategy modified the clinical characteristics of PLWH toward higher CD4 cell counts and a greater proportion of patients at WHO stages I and II at treatment initiation. Initiation of ART after the implementation of the 'treat all" strategy was associated with higher attrition (p<0.0001) and higher LTFU (p<0.0001). Attrition has remained high in recent years. The implementation of the "treat-all" strategy was associated with higher attrition and LTFU in our study. Interventions to improve early and ongoing commitment to care are needed, with specific attention to high-risk groups to improve ART coverage and limit HIV transmission.
Collapse
Affiliation(s)
- Nadine Mayasi
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Hippolyte Situakibanza
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Marcel Mbula
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Murielle Longokolo
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Nathalie Maes
- Biostatistics and Medico-Economic Information Department, University Hospital of Liège, Liège, Belgium
| | - Ben Bepouka
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Jérôme Odio Ossam
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Michel Moutschen
- Department of Internal Medicine and Infectious Diseases, Liège University Hospital, Liège, Belgium
- AIDS Reference Laboratory, University of Liège, Liège, Belgium
| | - Gilles Darcis
- Department of Internal Medicine and Infectious Diseases, Liège University Hospital, Liège, Belgium
| |
Collapse
|
6
|
Recent infections among individuals with a new HIV diagnosis in Rwanda, 2018-2020. PLoS One 2021; 16:e0259708. [PMID: 34788323 PMCID: PMC8598012 DOI: 10.1371/journal.pone.0259708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/26/2021] [Indexed: 11/19/2022] Open
Abstract
Background Despite Rwanda’s progress toward HIV epidemic control, 16.2% of HIV-positive individuals are unaware of their HIV positive status. Tailoring the public health strategy could help reach these individuals with new HIV infection and achieve epidemic control. Recency testing is primarily for surveillance, monitoring, and evaluation but it’s not for diagnostic purposes. However, it’s important to know what proportion of the newly diagnosed are recent infections so that HIV prevention can be tailored to the profile of people who are recently infected. We therefore used available national data to characterize individuals with recent HIV infection in Rwanda to inform the epidemic response. Methods We included all national-level data for recency testing reported from October 2018 to June 2020. Eligible participants were adults (aged ≥15 years) who had a new HIV diagnosis, who self-reported being antiretroviral therapy (ART) naïve, and who had consented to recency testing. Numbers and proportions of recent HIV infections were estimated, and precision around these estimates was calculated with 95% confidence intervals (CI). Logistic regression was used to assess factors associated with being recently (within 12 months) infected with HIV. Results Of 7,785 eligible individuals with a new HIV-positive diagnosis, 475 (6.1%) met the criteria for RITA recent infection. The proportion of RITA recent infections among individuals with newly identified HIV was high among those aged 15–24 years (9.6%) and in men aged ≥65 years (10.3%) compared to other age groups; and were higher among women (6.7%) than men (5.1%). Of all recent cases, 68.8% were women, and 72.2% were aged 15–34 years. The Northern province had the fewest individuals with newly diagnosed HIV but had the highest proportion of recent infections (10.0%) compared to other provinces. Recent infections decreased by 19.6% per unit change in time (measured in months). Patients aged ≥25 years were less likely to have recent infection than those aged 15–24 years with those aged 35–49 years being the least likely to have recent infection compared to those aged 15–24 years (adjusted odds ratio [aOR], 0.415 [95% CI: 0.316–0.544]). Conclusion Public health surveillance targeting the areas and the identified groups with high risk of recent infection could help improve outcomes.
