Changes in rapid HIV treatment initiation after national "treat all" policy adoption in 6 sub-Saharan African countries: Regression discontinuity analysis

Modeling the HIV Cascade of Care Using Routinely Collected Clinical Data to Guide Programmatic Interventions and Policy Decisions

BACKGROUND

The HIV care cascade is a framework to examine effectiveness of HIV programs and progress toward global targets to end the epidemic but has been conceptualized as a unidirectional process that ignores cyclical care patterns. We present a dynamic cascade that accounts for patient "churn" and apply novel analytic techniques to readily available clinical data to robustly estimate program outcomes and efficiently assess progress toward global targets.

METHODS

Data were assessed for 35,649 people living with HIV and receiving care at 78 clinics in East Africa between 2014 and 2020. Patients were aged ≥15 years and had ≥1 viral load measurements. We used multi-state models to estimate the probability of being in 1 of 5 states of a dynamic HIV cascade: (1) in HIV care but not on antiretroviral therapy (ART), (2) on ART, (3) virally suppressed, (4) in a gap-in-care, and (5) deceased and compared these among subgroups. To assess progress toward global targets, we summed those probabilities across patients and generated population-level proportions of patients on ART and virally suppressed in mid-2020.

RESULTS

One year after enrollment, 2.8% of patients had not initiated ART, 86.7% were receiving ART, 57.4% were virally suppressed, 10.2% were disengaged from care, and 0.3% had died. At 5 years, the proportion on ART remained steady but viral suppression increased to 77.2%. Of those aged 15-25, >20% had disengaged from care and <60% were virally suppressed. In mid-2020, 90.1% of the cohort was on ART, 90.7% of whom had suppressed virus.

CONCLUSIONS

Novel analytic approaches can characterize patient movement through a dynamic HIV cascade and, importantly, by capitalizing on readily available data from clinical cohorts, offer an efficient approach to estimate population-level proportions of patients on ART and virally suppressed. Significant progress toward global targets was observed in our cohort but challenges remain among younger patients.

HIV-1 subtype-specific drug resistance on dolutegravir-based antiretroviral therapy: protocol for a multicentre longitudinal study (DTG RESIST)

Introduction

HIV drug resistance poses a challenge to the United Nation's goal of ending the HIV/AIDS epidemic. The integrase strand transfer inhibitor (InSTI) dolutegravir, which has a higher resistance barrier, was endorsed by the World Health Organization in 2019 for first-, second-, and third-line antiretroviral therapy (ART). This multiplicity of roles of dolutegravir in ART may facilitate the emergence of dolutegravir resistance.

Methods and analysis

DTG RESIST is a multicentre longitudinal study of adults and adolescents living with HIV in sub-Saharan Africa, Asia, and South and Central America who experienced virologic failure on dolutegravir-based ART. At the time of virologic failure whole blood will be collected and processed to prepare plasma or dried blood spots. Laboratories in Durban, Mexico City and Bangkok will perform genotyping. Analyses will focus on (i) individuals who experienced virologic failure on dolutegravir, and (ii) on those who started or switched to such a regimen and were at risk of virologic failure. For population (i), the outcome will be any InSTI drug resistance mutations, and for population (ii) virologic failure defined as a viral load >1000 copies/mL. Phenotypic testing will focus on non-B subtype viruses with major InSTI resistance mutations. Bayesian evolutionary models will explore and predict treatment failure genotypes. The study will have intermediate statistical power to detect differences in resistance mutation prevalence between major HIV-1 subtypes; ample power to identify risk factors for virologic failure and limited power for analysing factors associated with individual InSTI drug resistance mutations.

Ethics and dissemination

The research protocol was approved by the Biomedical Research Ethics Committee at the University of KwaZulu-Natal, South Africa, and the Ethics Committee of the Canton of Bern, Switzerland. All sites participate in IeDEA and have obtained ethics approval from their local ethics committee to conduct the additional data collection.

Registration

NCT06285110.

Strengths and limitations of this study

- DTG RESIST is a large international study to prospectively examine emergent dolutegravir resistance in diverse settings characterised by different HIV-1 subtypes, provision of ART, and guidelines on resistance testing. - Embedded within the International epidemiology Databases to Evaluate AIDS (IeDEA), DTG RESIST will benefit from harmonized clinical data across participating sites and expertise in clinical, epidemiological, biological, and computational fields. - Procedures for sequencing and assembling genomes from different HIV-1 strains will be developed at the heart of the HIV epidemic, by the KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), in Durban, South Africa. Phenotypic testing, Genome Wide Association Study (GWAS) methods and Bayesian evolutionary models will explore and predict treatment failure genotypes. - A significant limitation is the absence of genotypic resistance data from participants before they started dolutegravir treatment, as collecting and bio-banking pre-treatment samples was not feasible at most IeDEA sites. Consistent and harmonized data on adherence to treatment are also lacking. - The distribution of HIV-1 subtypes across different sites is uncertain, which may limit the statistical power of the study in analysing patterns and risk factors for dolutegravir resistance. The results from GWAS and Bayesian modelling analyses will be preliminary and hypothesis-generating.

