Impact of Universal Antiretroviral Treatment Eligibility on Rapid Treatment Initiation Among Young Adolescents with Human Immunodeficiency Virus in Sub-Saharan Africa

The impact of same-day and rapid ART initiation under the Universal Health Coverage programme on HIV outcomes in Thailand: a retrospective real-life cohort study

INTRODUCTION

Antiretroviral therapy (ART) initiation, regardless of CD4 count, has been recommended in Thailand since 2014, with same-day initiation recommended since 2021. We assessed HIV treatment outcomes among Thai people living with HIV (PLHIV) by the time from HIV diagnosis to ART initiation under the Universal Health Coverage (UHC) programme and identified factors associated with virological failure (VF).

METHODS

PLHIV aged ≥15 years initiating ART between 2014 and 2022 were included from the UHC database. We categorized participants into four groups using the duration from HIV diagnosis to ART initiation: (1) ≤ 7 days (same-day ART); (2) 8 days to <1 month; (3) 1-3 months; and (4) >3 months. Viral load (VL) was measured 6 months after starting ART, and annually thereafter. VF was defined as VL ≥1000 copies/ml. Factors associated with VF were analysed using competing risk models considering death and loss to follow-up (LTFU) as competing events.

RESULTS

Among 252,239 PLHIV who started ART, the median age at initiation was 34 years (interquartile range [IQR]: 26-43 years). The median (IQR) pre-ART CD4 count was 233 (76-420) cells/mm3. ART initiation occurred within 7 days for 25% (17% on the same day, 8% in 2-7 days), 24% in 8 days to <1 month, 23% in 1-3 months and 28% in >3 months. ART initiation within 7 days increased from 20% (2014-2016) to 32% (2021-2022). VF occurred with a rate of 3.11 (95% CI 3.07-3.159) per 100 person-years (PYs). PLHIV initiating ART 8 days to 1 month were at lower risk of VF (aSHR 0.52, 95% CI 0.50-0.54) when compared to ART initiation >3 months. ART initiation within 7 days resulted in the lowest mortality (6%: 1.28 [95% CI 1.24-1.32] per 100 PYs), but the highest rate of LTFU (12%: 2.69 [95% CI 2.63-2.75] per 100 PYs) when compared to other ART initiation groups.

CONCLUSIONS

Although ART initiation within 7 days has increased in Thailand, the overall rate of early initiation remains low. ART initiation within 1 month significantly lowered the risk of VF. ART initiation within 7 days significantly reduced mortality. To further optimize health outcomes, innovative strategies are urgently needed to promote earlier ART initiation in Thailand.

Long-term HIV care outcomes under universal HIV treatment guidelines: A retrospective cohort study in 25 countries

BACKGROUND

While national adoption of universal HIV treatment guidelines has led to improved, timely uptake of antiretroviral therapy (ART), longer-term care outcomes are understudied. There is little data from real-world service delivery settings on patient attrition, viral load (VL) monitoring, and viral suppression (VS) at 24 and 36 months after HIV treatment initiation.

