HIV programmatic outcomes following implementation of the 'Treat-All' policy in a public sector setting in Eswatini: a prospective cohort study

"It is still very little; I cannot pass it on": a qualitative study of experiences of diagnosis and treatment of acute HIV infection in Eswatini

Acute and early HIV infection (AEHI) is rarely diagnosed in sub-Saharan Africa, despite its potential contribution to incidence reduction. This qualitative study in Eswatini explored the experiences of health workers, people diagnosed with AEHI, and their partners towards AEHI diagnosis, to inform its scale-up. In-depth interviews were undertaken with 11 women and four men diagnosed with AEHI. Three patients' partners were interviewed about their understanding of AEHI and six health workers were interviewed about experiences of delivering AEHI services. Data were coded inductively and analysed iteratively following the principles of grounded theory. Experiences with AEHI diagnoses were shaped by (i) understanding the nature and consequences of AEHI, and (ii) social norms that influence disclosure and sexual behaviour. AEHI was a new concept for health workers who struggled to explain it to patients, leading to some confusion over their HIV status and misunderstandings around its high transmissibility and prognosis. Disclosure tended to occur to primary partners, if at all, limiting the ability to provide partner services, and one relationship breakdown was reported. If AEHI diagnosis and care interventions are to realise their full potential, it will be essential to reinforce the accompanying counselling sessions and closely monitor for potential social harms.

An assessment on the implementation of same day antiretroviral therapy initiation in eThekwini clinics, KwaZulu-Natal, South Africa

The World Health Organization (WHO) recommends same-day initiation (SDI) of antiretroviral therapy (ART) for all individuals diagnosed with HIV irrespective of CD4+ count or clinical stage. Implementation of program is still far from reaching its goals. This study assessed the level of implementation of same day ART initiation. A longitudinal study was conducted at four primary healthcare clinics in eThekwini municipality KwaZulu-Natal. Data was collected between June 2020 to October 2020 using a data extraction form. Data on individuals tested HIV positive, number of SDI of ART; and clinicians working on UTT program were compiled from clinic registers, and Three Interlinked Electronic Registers.Net (TIER.Net). Non-governmental organisations (NGO) supporting the facility and services information was collected. Among the 403 individuals who tested HIV positive, 279 (69.2%) were initiated on ART on the same day of HIV diagnosis from the four facilities. There was a significant association between health facility and number of HIV positive individuals initiated on SDI (chi-square=10.59; P-value=0.008). There was a significant association between facilities with support from all NGOs and ART SDI (chi-square=10.18; P-value=0.015. There was a significant association between staff provision in a facility and SDI (chi-square=7.51; P-value=0.006). Urban areas clinics were more likely to have high uptake of SDI compared to rural clinics (chi-square=11,29; P-value=0.003). Implementation of the Universal Test and Treat program varies by facility indicating the need for the government to monitor and standardize implementation of the policy if the program is to yield success.

Universal test and treat in Cameroon: a comparative retrospective analysis of mortality and loss to follow-up before and after a strategic change in approach to HIV care

Introduction

an increasing number of persons living with HIV (PLHIV) are accessing antiretroviral therapy (ART) since the adoption of the universal test and treat (UTT) policy by Cameroon in 2016. We sought to evaluate the effectiveness of the UTT approach to keep this growing number of PLHIV on a lifelong treatment.

Methods

a retrospective cohort analysis was conducted at the Nkongsamba Regional Hospital between 2002 and 2020, using routine data to compare the cumulative incidence of loss to follow-up (LTFU) and mortality between PLHIV initiated on ART under UTT guidelines and those initiated under the standard deferred approach. Chi-squared test was used to compare the risk of attrition between the guideline periods while multiple logistic regression modelling was used to adjust for confounders.

Results

of 1627 PLHIV included for analysis, 756 (46.47%) were enrolled during the era of UTT with 545 (33.54%) initiated on ART on the same day of HIV diagnosis. The transition to the UTT era was associated with an overall reduction in the risk of LTFU by 73% (aOR = 0.27, 95%CI: 0.17 - 0.45). There was modest evidence that the odds of mortality had increased under the UTT policy by about 3-fold (aOR = 2.86, 95%CI: 0.91-8.94). Same-day initiation had no overall effect on LTFU or mortality. LTFU was lower among the same-day initiators in the first 24 months but increased thereafter above the rate among late initiators.