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.

The effect of the Universal Test and Treat policy uptake on CD4 count testing and incidence of opportunistic infections among people living with HIV infection in Cameroon: a retrospective analysis of routine data

Background

Cameroon adopted and started implementing in 2016, the 'universal test and treat' (UTT) guidelines to fast-track progress towards the 95-95-95 ambitious targets to end the HIV epidemic. UTT has shown inconsistent results elsewhere and has not yet been assessed in Cameroon. We aimed to evaluate the effectiveness of this novel approach on the quality of care and health outcomes of people living with HIV (PLHIV).

Methods

A retrospective cohort design was conducted at The Nkongsamba Regional Hospital, using routine clinical service delivery data to measure uptake levels of UTT and CD4 testing, and to compare the incidence of opportunistic infections (OI) between PLHIV initiated on ART based on the "Universal Test and Treat" strategy and those initiated on ART based on the standard deferred approach between 2002 and 2020. Kaplan Meier plots and log-rank tests were used to compare OI events between the pre-UTT and post-UTT eras. The Cox regression model was used to screen for factors independently associated with the risk of acquisition of OI.

Results

The uptake of UTT ranged from 39.1% to 92.8% while baseline CD4 count testing reduced drastically from 89.4% to 0.4% between 2016 to 2020 respectively. The median delay in ART initiation declined significantly from 21 days (IQR: 9 - 113) in the pre-UTT era to the same day of diagnosis (IQR: 0 - 2) in the UTT era (p < 0.001). The incidence of all OI events reported was over five times higher during the UTT era than in the pre-UTT era [aHR = 5.55 (95% CI: 3.18 - 9.69), p < 0.001].

Conclusion

The UTT policy has been effectively rolled out and has contributed to improved access to rapid and immediate ART initiation, but a higher incidence of OIs was observed with a rollback of baseline CD4 testing. We advocate for a return to routine baseline CD4 measurement to identify PLHIV who should benefit from interventions to prevent OIs for optimal outcomes under the UTT approach.

Prevalence of delayed antiretroviral therapy initiation among people living with HIV: A systematic review and meta-analysis

OBJECTIVE

HIV continues to be a global challenge. Key recommendations for HIV prevention and treatment are presented on rapid antiretroviral therapy (ART) initiation. However, several studies showed a high prevalence of delayed ART initiation. The aim of this systematic review and meta-analysis was to assess the prevalence of delayed ART initiation among HIV-infected patients globally.

METHODS

This review summarised eligible studies conducted between January 2015 and August 2022 on the prevalence of delayed ART initiation in HIV-infected adults (age ≥ 15). Relevant studies were systematic searched through PubMed/Medline, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and Chongqing VIP databases. Random-effects models were used to calculate pooled prevalence estimates. The heterogeneity was evaluated using Cochran's Q test and I2 statistics. Moreover, potential sources of heterogeneity were explored using univariate subgroup analysis.

RESULTS

Data on the prevalence of delayed ART initiation was pooled across 29 studies involving 34,937 participants from 15 countries. The overall pooled prevalence of delayed ART initiation was 36.1% [95% confidence interval (CI), 29.7-42.5%]. In subgroup analysis, the estimated pooled prevalence decreased with age. By sex, the prevalence was higher among male patients (39.3%, 95% CI: 32.2-46.4%) than female (36.5%, 95% CI: 26.9-50.7%). Patients with high CD4 cell count were more likely to delay ART initiation than those with low CD4 cell count (>500cells/mm3: 40.3%; 201-500cells/mm3: 33.4%; and ≤200cells/mm3: 25.3%).

CONCLUSIONS

Our systematic review and meta-analysis identified a high prevalence of delayed ART initiation. The prolonged time interval between diagnosis and treatment is a prevalent and unaddressed problem that should spur initiatives from countries globally. Further research is urgently needed to identify effective strategies for promoting the early ART initiation.

Factors Associated with Late Diagnosis of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) in a University Hospital in Brazil: Challenges to Achieving the 2030 Target

INTRODUCTION

This study aimed to identify factors associated with late diagnosis and clinically monitor newly diagnosed HIV/AIDS patients.

METHOD

Retrospective study, based on secondary data from a specialized unit at the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto of the University of Sao Paulo. Data collection included sociodemographic, behavioral, clinical, and laboratory data of newly diagnosed HIV patients between 2015 and 2019. Data analysis was undertaken using inferential statistical tests.

RESULTS

A total of 314 individuals were newly diagnosed with HIV/AIDS, 86.6% (272) had a late diagnosis and 53.8% (169) were diagnosed very late. Using the adjusted odds ratio, we observed that bisexual and MSM patients were less likely to have a late diagnosis compared to straight patients. Individuals who entered through the emergency department and Outpatient Clinic had a lower chance of having a very late diagnosis compared to those diagnosed in the ward/inpatient unit. Having a higher education and university education were protective factors against having a very late diagnosis of HIV infection compared to elementary school education only. In addition, male patients were more likely to have a very late diagnosis compared to female patients.