METHODS AND FINDINGS

For this retrospective cohort analysis, we used observational data from 25 countries in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium's Asia-Pacific, Central Africa, East Africa, Central/South America, and North America regions for patients who were ART naïve and aged ≥15 years at care enrollment between 24 months before and 12 months after national adoption of universal treatment guidelines, occurring 2012 to 2018. We estimated crude cumulative incidence of loss-to-clinic (CI-LTC) at 12, 24, and 36 months after enrollment among patients enrolling in care before and after guideline adoption using competing risks regression. Guideline change-associated hazard ratios of LTC at each time point after enrollment were estimated via cause-specific Cox proportional hazards regression models. Modified Poisson regression was used to estimate relative risks of retention, VL monitoring, and VS at 12, 24, and 36 months after ART initiation. There were 66,963 patients enrolling in HIV care at 109 clinics with ≥12 months of follow-up time after enrollment (46,484 [69.4%] enrolling before guideline adoption and 20,479 [30.6%] enrolling afterwards). More than half (54.9%) were females, and median age was 34 years (interquartile range [IQR]: 27 to 43). Mean follow-up time was 51 months (standard deviation: 17 months; range: 12, 110 months). Among patients enrolling before guideline adoption, crude CI-LTC was 23.8% (95% confidence interval [95% CI] 23.4, 24.2) at 12 months, 31.0% (95% CI [30.6, 31.5]) at 24 months, and 37.2% (95% [CI 36.8, 37.7]) at 36 months after enrollment. Adjusting for sex, age group, enrollment CD4, clinic location and type, and country income level, enrolling in care and initiating ART after guideline adoption was associated with increased hazard of LTC at 12 months (adjusted hazard ratio [aHR] 1.25 [95% CI 1.08, 1.44]; p = 0.003); 24 months (aHR 1.38 [95% CI 1.19, 1.59]; p < .001); and 36 months (aHR 1.34 [95% CI 1.18, 1.53], p < .001) compared with enrollment before guideline adoption, with no before-after differences among patients with no record of ART initiation by end of follow-up. Among patients retained after ART initiation, VL monitoring was low, with marginal improvements associated with guideline adoption only at 12 months after ART initiation. Among those with VL monitoring, VS was high at each time point among patients enrolling before guideline adoption (86.0% to 88.8%) and afterwards (86.2% to 90.3%), with no substantive difference associated with guideline adoption. Study limitations include lags in and potential underascertainment of care outcomes in real-world service delivery data and potential lack of generalizability beyond IeDEA sites and regions included in this analysis.

CONCLUSIONS

In this study, adoption of universal HIV treatment guidelines was associated with lower retention after ART initiation out to 36 months of follow-up, with little change in VL monitoring or VS among retained patients. Monitoring long-term HIV care outcomes remains critical to identify and address causes of attrition and gaps in HIV care quality.

Long-term outcomes of rapid antiretroviral NNRTI-based initiation among Thai youth living with HIV: a national registry database study

INTRODUCTION

The Thai National AIDS programme (NAP) treatment guidelines have recommended rapid antiretroviral therapy (ART) initiation, regardless of CD4 count since 2014. We assessed treatment outcomes among youth living with HIV (YLHIV), initiating first-line ART and assessed the association between virological failure (VF) and timing of ART initiation.

METHODS

We retrospectively reviewed data for YLHIV aged 15-24 years, initiating non-nucleoside reverse transcriptase inhibitor-based ART from 2014 to 2019, through the NAP database. We classified the timing of ART into three groups based on duration from HIV-positive diagnosis or system registration to ART initiation: (1) <1 month (rapid ART); (2) 1-3 months (intermediate ART); and (3) >3 months (delayed ART). VF was defined as viral load (VL) ≥ 1000 copies/ml after at least 6 months of first-line ART. Factors associated with VF were analysed using generalized estimating equations.

RESULTS

Of 19,825 YLHIV who started ART, 78% were male. Median (interquartile range, IQR) age was 21 (20-23) years and CD4 count was 338 (187-498) cells/mm³ . After registration, 12,216 (62%) started rapid ART, 4272 (22%) intermediate ART and 3337 (17%) delayed ART. The proportion of YLHIV starting ART <30 days significantly increased from 43% to 57% from 2014-2016 to 2017-2019 (p < 0.001). The median duration of first-line therapy was 2 (IQR 1-3) years and 89% started with efavirenz-based regimens. Attrition outcomes showed that 325 (2%) died (0.73 [95% CI 0.65-0.81] per 100 person-years [PY]) and 1762 (9%) were loss to follow-up (3.96 [95% CI 3.78-4.15] per 100 PY). Of 17,512 (88%) who had VL checked from 6 to 12 months after starting treatment, 80% achieved VL <200 copies/ml. Overall, 2512 experienced VF 5.87 (95% CI 5.65-6.11) per 100 PY). In a multivariate model, the adjusted incidence rate ratio for VF was 1.47 (95% CI 1.33-1.63, p < 0.001) in the delayed ART group and 1.14 (95% CI 1.03-1.25, p< 0.001) in the intermediate ART group, compared to YLHIV in the rapid ART group.