Conclusion

overall ART programme implementation under the UTT has led to a significant decline in LTFU though mortality appeared to have increased. Ongoing efforts to keep patients on long-term treatment should be sustained while other innovative schemes are sought.

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

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 .

Persistent High Burden and Mortality Associated With Advanced HIV Disease in Rural Tanzania Despite Uptake of World Health Organization "Test and Treat" Guidelines

BACKGROUND

Information about burden, characteristics, predictors, and outcomes of advanced human immunodeficiency virus disease (AHD) is scarce in rural settings of sub-Saharan Africa. Human immunodeficiency virus (HIV) infections and associated deaths remain high despite specific guidelines issued by the World Health Organization (WHO).

METHODS

Burden of AHD and 6-month death/loss to follow-up (LTFU) were described among 2498 antiretroviral therapy (ART)-naive nonpregnant people with HIV (PWH) aged >15 years enrolled in the Kilombero Ulanga Antiretroviral Cohort in rural Tanzania between 2013 and 2019. Baseline characteristics associated with AHD and predictors of death/LTFU among those with AHD were analyzed using multivariate logistic and Cox regression, respectively.

RESULTS

Of the PWH, 62.2% had AHD at diagnosis (66.8% before vs 55.7% after national uptake of WHO "test and treat" guidelines in 2016). At baseline, older age, male sex, lower body mass index, elevated aminotransferase aspartate levels, severe anemia, tachycardia, decreased glomerular filtration rate, clinical complaints, impaired functional status, and enrollment into care before 2018 were independently associated with AHD. Among people with AHD, incidence of mortality, and LTFU were 16 and 34 per 100 person-years, respectively. WHO clinical stage 3 or 4, CD4 counts <100 cells/µL, severe anemia, tachypnea, and liver disease were associated with death/LTFU.

CONCLUSIONS

More than 50% of PWH enrolled in our cohort after test and treat implementation still had AHD at diagnosis. Increasing HIV testing and uptake and implementation of the WHO-specific guidelines on AHD for prevention, diagnosis, treatment of opportunistic infections, and reducing the risks of LTFU are urgently needed to reduce morbidity and mortality.

Virological outcomes and risk factors for non-suppression for routine and repeat viral load testing after enhanced adherence counselling during viral load testing scale-up in Zimbabwe: analytic cross-sectional study using laboratory data from 2014 to 2018

BACKGROUND

Since the scale-up of routine viral load (VL) testing started in 2016, there is limited evidence on VL suppression rates under programmatic settings and groups at risk of non-suppression. We conducted a study to estimate VL non-suppression (> 1000 copies/ml) and its risk factors using "routine" and "repeat after enhanced adherence counselling (EAC)" VL results.

METHODS

We conducted an analytic cross-sectional study using secondary VL testing data collected between 2014 and 2018 from a centrally located laboratory. We analysed data from routine tests and repeat tests after an individual received EAC. Our outcome was viral load non-suppression. Bivariable and multivariable logistic regression was performed to identify factors associated with having VL non-suppression for routine and repeat VL.

RESULTS

We analysed 103,609 VL test results (101,725 routine and 1884 repeat test results) collected from the country's ten provinces. Of the 101,725 routine and 1884 repeat VL tests, 13.8% and 52.9% were non-suppressed, respectively. Only one in seven (1:7) of the non-suppressed routine VL tests had a repeat test after EAC. For routine VL tests; males (vs females, adjusted odds ratio (aOR) = 1.19, [95% CI 1.14-1.24]) and adolescents (10-19 years) (vs adults (25-49 years), aOR = 3.11, [95% CI 2.9-3.31]) were more at risk of VL non-suppression. The patients who received care at the secondary level (vs primary, aOR = 1.21, [95% CI 1.17-1.26]) and tertiary level (vs primary, aOR = 1.63, [95% CI 1.44-1.85]) had a higher risk of VL non-suppression compared to the primary level. Those that started ART in 2014-2015 (vs < 2010, aOR = 0.83, [95% CI 0.79-0.88]) and from 2016 onwards (vs < 2010, aOR = 0.84, [95% CI 0.79-0.89]) had a lower risk of VL non-suppression. For repeat VL tests; young adults (20-24 years) (vs adults (25-49 years), (aOR) = 3.48, [95% CI 2.16 -5.83]), adolescents (10-19 years) (vs adults (25-49 years), aOR = 2.76, [95% CI 2.11-3.72]) and children (0-9 years) (vs adults (25-49 years), aOR = 1.51, [95% CI 1.03-2.22]) were at risk of VL non-suppression.