CONCLUSIONS

This study evidenced a high prevalence of late and very late diagnoses. Therefore, attention should be directed towards factors related to late and very late presentation.

Epigenetic aging in older people living with HIV in Eswatini: a pilot study of HIV and lifestyle factors and epigenetic aging

Background

People living with HIV (PLHIV) on effective antiretroviral therapy (ART) are living near-normal lives. Although they are less susceptible to AIDS-related complications, they remain highly vulnerable to non-communicable diseases (NCD). In this exploratory study of older PLHIV (OPLHIV) in Eswatini, we investigated whether biological aging (i.e., the difference between epigenetic age and chronological age, termed 'epigenetic age acceleration [EAA]') was associated with HIV-related parameters, and whether lifestyle factors modified these relationships. We calculated EAA focusing on the second-generation epigenetic clocks, PhenoAge and GrimAge, and a pace of aging biomarker (DunedinPACE) among 44 OPLHIV in Eswatini.

Results

Among participants, the PhenoAge clock showed older epigenetic age (68 years old [63, 77]) but a younger GrimAge epigenetic age (median=56 years old [interquartile range=50, 61]) compared to the chronological age (59 years old [54, 66]). Participants diagnosed with HIV at an older age showed slower DunedinPACE (β-coefficient [95% Confidence Interval]; -0.02 [-0.04, -0.01], p=0.002) and longer duration since HIV diagnosis was associated with faster DunedinPACE (0.02 [0.01, 0.04], p=0.002). The average daily dietary intake of fruits and vegetables was associated with faster DunedinPACE (0.12 [0.03, 0.22], p=0.01) and modified the relationship between HIV status variables (number of years living with HIV since diagnosis, age at HIV diagnosis, CD4+ T cell counts) and PhenoAge EAA, and DunedinPACE.

Conclusions

Biological age is accelerated in OPLHIV in Eswatini, with those living with HIV for a longer duration at risk for faster biological aging. Lifestyle factors, especially healthier diets, may attenuate biological aging in OPLHIV. To our knowledge, this is the first study to assess biological aging in Eswatini and one of the few in sub-Saharan Africa.

Experiences of stigma and HIV care engagement in the context of Treat All in Rwanda: a qualitative study

BACKGROUND

'Treat All' policies recommending immediate antiretroviral therapy (ART) soon after HIV diagnosis for all people living with HIV (PLHIV) are now ubiquitous in sub-Saharan Africa. While early ART initiation and retention is effective at curtailing disease progression and transmission, evidence suggests that stigma may act as a barrier to engagement in care. This study sought to understand the relationships between HIV stigma and engagement in care for PLHIV in Rwanda in the context of Treat All.

METHODS

Between September 2018 and March 2019, we conducted semi-structured, qualitative interviews with adult PLHIV receiving care at two health centers in Kigali, Rwanda. We used a grounded theory approach to data analysis to develop conceptual framework describing how stigma influences HIV care engagement in the context of early Treat All policy implementation in Rwanda.

RESULTS

Among 37 participants, 27 (73%) were women and the median age was 31 years. Participants described how care engagement under Treat All, including taking medications and attending appointments, increased their visibility as PLHIV. This served to normalize HIV and use of ART but also led to high levels of anticipated stigma in the health center and community at early stages of treatment. Enacted stigma from family and community members and resultant internalized stigma acted as additional barriers to care engagement. Nonetheless, participants described how psychosocial support from care providers and family members helped them cope with stigma and promoted continued engagement in care.

CONCLUSIONS

Treat All policy in Rwanda has heightened the visibility of HIV at the individual and social levels, which has influenced HIV stigma, normalization, psychosocial support and care engagement in complex ways. Leveraging the individual and community support described by PLHIV to deliver evidence-based, peer or provider-delivered stigma reduction interventions may aid in attaining Treat All goals.

Immediate and long-term outcomes after treat-all among people living with HIV in China: an interrupted time series analysis

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.

Age-varying Associations of Depressive Symptoms and Heavy Episodic Drinking Throughout Adulthood Among People with HIV and Receiving care in Cameroon Within a National "treat all" Policy

Comorbid depression and heavy episodic drinking (HED) may threaten the success of "treat all" policies in sub-Saharan Africa as the population of people with HIV (PWH) ages. We investigated associations between depressive symptoms and heavy episodic drinking (HED) and the extent the relationship differed across ages among PWH receiving HIV care in Cameroon. We conducted a retrospective analysis of 18-60-year-old PWH on antiretroviral therapy in Cameroon from January 2016 to March 2020. Age-varying effect modelling was conducted to assess associations between depressive symptoms and HED across ages and by gender. Prevalence of depression and HED was highest at ages 20 and 25, respectively. After age 25, the magnitude of the association between depressive symptoms and HED was significant and increased until age 30 (aOR: 1.88, 95% CI: 1.48, 2.39), with associations remaining significant until age 55 (aOR: 1.64, 95% CI: 1.17, 2.29). Women had more variability and higher magnitudes of associations between depressive symptoms and HED than men. The interrelationship between depressive symptoms and HED was significant throughout most of adulthood for PWH receiving HIV care in Cameroon. Understanding age and gender trends in these associations can guide integration efforts in HIV care settings.