Collapse
|
7
|
Effects of implementing universal and rapid HIV treatment on initiation of antiretroviral therapy and retention in care in Zambia: a natural experiment using regression discontinuity. Lancet HIV 2021; 8:e755-e765. [PMID: 34656208 DOI: 10.1016/s2352-3018(21)00186-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Universal testing and treatment (UTT) for all people living with HIV has only been assessed under experimental conditions in cluster-randomised trials. The public health effectiveness of UTT policies on the HIV care cascade under real-world conditions is not known. We assessed the real-world effectiveness of universal HIV treatment policies that were implemented in Zambia on Jan 1, 2017. METHODS We used data from Zambia's routine electronic health record system to analyse antiretroviral therapy (ART)-naive adults who newly enrolled in HIV care up to 1 year before and after the implementation of universal treatment (ie, Jan 1, 2016, to Jan 1, 2018) at 117 clinics supported by the Centre for Infectious Disease Research in Zambia. We used a regression discontinuity design to estimate the effects of implementing UTT on same-day ART initiation, ART initiation within 1 month, and retention on ART at 12 months (defined as clinic attendance 9-15 months after enrolment and at least 6 months on ART), under the assumption that patients presenting immediately before and after UTT implementation were balanced on both measured and unmeasured characteristics. We did an instrumental variable analysis to estimate the effect of same-day ART initiation under routine conditions on 12-month retention on ART. FINDINGS 65 673 newly enrolled patients with HIV (40 858 [62·2%] female, median age 32 years [IQR 26-39], median CD4 count 287 cells per μL [IQR 147-466]) were eligible for inclusion in the analyses; 31 145 enrolled before implementation of UTT, and 34 528 enrolled after UTT. Implementation of universal treatment increased same-day ART initiation from 41·7% to 74·8% (risk difference [RD] 33·1%, 95% CI 30·5-35·7), ART initiation by 1 month from 69·6% to 87·0% (RD 17·4%, 15·5-19·3), and 12-month retention on ART from 56·2% to 63·3% (RD 7·1%, 4·3-9·9). ART initiation rates became more uniform across patient subgroups after implementation of universal treatment, but heterogeneity in 12-month retention on ART between subgroups was unchanged. Instrumental variable analyses indicated that same-day ART initiation in routine settings led to a 15·8% increase (95% CI 12·1-19·5) in 12-month retention on ART. INTERPRETATION UTT policies implemented in Zambia increased the rapidity and uptake of ART, as well as retention on ART at 12 months, although overall retention on ART remained suboptimal. UTT policies reduced disparities in treatment initiation, but not 12-month retention on ART. Natural experiments reveal both the anticipated and unanticipated effects of real-world implementation and indicate the need for new strategies leveraging the short-term effects of UTT to cultivate long-term treatment success. FUNDING National Institutes of Health.
Collapse
|
8
|
Understanding the Reasons for Deferring ART Among Patients Diagnosed Under the Same-Day-ART Policy in Johannesburg, South Africa. AIDS Behav 2021; 25:2779-2792. [PMID: 33534055 PMCID: PMC8373761 DOI: 10.1007/s10461-021-03171-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 12/20/2022]
Abstract
We aimed to examine the correlates of antiretroviral therapy (ART) deferral to inform ART demand creation and retention interventions for patients diagnosed with HIV during the Universal Test and Treat (UTT) policy in South Africa. We conducted a cohort study enrolling newly diagnosed HIV-positive adults (≥ 18 years), at four primary healthcare clinics in Johannesburg between October 2017 and August 2018. Patients were interviewed immediately after HIV diagnosis, and ART initiation was determined through medical record review up to six-months post-test. ART deferral was defined as not starting ART six months after HIV diagnosis. Participants who were not on ART six-months post-test were traced and interviewed telephonically to determine reasons for ART deferral. Modified Poisson regression was used to evaluate correlates of six-months ART deferral. We adjusted for baseline demographic and clinical factors. We present crude and adjusted risk ratios (aRR) associated with ART deferral. Overall, 99/652 (15.2%) had deferred ART by six months, 20.5% men and 12.2% women. Baseline predictors of ART deferral were older age at diagnosis (adjusted risk ratio (aRR) 1.5 for 30-39.9 vs 18-29.9 years, 95% confidence intervals (CI): 1.0-2.2), disclosure of intentions to test for HIV (aRR 2.2 non-disclosure vs disclosure to a partner/spouse, 95% CI: 1.4-3.6) and HIV testing history (aRR 1.7 for > 12 months vs < 12 months/no prior test, 95% CI: 1.0-2.8). Additionally, having a primary house in another country (aRR 2.1 vs current house, 95% CI: 1.4-3.1) and testing alone (RR 4.6 vs partner/spouse support, 95% CI: 1.2-18.3) predicted ART deferral among men. Among the 43/99 six-months interviews, women (71.4%) were more likely to self-report ART initiation than men (RR 0.4, 95% CI: 0.2-0.8) and participants who relocated within SA (RR 2.1 vs not relocated, 95% CI: 1.2-3.5) were more likely to still not be on ART. Under the treat-all ART policy, nearly 15.2% of study participants deferred ART initiation up to six months after the HIV diagnosis. Our analysis highlighted the need to pay particular attention to patients who show little social preparation for HIV testing and mobile populations.