CONCLUSIONS

Rapid ART initiation after diagnosis was associated with significantly reduced risks of VF and death in YLHIV, supporting the implementation of rapid ART for optimizing health outcomes.

The IeDEA harmonist data toolkit: A data quality and data sharing solution for a global HIV research consortium

We describe the design, implementation, and impact of a data harmonization, data quality checking, and dynamic report generation application in an international observational HIV research network. The IeDEA Harmonist Data Toolkit is a web-based application written in the open source programming language R, employs the R/Shiny and RMarkdown packages, and leverages the REDCap data collection platform for data model definition and user authentication. The Toolkit performs data quality checks on uploaded datasets, checks for conformance with the network's common data model, displays the results both interactively and in downloadable reports, and stores approved datasets in secure cloud storage for retrieval by the requesting investigator. Including stakeholders and users in the design process was key to the successful adoption of the application. A survey of regional data managers as well as initial usage metrics indicate that the Toolkit saves time and results in improved data quality, with a 61% mean reduction in the number of error records in a dataset. The generalized application design allows the Toolkit to be easily adapted to other research networks.

Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African countries

OBJECTIVE

To determine whether Treat-All policy impacted laboratory testing practices of antiretroviral therapy (ART) programs in Southern Africa.

STUDY DESIGN AND SETTING

We used HIV cohort data from Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in a regression discontinuity design to estimate changes in pre-ART CD4 testing and viral load monitoring following national Treat-all adoption that occurred during 2016 to 2017. This study included more than 230,000 ART-naïve people living with HIV (PLHIV) aged five years or older who started ART within two years of national Treat-All adoption.

RESULTS

We found pre-ART CD4 testing decreased following adoption of Treat-All recommendations in Malawi (-21.4 percentage points (pp), 95% confidence interval, CI: -26.8, -16.0) and in Mozambique (-8.8pp, 95% CI: -14.9, -2.8), but increased in Zambia (+2.7pp, 95% CI: +0.4, +5.1). Treat-All policy had no effect on viral load monitoring, except among females in South Africa (+7.1pp, 95% CI: +1.1, +13.0).

CONCLUSION

Treat-All policy expanded ART eligibility, but led to reductions in pre-ART CD4 testing in some countries that may weaken advanced HIV disease management. Continued and expanded support of CD4 and viral load laboratory capacity is needed to further improve treatment successes and allow for uniform evaluation of ART implementation across Southern Africa.

Timeliness of antiretroviral therapy initiation in the era before universal treatment

We assessed the prevalence and factors related to the time to antiretroviral (ART) initiation among persons who entered HIV care and subsequently started ART in Croatia from 2005 to 2014. Included were patients ≥ 18 years, the follow-up ended on Dec/31/2017. 628 patients were included into the study 91.9% were men; median age was 36.1 (Q1-Q3: 29.6-43.8) years. Rapid (within 7 days of diagnosis) ART initiation was observed in 21.8% patients, 49.8% initiated ART within 30 days, 21.7% and 28.5% had intermediate (31 days-1 year) and late initiation (> 1 year), respectively. Of 608 patients that achieved an undetectable viral load, 94% had a plasma HIV-1 RNA < 50 copies/ml at last measurement after a median follow-up of 5.2 years. On quantile regression analysis, calendar year of entry into care, and markers of more advanced HIV disease (higher viral load, lower CD4 cell count and clinical AIDS) were significantly associated with earlier ART initiation. Early ART was not related to a gap in care afterwards at all quantiles. In conclusion, a significant proportion of patients started ART early in Croatia in 2005-2014. Early ART initiation led to durable viral load suppression and was not associated with a subsequent gap 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.