Effect of the "universal test and treat" policy on the characteristics of persons registering for HIV care and initiating antiretroviral therapy in Uganda

We examined the effect of the Universal Test and Treat (UTT) policy on the characteristics of people living with HIV (PLHIV) at enrolment in HIV care and initiation of antiretroviral therapy (ART) in Uganda using data from 11 nationally representative clinics of The AIDS Support Organisation (TASO). We created two retrospective PLHIV cohorts: pre-UTT (2004-2016), where ART initiation was conditional on CD4 cell count and UTT (2017-2022), where ART was initiated regardless of World Health Organisation (WHO) clinical stage or CD4 cell count. We used a two-sample test of proportions and Wilcoxon rank-sum test to compare proportions and medians, respectively, between the cohorts. A total of 244,693 PLHIV were enrolled at the clinics [pre-UTT, 210,251 (85.9%); UTT, 34,442 (14.1%)]. Compared to the pre-UTT cohort, the UTT cohort had higher proportions of PLHIV that were male (p < 0.001), aged 18-29 years (p < 0.001), aged >69 years, never married (p < 0.001), and educated to primary (p < 0.001) and post-primary (p < 0.001) school level at enrolment in HIV care and ART initiation. Overall, 97.9% of UTT PLHIV initiated ART compared to 45.2% under pre-UTT. The median time from enrolment in HIV care to ART initiation decreased from 301 [interquartile range (IQR): 58-878] pre-UTT to 0 (IQR: 0-0) under UTT. The median CD4 count at ART initiation increased from 254 cells/μL pre-UTT to 482 cells/μL under UTT (p < 0.001). Compared to the pre-UTT cohort, the UTT cohort had higher proportions of PLHIV with a CD4 count >500 cells/μL (47.3% vs. 13.2%, p < 0.001) and WHO stage 1 (31.7% vs. 4.5%, p < 0.001) at ART initiation. Adoption of the UTT policy in Uganda was successful in enrolling previously unreached individuals, such as men and younger and older adults, as well as those with less advanced HIV disease. Future research will investigate the effect of UTT on long-term outcomes such as retention in care, HIV viral suppression, morbidity, and mortality.

Temporal trends in inequalities of the burden of HIV/AIDS across 186 countries and territories

BACKGROUND

The Global Burden of Disease, Injuries, and Risk Factors Study (GBD) has reported that HIV/AIDS continues to take a disproportionate toll on global health. However, the trends in global inequality of HIV/AIDS burden have remained ambiguous over the past two decades. The objectives of our study were to assess the socioeconomic inequalities, and temporal trends of HIV/AIDS across 186 countries and territories from 2000 to 2019.

METHODS

We extracted data from the GBD 2019, and conducted a cross-national time-series analysis. Age-standardized disability-adjusted life-year (DALY) rates were used to measure the global burden of HIV/AIDS. Gross national income (GNI) per capita was used to approximate the national socioeconomic status. Linear regression analysis was conducted to investigate the relationship between age-standardized DALY rates due to HIV/AIDS and GNI per capita. The concentration curve and concentration index (CI) were generated to evaluate the cross-national socioeconomic inequality of HIV/AIDS burden. A joinpoint regression analysis was used to quantify the changes in trends in socioeconomic inequality of HIV/AIDS burden from 2000 to 2019.

RESULTS

A decrease in age-standardized DALY rates for HIV/AIDS occurred in 132 (71%) of 186 countries/territories from 2000 to 2019, of which 52 (39%) countries/territories achieved a decrease in DALYs of more than 50%, and 27 (52%) of the 52 were from sub-Saharan Africa. The concentration curves of the age-standardized DALY rates of HIV/AIDS were above the equality line from 2000 to 2019. The CI rose from - 0.4625 (95% confidence interval - 0.6220 to -0.2629) in 2000 to -0.4122 (95% confidence interval - 0.6008 to -0.2235) in 2019. A four-phase trend of changes in the CIs of age-standardized DALY rates for HIV/AIDS was observed across 2000 to 2019, with an average increase of 0.6% (95% confidence interval 0.4 to 0.8, P < 0.001).

CONCLUSIONS

Globally, the burden of HIV/AIDS has decreased over the past two decades, accompanied by a trend of narrowing cross-country inequalities of HIV/AIDS burden. Moreover, the burden of HIV/AIDS continues to fall primarily in low-income countries.

Association Between Time to Antiretroviral Therapy and Loss to Care Among Newly Diagnosed Rwandan People Living with Human Immunodeficiency Virus

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.

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.