Collapse
|
9
|
Kerschberger B, Boulle A, Kuwengwa R, Ciglenecki I, Schomaker M. The Impact of Same-Day Antiretroviral Therapy Initiation Under the World Health Organization Treat-All Policy. Am J Epidemiol 2021; 190:1519-1532. [PMID: 33576383 PMCID: PMC8327202 DOI: 10.1093/aje/kwab032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 12/18/2022] Open
Abstract
Rapid initiation of antiretroviral therapy (ART) is recommended for people living with human immunodeficiency virus (HIV), with the option to start treatment on the day of diagnosis (same-day ART). However, the effect of same-day ART remains unknown in realistic public sector settings. We established a cohort of ≥16-year-old patients who initiated first-line ART under a treat-all policy in Nhlangano (Eswatini) during 2014-2016, either on the day of HIV care enrollment (same-day ART) or 1-14 days thereafter (early ART). Directed acyclic graphs, flexible parametric survival analysis, and targeted maximum likelihood estimation (TMLE) were used to estimate the effect of same-day-ART initiation on a composite unfavorable treatment outcome (loss to follow-up, death, viral failure, treatment switch). Of 1,328 patients, 839 (63.2%) initiated same-day ART. The adjusted hazard ratio of the unfavorable outcome was higher, 1.48 (95% confidence interval: 1.16, 1.89), for same-day ART compared with early ART. TMLE suggested that after 1 year, 28.9% of patients would experience the unfavorable outcome under same-day ART compared with 21.2% under early ART (difference: 7.7%; 1.3%-14.1%). This estimate was driven by loss to follow-up and varied over time, with a higher hazard during the first year after HIV care enrollment and a similar hazard thereafter. We found an increased risk with same-day ART. A limitation was that possible silent transfers that were not captured.
Collapse
Affiliation(s)
- Bernhard Kerschberger
- Correspondence to Dr. Bernhard Kerschberger, Médecins Sans Frontières, Mantsholo Road 325, Mbabane, Eswatini (e-mail: )
| | | | | | | | | |
Collapse
|
10
|
How early is too early? Challenges in ART initiation and engaging in HIV care under Treat All in Rwanda-A qualitative study. PLoS One 2021; 16:e0251645. [PMID: 33984044 PMCID: PMC8118273 DOI: 10.1371/journal.pone.0251645] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/29/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction HIV treatment guidelines recommend that all people living with HIV (PLWH) initiate antiretroviral therapy (ART) as soon as possible after diagnosis (Treat All). As Treat All is more widely implemented, an increasing proportion of PLWH are likely to initiate ART when they are asymptomatic, and they may view the relative benefits and risks of ART differently than those initiating at more advanced disease stages. To date, patient perspectives of initiating care under Treat All in sub-Saharan Africa have not been well described. Methods From September 2018 to March 2019, we conducted individual, semi-structured, qualitative interviews with 37 patients receiving HIV care in two health centers in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive thematic analysis approach to describe perceived barriers to, facilitators of and acceptability of initiating and adhering to ART rapidly under Treat All. Results Of 37 participants, 27 were women and the median age was 31 years. Participants described feeling traumatized and overwhelmed by their HIV diagnosis, resulting in difficulty accepting their HIV status. Most were prescribed ART soon after diagnosis, yet fear of lifelong medication and severe side effects in the immediate period after initiating ART led to challenges adhering to therapy. Moreover, because many PLWH initiated ART while healthy, taking medications and attending appointments were visible signals of HIV status and highly stigmatizing. Nonetheless, many participants expressed enthusiasm for Treat All as a program that improved health as well as health equity. Conclusion For newly-diagnosed PLWH in Rwanda, initiating ART rapidly under Treat All presents logistical and emotional challenges despite the perceived benefits. Our findings suggest that optimizing early engagement in HIV care under Treat All requires early and ongoing intervention to reduce trauma and stigma, and promote both individual and community benefits of ART.