CONCLUSION

Close to 90% suppression in routine VL shows that Zimbabwe is on track to reach the third UNAIDS target. Strategies to improve the identification of clients with high routine VL results for repeating testing after EAC and ART adherence in subpopulations (men, adolescents and young adolescents) at risk of viral non-suppression should be prioritised.

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

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.

Same-day antiretroviral therapy initiation for people living with HIV who have tuberculosis symptoms: a systematic review

OBJECTIVES

Tuberculosis symptoms are very common among people living with HIV (PLHIV) initiating antiretroviral therapy (ART), are not specific for tuberculosis disease and may result in delayed ART start. The risks and benefits of same-day ART initiation in PLHIV with tuberculosis symptoms are unknown.

METHODS

We systematically reviewed nine databases on 12 March 2020 to identify studies that investigated same-day ART initiation among PLHIV with tuberculosis symptoms and reported both their approach to TB screening and clinical outcomes. We extracted and summarized data about TB screening, numbers of people starting same-day ART and outcomes.

RESULTS

We included four studies. Two studies deferred ART for everyone with any tuberculosis symptoms (one or more of cough, fever, night sweats or weight loss) and substantial numbers of people had deferred ART start (28% and 39% did not start same-day ART). Two studies permitted some people with tuberculosis symptoms to start same-day ART, and fewer people deferred ART (2% and 16% did not start same-day). Two of the four studies were conducted sequentially; proven viral load suppression at 8 months was 31% when everyone with tuberculosis symptoms had ART deferred, and 44% when the algorithm was changed so that some people with tuberculosis symptoms could start same-day ART.

CONCLUSIONS

Although tuberculosis symptoms are very common in people starting ART, there is insufficient evidence about whether presence of tuberculosis symptoms should lead to ART start being deferred or not. Research to inform clear guidelines would help to maximise the benefits of same-day ART.

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

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.

Attrition and Its Predictors Among Adults Receiving First-Line Antiretroviral Therapy in Woldia Town Public Health Facilities, Northeast Ethiopia: A Retrospective Cohort Study

Introduction

There is an expansion and advancement of antiretroviral therapy. However, attrition of patients from HIV care is one of the major drivers of poor performance of HIV/AIDS programs, which leads to drug resistance, morbidity and mortality. The study aimed to assess the incidence of attrition and its predictors among adults receiving first-line antiretroviral therapy.

Methods

An institution-based retrospective cohort study was conducted among 634 adults receiving antiretroviral therapy, and study participants were selected using a simple random sampling technique. Data were cleaned and entered into Epi Data version 3.1 and exported to STATA 14.1 for further analysis. The predictors of attrition were identified using bivariable and multivariable Cox Proportional hazard models; then, variables at a p-value of less than 0.25 and 0.05 were included in the multivariable analysis and statistically significant, respectively.

Results

The total time observed was found to be 1807.08 person-years of observation with a median follow-up time of 2.67 years (IQR 1.25−4.67). The incidence rate of attrition was 8.36 (95% CI: 7.12−9.80) per 100 person-years. Significant predictors of attrition were being young age [adjusted hazard ratio (AHR) =2.0, 95% CI, (1.11−3.58)], nearest calendar year of ART initiation [AHR =2.32, 95% CI, (1.08–5.01)], bedridden functional status [AHR=3.25, 95% CI, (1.33−7.96)], WHO stage III [AHR=3.57, 95% CI, (1.58−8.06)] and stage IV [AHR=5.46, 95% CI, (1.97−15.13)], viral load result of ≤1000 [AHR=0.11, 95% CI, (0.06−0.23)], disclosure status [AHR=2.03, 95% CI, (1.22−3.37)] and adherence level of poor [AHR=3.19, 95 CI, (1.67−6.09)].

Conclusion

The result of this study showed that the incidence of attrition among adults receiving antiretroviral therapy was high. However, as a standard, every client who started antiretroviral therapy should be retained. Positive predictors of attrition were young age (15–24), recent year of ART initiation, baseline functional status, advanced WHO stage III and IV, no disclosure status, fair/poor adherence whereas, viral load result of ≤1000 copies/mL had a preventive effect on attrition.

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

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.

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

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.

HIV programmatic outcomes following implementation of the 'Treat-All' policy in a public sector setting in Eswatini: a prospective cohort study

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.