Uptake and effect of universal test-and-treat on twelve months retention and initial virologic suppression in routine HIV program in Kenya

Early combination antiretroviral therapy (cART), as recommended in WHO's universal test-and-treat (UTT) policy, is associated with improved linkage to care, retention, and virologic suppression in controlled studies. We aimed to describe UTT uptake and effect on twelve-month non-retention and initial virologic non-suppression (VnS) among HIV infected adults starting cART in routine HIV program in Kenya. Individual-level HIV service delivery data from 38 health facilities, each representing 38 of the 47 counties in Kenya were analysed. Adults (>15 years) initiating cART between the second-half of 2015 (2015HY2) and the first-half of 2018 (2018HY1) were followed up for twelve months. UTT was defined based on time from an HIV diagnosis to cART initiation and was categorized as same-day, 1-14 days, 15-90 days, and 91+ days. Non-retention was defined as individuals lost-to-follow-up or reported dead by the end of the follow up period. Initial VnS was defined based on the first available viral load test with >400 copies/ml. Hierarchical mixed-effects survival and generalised linear regression models were used to assess the effect of UTT on non-retention and VnS, respectively. Of 8592 individuals analysed, majority (n = 5864 [68.2%]) were female. Same-day HIV diagnosis and cART initiation increased from 15.3% (2015HY2) to 52.2% (2018HY1). The overall non-retention rate was 2.8 (95% CI: 2.6-2.9) per 100 person-months. When compared to individuals initiated cART 91+ days after a HIV diagnosis, those initiated cART on the same day of a HIV diagnosis had the highest rate of non-retention (same-day vs. 91+ days; aHR, 1.7 [95% CI: 1.5-2.0], p<0.001). Of those included in the analysis, 5986 (69.6%) had a first viral load test done at a median of 6.3 (IQR, 5.6-7.6) months after cART initiation. Of these, 835 (13.9%) had VnS. There was no association between UTT and VnS (same-day vs. 91+ days; aRR, 1.0 [95% CI: 0.9-1.2], p = 0.664). Our findings demonstrate substantial uptake of the UTT policy but poor twelve-month retention and lack of an association with initial VnS from routine HIV settings in Kenya. These findings warrant consideration for multi-pronged program interventions alongside UTT policy for maximum intended benefits in Kenya.

Adherence to option B+ and its association with disclosure status and counseling among HIV-positive pregnant and lactating women in Ethiopia: systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to assess the pooled estimate of option B+ level of adherence and its association with disclosure status and counseling among pregnant and lactation women in Ethiopia after option B+ implementation.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We searched Web of Science, MEDLINE, PUBMED, Scopus, Embase, CINAHL, and Google Scholar databases for studies reporting adherence to option B+ and its association with disclosure status and counseling among pregnant and lactating women in Ethiopia. Heterogeneity was assessed by forest plot, Cochran's Q test, and I² test. A random effects model was calculated to estimate the pooled prevalence of adherence toward option B+.

RESULTS

We included eight studies, which gives a total of 1852 pregnant and lactating women in this systematic review and meta-analysis. The overall pooled estimate of good adherence toward option B+ antiretroviral therapy (ART) drug among pregnant and lactating women in Ethiopia was 84.23% (95% confidence interval [CI]: 80.79-87.66). Women who have disclosed their HIV status to their partner (adjusted odds ratio = 4.48, 95% CI: 1.86-10.76) and got counseling during the antenatal period (adjusted odds ratio = 5.02, 95% CI: 2.43-10.34) had a positive association with good adherence to option B+ ART drugs.

CONCLUSION

Four of five pregnant and lactating women have good adherence to option B+ ART drugs in Ethiopia. Therefore, promoting HIV disclosure status to partners and enhancing counseling services should be strengthened to improve adherence toward option B+ among pregnant and lactating women.

Factors Influencing Rapid Antiretroviral Therapy Initiation at Four eThekwini Clinics, KwaZulu-Natal, South Africa

Timely uptake of Antiretroviral therapy considerably improves the health of people living with the Human Immunodeficiency virus. We conducted a cross-sectional study of newly HIV diagnosed individuals in four clinics in eThekwini municipality, KwaZulu-Natal. Data was collected between June 2020 and December 2020. Participants completed an interviewer-administered questionnaire after HIV testing, on the day of HIV diagnosis. We evaluated factors influencing uptake of same-day ART initiation in eThekwini clinics, KwaZulu Natal, South Africa. Demographic information, health status, sexual behaviour, knowledge of universal test and treat (UTT), ART initiation uptake, and disclosure data was collected. Among the 403 participants, same-day initiation (SDI) was 69.2% (n = 279). We observed the number of sexual partners (aOR 0.35; 95% CI 0.15–0.81), HIV status of the partner (aOR 5.03; 95% CI 2.74–9.26) and knowledge of UTT (aOR 1.97; 95% CI 1.34–2.90) were identified as major factors influencing uptake of same-day ART initiation. More strategies are needed to achieve the SDI uptake within the framework of UTT.