Collapse
|
11
|
Murenzi G, Kanyabwisha F, Murangwa A, Kubwimana G, Mutesa L, Burk RD, Anastos K, Castle PE. Twelve-Year Trend in the Prevalence of High-Risk Human Papillomavirus Infection Among Rwandan Women Living With HIV. J Infect Dis 2021; 222:74-81. [PMID: 32050023 DOI: 10.1093/infdis/jiaa065] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/07/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND We examined the trend in prevalence of high-risk human papillomavirus (hrHPV) cervical infection among Rwandan women living with HIV (WLWH) over 12 years. METHODS Prevalence of cervical hrHPV DNA was measured in 3 studies at 3 different time periods in 3 different groups of WLWH using 3 different but comparable hrHPV tests: a MY09/MY11 PCR test in 2005 (RWISA; n = 497), careHPV in 2009-2010 (HPV Demonstration; n = 1242), and Xpert HPV test in 2016-2018 (U54; n = 4734). Prevalences were adjusted for age and CD4 cell count. RESULTS HrHPV prevalence decreased over time from 42.5% to 32.2% to 26.5% (P < .001). CD4 cell counts improved over time (Ptrend <.001) so that the percentage of WLWH with CD4 counts of ≥500 cells/μL increased from 7.7% in 2005 to 42.2% in 2009-2010 and 61.1% in 2016-2018. Thus, after adjustment for differences in CD4 counts and age, hrHPV prevalences were more similar over time: 32.6% for RWISA, 30.6% for HPV Demonstration, and 27.1% for U54 (P = .007). CONCLUSIONS Prevalence of hrHPV among WLWH has decreased over the past decade, most likely the result of improved immune reconstitution due to better HIV care and management in Rwanda.
Collapse
Affiliation(s)
| | | | | | | | - Leon Mutesa
- Center for Human Genetics, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Robert D Burk
- Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | |
Collapse
|
12
|
Tlhajoane M, Dzamatira F, Kadzura N, Nyamukapa C, Eaton JW, Gregson S. Incidence and predictors of attrition among patients receiving ART in eastern Zimbabwe before, and after the introduction of universal 'treat-all' policies: A competing risk analysis. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000006. [PMID: 36962073 PMCID: PMC10021537 DOI: 10.1371/journal.pgph.0000006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 09/15/2021] [Indexed: 11/18/2022]
Abstract
As HIV treatment is expanded, attention is focused on minimizing attrition from care. We evaluated the impact of treat-all policies on the incidence and determinants of attrition amongst clients receiving ART in eastern Zimbabwe. Data were retrospectively collected from the medical records of adult patients (aged≥18 years) enrolled into care from July 2015 to June 2016-pre-treat-all era, and July 2016 to June 2017-treat-all era, selected from 12 purposively sampled health facilities. Attrition was defined as an absence from care >90 days following ART initiation. Survival-time methods were used to derive incidence rates (IRs), and competing risk regression used in bivariate and multivariable modelling. In total, 829 patients had newly initiated ART and were included in the analysis (pre-treat-all 30.6%; treat-all 69.4%). Incidence of attrition (per 1000 person-days) increased between the two time periods (pre-treat-all IR = 1.18 (95%CI: 0.90-1.56) versus treat-all period IR = 1.62 (95%CI: 1.37-1.91)). In crude analysis, patients at increased risk of attrition were those enrolled into care during the treat-all period, <34 years of age, WHO stage I at enrolment, and had initiated ART on the same day as HIV diagnosis. After accounting for mediating clinical characteristics, the difference in attrition between the pre-treat-all, and treat-all periods ceased to be statistically significant. In a full multivariable model, attrition was significantly higher amongst same-day ART initiates (aSHR = 1.47, 95%CI:1.05-2.06). Implementation of treat-all policies was associated with an increased incidence of ART attrition, driven largely by ART initiation on the same day as HIV diagnosis which increased significantly in the treat all period. Differentiated adherence counselling for patients at increased risk of attrition, and improved access to clinical monitoring may improve retention in care.