One Pill, Once a Day: Simplified Treatment Regimens and Retention in HIV Care

Simplified drug regimens may improve retention in care for persons with chronic diseases. In April 2013, South Africa adopted a once-daily single-pill human immunodeficiency virus (HIV) treatment regimen as the standard of care, replacing a multiple-pill regimen. Because the regimens had similar biological efficacy, the shift to single-pill therapy offered a real-world test of the impact of simplified drug-delivery mechanisms on patient behavior. Using a quasi-experimental regression discontinuity design, we assessed retention in care among patients starting HIV treatment just before and just after the guideline change. The study included 4,484 patients starting treatment at a large public sector clinic in Johannesburg, South Africa. The share of patients prescribed a single-pill regimen increased by over 40 percentage points between March and April 2013. Initiating treatment after the policy change was associated with 11.7-percentage-points' higher retention at 12 months (95% confidence interval: -2.2, 29.4). Findings were robust to different measures of retention, different bandwidths, and different statistical models. Patients starting treatment early in HIV infection-a key population in the test-and-treat era-experienced the greatest improvements in retention from single-pill regimens.

Spatial and Temporal Trends in HIV/AIDS Burden Among Worldwide Regions From 1990 to 2019: A Secondary Analysis of the Global Burden of Disease Study 2019

Purpose

HIV/AIDS is a critical public health concern worldwide. This article investigated the spatial and temporal trends in HIV/AIDS burden from 1990 to 2019.

Methods

Data were extracted from the Global Burden of Disease (GBD) Study 2019. The estimated annual percentage change (EAPC) and the age-standardized rate (ASR) were used to quantify the change in trends at the global, regional, and national levels.

Results

In terms of temporal trends, during the period 1990–2004, increasing trends in prevalence (EAPC = 7.47, 95% confidence interval [CI] 5.84, 9.12), death (EAPC = 10.85, 95% CI 8.90–12.84), and disability-adjusted life years (DALYs) (EAPC = 10.40, 95% CI 8.47–12.36) of HIV/AIDS were observed. During the period 2005–2019, the global trends in HIV/AIDS incidence, death, and DALYs of HIV/AIDS decreased, with the EAPCs of −2.68 (95% CI−2.82–−2.53), −6.73 (95% CI −6.98–−6.47), and −6.75 (95% CI −6.95–−6.54), respectively. However, the disease prevalence showed a slight increasing trend (EAPC = 0.71, 95% CI 0.54–0.87). In terms of spatial trends, over the past 15 years, trends in HIV/AIDS incidence of HIV/AIDS appeared upward in High-middle and High sociodemographic index (SDI) areas (EAPC = 6.51, 95% CI 5.50–7.53; EAPC = 2.31, 95% CI 2.02–2.60, respectively).

Conclusion

Decreasing trends in HIV/AIDS incidence, death, and DALYs have been observed worldwide over the past 15 years, especially in death and DALYs rates. However, the global population living with HIV/AIDS is still increasing. It is worth noting that an unfavorable trend emerged in High-middle and High SDI areas. Prevention and control of HIV/AIDS still need to be strengthened to counteract these concerning trends.

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.

Mental health and initiation of antiretroviral treatment at enrolment into HIV care in Cameroon under a national "treat all" policy: a cross-sectional analysis

Introduction

Rapid antiretroviral treatment (ART) initiation reduces time from HIV infection to viral suppression, decreasing HIV transmission risk. Mental health symptoms may influence timing of ART initiation. This study estimated the prevalence of ART initiation at enrolment into HIV care and the relationship between mental health and ART initiation at enrolment into HIV care.

Methods

We conducted interviews with 426 individuals initiating HIV care in Cameroon between June 2019 and March 2020 to estimate the association between mental health and timing of ART initiation. Depression (Patient Health Questionnaire‐9; cut‐point 10), anxiety (Generalized Anxiety Disorder‐7; cut‐point 10), post‐traumatic stress disorder (PTSD) (PTSD Checklist for DSM‐5; cut‐point 31) and harmful alcohol use (Alcohol Use Disorders Identification Test; cut‐point 16) were dichotomized to represent those with and without each exposure at first HIV care appointment. Date of ART initiation (date ART prescribed) was ascertained from medical records. Separate multivariable log‐binomial regression models were used to estimate the association between mental health exposures and ART initiation at enrolment into care.

Results and discussion

Overall, 87% initiated ART at enrolment into HIV care. Approximately 20% reported depressive symptoms, 15% reported PTSD symptoms, 12% reported anxiety symptoms and 13% reported harmful alcohol use. In multivariable analyses, individuals with moderate to severe depressive symptoms had 1.7 (95% confidence interval [CI] 1.1, 2.7) times the prevalence of not initiating ART at enrolment into HIV care compared to those with no or mild depressive symptoms. Those with symptoms of PTSD, compared to those without, had 1.9 (95% CI 1.2, 2.9) times the prevalence of not initiating ART at enrolment into HIV care. Symptoms of anxiety or harmful drinking were not associated with ART initiation at enrolment into HIV care in multivariable models.

Conclusions

Symptoms of depression and PTSD were associated with lower prevalence of ART initiation at enrolment into HIV care among this sample of individuals initiating HIV care in Cameroon under a “treat all” policy. Research should examine barriers to timely ART initiation, whether incorporating mental health services into HIV care improves timely ART initiation, and whether untreated symptoms of depression and PTSD drive suboptimal HIV care outcomes.

Timely initiation of HIV antiretroviral therapy in Haiti 2004-2018: a retrospective cohort study

OBJECTIVE

To describe trends in timing of ART initiation for newly diagnosed people living with HIV before and after Haiti adopted its Test and Start policy for universal HIV antiretroviral therapy (ART) in July 2016, and to explore predictors of timely ART initiation for both newly and previously diagnosed people living with HIV following Test and Start adoption.

METHODS

This retrospective cohort study explored timing of ART initiation among 147 900 patients diagnosed with HIV at 94 ART clinics in 2004-2018 using secondary electronic medical record data. The study used survival analysis methods to assess time trends and risk factors for ART initiation.

RESULTS

Timely uptake of ART expanded with Test and Start, such that same-day ART initiation rates increased from 3.7% to 45.0%. However, only 11.0% of previously diagnosed patients initiated ART after Test and Start. In adjusted analyses among newly diagnosed people living with HIV, factors negatively associated with timely ART initiation included being a pediatric patient aged 0-14 years (HR = 0.23, p < 0.001), being male (HR = 0.92, p = 0.03), being 50+ years (HR = 0.87, p = 0.03), being underweight (HR = 0.79, p < 0.001), and having WHO stage 3 (HR = 0.73, p < 0.001) or stage 4 disease (HR = 0.49, p < 0.001). Variation in timely ART initiation by geographic department and health facility was observed.

CONCLUSIONS

Haiti has made substantial progress in scaling up Test and Start, but further work is needed to enroll previously diagnosed patients and to ensure rapid ART in key patient subgroups. Further research is needed on facility and geographic factors and on strategies for improving timely ART initiation among vulnerable subgroups.

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.

Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis

BACKGROUND

The World Health Organization's Treat-All guidance recommends CD4 testing before initiating antiretroviral therapy (ART), and routine viral load (VL) monitoring (over CD4 monitoring) for patients on ART.

METHODS

We used regression discontinuity analyses to estimate changes in CD4 testing and VL monitoring among 547 837 ART-naive patients enrolling in human immunodeficiency virus (HIV) care during 2006-2018 at 225 clinics in 26 countries where Treat-All policies were adopted. We examined CD4 testing within 12 months before and VL monitoring 6 months after ART initiation among adults (≥20 years), adolescents (10-19 years), and children (0-9 years) in low/lower-middle-income countries (L/LMICs) and high/upper-middle-income countries (H/UMICs).

RESULTS

Treat-All adoption led to an immediate decrease in pre-ART CD4 testing among adults in L/LMICs, from 57.0% to 48.1% (-8.9 percentage points [pp]; 95% CI: -11.0, -6.8), and a small increase in H/UMICs, from 90.1% to 91.7% (+1.6pp; 95% CI: 0.2, 3.0), with no changes among adolescents or children; decreases in pre-ART CD4 testing accelerated after Treat-All adoption in L/LMICs. In L/LMICs, VL monitoring after ART initiation was low among all patients in L/LMICs before Treat-All; while there was no immediate change at Treat-All adoption, VL monitoring trends significantly increased afterwards. VL monitoring increased among adults immediately after Treat-All adoption, from 58.2% to 61.1% (+2.9pp; 95% CI: 0.5, 5.4), with no significant changes among adolescents/children.

CONCLUSIONS

While on-ART VL monitoring has improved in L/LMICs, Treat-All adoption has accelerated and disparately worsened suboptimal pre-ART CD4 monitoring, which may compromise care outcomes for individuals with advanced HIV.

The Impact of Same-Day Antiretroviral Therapy Initiation Under the World Health Organization Treat-All Policy

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.

CD4+ T-Cell Count at Antiretroviral Therapy Initiation in the "Treat-All" Era in Rural South Africa: An Interrupted Time Series Analysis

BACKGROUND

South Africa implemented universal test and treat (UTT) in September 2016 in an effort to encourage earlier initiation of antiretroviral therapy (ART).

METHODS

We therefore conducted an interrupted time series (ITS) analysis to assess the impact of UTT on mean CD4 count at ART initiation among adults aged ≥16 years attending 17 public sector primary care clinics in rural South Africa, between July 2014 and March 2019.

RESULTS

Among 20 599 individuals (69% women), CD4 counts were available for 74%. Mean CD4 at ART initiation increased from 317.1 cells/μL (95% confidence interval [CI], 308.6 to 325.6) 1 to 8 months prior to UTT to 421.0 cells/μL (95% CI, 413.0 to 429.0) 1 to 12 months after UTT, including an immediate increase of 124.2 cells/μL (95% CI, 102.2 to 146.1). However, mean CD4 count subsequently fell to 389.5 cells/μL (95% CI, 381.8 to 397.1) 13 to 30 months after UTT but remained above pre-UTT levels. Men initiated ART at lower CD4 counts than women (-118.2 cells/μL, 95% CI, -125.5 to -111.0) throughout the study.