Collapse
Affiliation(s)
- Malebogo Tlhajoane
- Department for Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Noah Kadzura
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Constance Nyamukapa
- Department for Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Jeffrey W Eaton
- Department for Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Simon Gregson
- Department for Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| |
Collapse
|
13
|
Chauke P, Huma M, Madiba S. Lost to follow up rate in the first year of ART in adults initiated in a universal test and treat programme: a retrospective cohort study in Ekurhuleni District, South Africa. Pan Afr Med J 2020; 37:198. [PMID: 33505567 PMCID: PMC7813655 DOI: 10.11604/pamj.2020.37.198.25294] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/26/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction South Africa adopted and implemented the Universal Test and Treat (UTT) strategy for HIV since 2016. However, the care outcomes for patients initiated antiretroviral therapy (ART) through the UTT strategy have not been established. We determined the rate of lost to follow up (LTFU) and associated factors in patients who were initiated on ART through the UTT and the pre-ART strategy at 12 months post ART initiation. Methods this retrospective study analyzed the records of a cohort of patients at 12 months post the initiation of ART. We extracted data from the TIER.Net electronic database of selected facilities in a sub-district in Gauteng Province, South Africa. Factors associated with LFTU at 12 months of ART were assessed and logistic regression performed to identify predictors of LFTU. Results records of 367 patients were evaluated, and 54% were initiated ART through the UTT strategy. The mean age was 36.3 years, mean CD4 cell count at ART initiation was 341 cells/mm3, and 25% were initiated at CD4 cell count above 500 cells/mm3. LTFU at 12 months was 28%, 50% were LFTU within six months, and 28% within three months of ART. LFTU in the UTT cohort was higher than in the pre-ART cohort, patients initiated through UTT were twice more likely to be LTFU (AOR = 1.84, CI: 1.13-3.00) than pre-ART patients. Conclusion the rate of LTFU at 12 months of ART was 28%, which indicate that the retention in care rate (60%) falls far short of the triple 90 targets required for viral suppression.
Collapse
Affiliation(s)
- Patricia Chauke
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Mmampedi Huma
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Sphiwe Madiba
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| |
Collapse
|
14
|
Kerschberger B, Schomaker M, Jobanputra K, Kabore SM, Teck R, Mabhena E, Mthethwa-Hleza S, Rusch B, Ciglenecki I, Boulle A. HIV programmatic outcomes following implementation of the 'Treat-All' policy in a public sector setting in Eswatini: a prospective cohort study. J Int AIDS Soc 2020; 23:e25458. [PMID: 32128964 PMCID: PMC7054447 DOI: 10.1002/jia2.25458] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/04/2019] [Accepted: 01/22/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The Treat-All policy - antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria - increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat-All in resource-limited settings. We aimed to describe and compare programmatic outcomes between Treat-All and standard of care (SOC) in the public sectors of Eswatini. METHODS This is a prospective cohort study of ≥16-year-old HIV-positive patients initiated on first-line ART under Treat-All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan-Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all-cause attrition and viral failure. RESULTS Of the 3170 patients, 1888 (59.6%) initiated ART under Treat-All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat-All (71%) than SOC (75%) (p = 0.002), it was similar in covariate-adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat-All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat-All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat-All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3 . Under Treat-All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine. CONCLUSIONS Compared to SOC, Treat-All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.
Collapse
Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Kiran Jobanputra
- The Manson Unit, Médecins Sans Frontières, London, United Kingdom
| | - Serge M Kabore
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Roger Teck
- The Manson Unit, Médecins Sans Frontières, London, United Kingdom
| | - Edwin Mabhena
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | | | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
15
|
Makurumidze R, Buyze J, Decroo T, Lynen L, de Rooij M, Mataranyika T, Sithole N, Takarinda KC, Apollo T, Hakim J, Van Damme W, Rusakaniko S. Patient-mix, programmatic characteristics, retention and predictors of attrition among patients starting antiretroviral therapy (ART) before and after the implementation of HIV "Treat All" in Zimbabwe. PLoS One 2020; 15:e0240865. [PMID: 33075094 PMCID: PMC7571688 DOI: 10.1371/journal.pone.0240865] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/03/2020] [Indexed: 12/30/2022] Open
Abstract
Background Since the scale-up of the HIV “Treat All” recommendation, evidence on its real-world effect on predictors of attrition (either death or lost to follow-up) is lacking. We conducted a retrospective study using Zimbabwe ART program data to assess the association between “Treat All” and, patient-mix, programmatic characteristics, retention and predictors of attrition. Methods We used patient-level data from the electronic patient monitoring system (ePMS) from the nine districts, which piloted the “Treat All” recommendation. We compared patient-mix, programme characteristics, retention and predictors of attrition (lost to follow-up, death or stopping ART) in two cohorts; before (April/May 2016) and after (January/February 2017) “Treat All”. Retention was estimated using survival analysis. Predictors of attrition were determined using a multivariable Cox regression model. Interactions were used to assess the change in predictors of attrition before and after “Treat All”. Results We analysed 3787 patients, 1738 (45.9%) and 2049 (54.1%) started ART before and after “Treat All”, respectively. The proportion of men was higher after “Treat All” (39.4.% vs 36.2%, p = 0.044). Same-day ART initiation was more frequent after “Treat All” (43.2% vs 16.4%; p<0.001) than before. Retention on ART was higher before “Treat All” (p<0.001). Among non-pregnant women and men, the adjusted hazard ratio (aHR) of attrition after compared to before “Treat All” was 1.73 (95%CI: 1.30–2.31). The observed hazard of attrition for women being pregnant at ART initiation decreased by 17% (aHR: 1.73*0.48 = 0.83) after “Treat All”. Being male (vs female; aHR: 1.45; 95%CI: 1.12–1.87) and WHO Stage IV (vs WHO Stage I-III; aHR: 2.89; 95%CI: 1.16–7.11) predicted attrition both before and after “Treat All” implementation. Conclusion Attrition was higher after “Treat All”; being male, WHO Stage 4, and pregnancy predicted attrition in both before and after Treat All. However, pregnancy became a less strong risk factor for attrition after “Treat All” implementation.
Collapse
Affiliation(s)
- Richard Makurumidze
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
- * E-mail:
| | | | - Tom Decroo
- Institute of Tropical Medicine, Antwerp, Belgium
- Research Foundation of Flanders, Brussels, Belgiums
| | | | - Madelon de Rooij
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Ngwarai Sithole
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | - Kudakwashe C. Takarinda
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Tsitsi Apollo
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | - James Hakim
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Wim Van Damme
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
| | | |
Collapse
|
16
|
Lebelonyane R, Bachanas P, Block L, Ussery F, Abrams W, Roland M, Theu J, Kapanda M, Matambo S, Lockman S, Gaolathe T, Makhema J, Moore J, Jarvis JN. Rapid antiretroviral therapy initiation in the Botswana Combination Prevention Project: a quasi-experimental before and after study. Lancet HIV 2020; 7:e545-e553. [PMID: 32763218 PMCID: PMC10921550 DOI: 10.1016/s2352-3018(20)30187-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ensuring that individuals who are living with HIV rapidly initiate antiretroviral therapy (ART) is an essential step in meeting the 90-90-90 targets. We evaluated the feasibility and outcomes of rapid ART initiation in the Botswana Combination Prevention Project (BCPP). We aimed to establish whether simplified ART initiation with the offer of same-day treatment could increase uptake and reduce time from clinic linkage to treatment initiation, while maintaining rates of retention in care and viral suppression. METHODS We did a quasi-experimental before and after study with use of data from the BCPP. The BCPP was a community-randomised HIV-prevention trial done in 30 communities across Botswana from Oct 1, 2013, to June 30, 2018. Participants in the 15 intervention clusters, who were HIV-positive and not already taking ART were offered universal HIV-treatment and same-day ART with a dolutegravir-based regimen at first clinic visit. This rapid ART intervention was implemented mid-way through the trial on June 1, 2016, enabling us to determine the effect of rapid ART guidelines on time to ART initiation and rates of retention in care and viral suppression at 1 year in the BCPP intervention group. FINDINGS We assessed 1717 adults linked to study clinics before rapid ART introduction and 800 after rapid ART introduction. During the rapid ART period, 457 (57·1%, 95% CI 53·7-60·6) individuals initiated ART within 1 day of linkage, 589 (73·7%, 70·6-76·7) of 799 within 1 week, 678 (84·9%, 82·4-87·3) of 799 within 1 month, and 744 (93·5%, 91·6-95·1) of 796 within 1 year. Before the introduction of rapid ART, 163 (9·5%, 95% CI 8·2-11·0) individuals initiated ART within 1 day of linkage, 276 (16·1%, 14·4-17·9) within 1 week, 839 (48·9%, 46·5-51·3) within 1 month, and 1532 (89·2%, 87·7-90·6) within 1 year. 1 year after ART initiation, 1472 (90·5%, 87·4-92·8) of 1627 individuals who linked in the standard ART period were in care and had a viral load of less than 400 copies per mL, compared with 578 (91·6%, 88·1-94·1) of 631 in the rapid ART period (risk ratio 1·01, 95% CI 0·92-1·11). INTERPRETATION Our findings provide support for the WHO recommendations for rapid ART initiation, and add to the accumulating evidence showing the feasibility, acceptability, and safety of rapid ART initiation in low-income and middle-income country settings. FUNDING US President's Emergency Plan for AIDS Relief.
Collapse
Affiliation(s)
| | - Pamela Bachanas
- Centers for Disease Control and Prevention, Division of Global HIV/AIDS and TB, Atlanta, GA, USA
| | | | - Faith Ussery
- Centers for Disease Control and Prevention, Division of Global HIV/AIDS and TB, Atlanta, GA, USA
| | - William Abrams
- Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Michelle Roland
- Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Joe Theu
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Max Kapanda
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | | | - Shahin Lockman
- Harvard T H Chan School of Public Health, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Tendani Gaolathe
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; University of Botswana School of Medicine, Gaborone, Botswana
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Janet Moore
- Centers for Disease Control and Prevention, Division of Global HIV/AIDS and TB, Atlanta, GA, USA
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| |
Collapse
|
17
|
Dorward J, Sookrajh Y, Gate K, Khubone T, Mtshaka N, Mlisana K, Ngobese H, Yende‐Zuma N, Garrett N. HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study. J Int AIDS Soc 2020; 23:e25479. [PMID: 32319203 PMCID: PMC7174836 DOI: 10.1002/jia2.25479] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/30/2020] [Accepted: 03/05/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The World Health Organisation recommends to Treat All people with HIV, irrespective of CD4 count. However, people with CD4 counts >500 cells/µL may be asymptomatic and therefore less motivated to adhere to antiretroviral therapy (ART). We aimed to assess whether people initiated with CD4 counts >500 cells/µL had worse treatment outcomes compared to those initiated at lower CD4 counts. METHODS We performed a retrospective cohort study among non-pregnant adults initiating ART at eight public clinics in South Africa between September 2016, when Treat All was implemented, and August 2017. We assessed whether initiation CD4 count >500 cells/µL was associated with the outcomes of attrition (death, lost to follow-up or treatment interruption >180 days), and viraemia >1000 copies/mL, by twelve months using Cox proportional hazards and Poisson regression models. RESULTS AND DISCUSSION Among 4952 patients initiating ART, the median age was 32.4 years (interquartile range (IQR) 27.2 to 39.7), 58.9% were women and 30.3% had an initiation CD4 count >500 cells/µL. After twelve months, 3382 (68.3%) were retained in care, 303 (6.1%) had transferred to another clinic, 1010 (20.4%) were lost to follow-up, 232 (4.7%) had a treatment interruption >180 days and 25 (0.5%) were known to have died. Overall, 1267 experienced attrition at a median time of 91 days (IQR 23 to 213), with 302 of these (23.8%) experiencing attrition immediately after their ART initiation visit. Among those in care at twelve months with viral load results, 4.6% had viraemia. In multivariable analysis, the hazard of attrition was similar between patients newly eligible for ART with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted hazard ratio 1.03, 95% confidence interval (CI) 0.90 to 1.17). The risk of viraemia was lower among patients with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted risk ratio 0.58, 95% CI 0.37 to 0.92). CONCLUSIONS After implementation of Treat All in South African public clinics, we found that patients newly eligible for ART with initiation CD4 counts >500 cells/µL had comparable or better outcomes compared to those with lower CD4 counts. These finding support ongoing implementation of Treat All in our setting.
Collapse
Affiliation(s)
- Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUnited Kingdom
| | - Yukteshwar Sookrajh
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Kelly Gate
- Bethesda HospitalUbomboSouth Africa
- Department of Family MedicineUniversity of KwaZulu‐NatalDurbanSouth Africa
| | - Thokozani Khubone
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Nomsa Mtshaka
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Koleka Mlisana
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- National Health Laboratory ServiceJohannesburgSouth Africa
- School of Laboratory Medicine and Medical SciencesUniversity of KwaZulu‐NatalDurbanSouth Africa
| | - Hope Ngobese
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Nonhlanhla Yende‐Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- Discipline of Public Health MedicineSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalDurbanSouth Africa
| |
Collapse
|
18
|
Tymejczyk O, Brazier E, Yiannoutsos CT, Vinikoor M, van Lettow M, Nalugoda F, Urassa M, Sinayobye JD, Rebeiro PF, Wools-Kaloustian K, Davies MA, Zaniewski E, Anderegg N, Liu G, Ford N, Nash D. Changes in rapid HIV treatment initiation after national "treat all" policy adoption in 6 sub-Saharan African countries: Regression discontinuity analysis. PLoS Med 2019; 16:e1002822. [PMID: 31181056 PMCID: PMC6557472 DOI: 10.1371/journal.pmed.1002822] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 05/10/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Most countries have formally adopted the World Health Organization's 2015 recommendation of universal HIV treatment ("treat all"). However, there are few rigorous assessments of the real-world impact of treat all policies on antiretroviral treatment (ART) uptake across different contexts. METHODS AND FINDINGS We used longitudinal data for 814,603 patients enrolling in HIV care between 1 January 2004 and 10 July 2018 in 6 countries participating in the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium: Burundi (N = 11,176), Kenya (N = 179,941), Malawi (N = 84,558), Rwanda (N = 17,396), Uganda (N = 96,286), and Zambia (N = 425,246). Using a quasi-experimental regression discontinuity design, we assessed the change in the proportion initiating ART within 30 days of enrollment in HIV care (rapid ART initiation) after country-level adoption of the treat all policy. A modified Poisson model was used to identify factors associated with failure to initiate ART rapidly under treat all. In each of the 6 countries, over 60% of included patients were female, and median age at enrollment ranged from 32 to 36 years. In all countries studied, national adoption of treat all was associated with large increases in rapid ART initiation. Significant increases in rapid ART initiation immediately after treat all policy adoption were observed in Rwanda, from 44.4% to 78.9% of patients (34.5 percentage points [pp], 95% CI 27.2 to 41.7; p < 0.001), Kenya (25.7 pp, 95% CI 21.8 to 29.5; p < 0.001), Burundi (17.7 pp, 95% CI 6.5 to 28.9; p = 0.002), and Malawi (12.5 pp, 95% CI 7.5 to 17.5; p < 0.001), while no immediate increase was observed in Zambia (0.4 pp, 95% CI -2.9 to 3.8; p = 0.804) and Uganda (-4.2 pp, 95% CI -9.0 to 0.7; p = 0.090). The rate of rapid ART initiation accelerated sharply following treat all policy adoption in Malawi, Uganda, and Zambia; slowed in Kenya; and did not change in Rwanda and Burundi. In post hoc analyses restricted to patients enrolling under treat all, young adults (16-24 years) and men were at increased risk of not rapidly initiating ART (compared to older patients and women, respectively). However, rapid ART initiation following enrollment increased for all groups as more time elapsed since treat all policy adoption. Study limitations include incomplete data on potential ART eligibility criteria, such as clinical status, pregnancy, and enrollment CD4 count, which precluded the assessment of rapid ART initiation specifically among patients known to be eligible for ART before treat all. CONCLUSIONS Our analysis indicates that adoption of treat all policies had a strong effect on increasing rates of rapid ART initiation, and that these increases followed different trajectories across the 6 countries. Young adults and men still require additional attention to further improve rapid ART initiation.
Collapse
Affiliation(s)
- Olga Tymejczyk
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
- * E-mail: (OT); (DN)
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Constantin T. Yiannoutsos
- Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | - Michael Vinikoor
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Medicine, University of Alabama, Birmingham, Alabama, United States of America
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Fred Nalugoda
- Rakai Health Sciences Program, Kalisizo and Entebbe, Uganda
| | - Mark Urassa
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | | | - Peter F. Rebeiro
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elizabeth Zaniewski
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Grace Liu
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Nathan Ford
- Global Hepatitis Programme, HIV/AIDS Department, World Health Organization, Geneva, Switzerland
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
- * E-mail: (OT); (DN)
| | | |
Collapse
|