CONCLUSIONS

Although UTT led to an immediate increase in CD4 count at ART initiation in this rural community, the long-term effects were modest. More efforts are needed to increase initiation of ART early in those living with human immunodeficiency virus, particularly men.

A systematic review of the effectiveness of non- health facility based care delivery of antiretroviral therapy for people living with HIV in sub-Saharan Africa measured by viral suppression, mortality and retention on ART

BACKGROUND

Alternative models for sustainable antiretroviral treatment (ART) delivery are necessary to meet the increasing demand to maintain population-wide ART for all people living with HIV (PLHIV) in sub-Saharan Africa. We undertook a review of published literature comparing health facility-based care (HFBC) with non-health facility based care (nHFBC) models of ART delivery in terms of health outcomes; viral suppression, loss to follow-up, retention and mortality.

METHODS

We conducted a systematic search of Medline, Embase and Global Health databases from 2010 onwards. UNAIDS reports, WHO guidelines and abstracts from conferences were reviewed. All studies measuring at least one of the following outcomes, viral load suppression, loss-to-follow-up (LTFU) and mortality were included. Data were extracted, and a descriptive analysis was performed. Risk of bias assessment was done for all studies. Pooled estimates of the risk difference (for viral suppression) and hazard ratio (for mortality) were made using random-effects meta-analysis.

RESULTS

Of 3082 non-duplicate records, 193 were eligible for full text screening of which 21 published papers met the criteria for inclusion. The pooled risk difference of viral load suppression amongst 4 RCTs showed no evidence of a difference in viral suppression (VS) between nHFBC and HFBC with an overall estimated risk difference of 1% [95% CI -1, 4%]. The pooled hazard ratio of mortality amongst 2 RCTs and 4 observational cohort studies showed no evidence of a difference in mortality between nHFBC and HFBC with an overall estimated hazard ratio of 1.01 [95% CI 0.88, 1.16]. Fifteen studies contained data on LTFU and 13 studies on retention. Although no formal quantitative analysis was performed on these outcomes due to the very different definitions between papers, it was observed that the outcomes appeared similar between HFBC and nHFBC.

CONCLUSIONS

Review of current literature demonstrates comparable outcomes for nHFBC compared to HFBC ART delivery programmes in terms of viral suppression, retention and mortality.

PROSPERO NUMBER

CRD42018088194 .

HIV infection in Eastern and Southern Africa: Highest burden, largest challenges, greatest potential

BACKGROUND

The burden of HIV is especially concerning for Eastern and Southern Africa (ESA), as despite expansion of test-and-treat programmes, this region continues to experience significant challenges resulting from high rates of morbidity, mortality and new infections. Hard-won lessons from programmes on the ground in ESA should be shared.

OBJECTIVES

This report summarises relevant evidence and regional experts' recommendations regarding challenges specific to ESA.

METHOD

This commentary includes an in-depth review of relevant literature, progress against global goals and consensus opinion from experts.

RESULTS

Recommendations include priorities for essential research (surveillance data collection, key and vulnerable population education and testing, in-country testing trials and evidence-based support services to improve retention in care) as well as research that can accelerate progress towards the prevention of new infections and achieving ambitious global goals in ESA.

CONCLUSION

The elimination of HIV in ESA will require continued investment, commitment to evidence-based programmes and persistence. Local research is critical to ensuring that responses in ESA are targeted, efficient and evaluated.

How early is too early? Challenges in ART initiation and engaging in HIV care under Treat All in Rwanda-A qualitative study

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.

Brief Report: The Impact of Disease Stage on Early Gaps in ART in the "Treatment for All" Era-A Multisite Cohort Study

BACKGROUND

Adoption of "Treat All" policies has increased antiretroviral therapy (ART) initiation in sub-Saharan Africa; however, unexplained early losses continue to occur. More information is needed to understand why treatment discontinuation continues at this vulnerable stage in care.

METHODS

The Monitoring Early Treatment Adherence Study involved a prospective observational cohort of individuals initiating ART at early-stage versus late-stage disease in South Africa and Uganda. Surveys and HIV-1 RNA levels were performed at baseline, 6, and 12 months, with adherence monitored electronically. This analysis included nonpregnant participants in the first 6 months of follow-up; demographic and clinical factors were compared across groups with χ2, univariable, and multivariable models.

RESULTS

Of 669 eligible participants, 91 (14%) showed early gaps of ≥30 days in ART use (22% in South Africa and 6% in Uganda) with the median time to gap of 77 days (interquartile range: 43-101) and 87 days (74, 105), respectively. Although 71 (78%) ultimately resumed care, having an early gap was still significantly associated with detectable viremia at 6 months (P ≤ 0.01). Multivariable modeling, restricted to South Africa, found secondary education and higher physical health score protected against early gaps [adjusted odds ratio (aOR) 0.4, 95% confidence interval (CI): 0.2 to 0.8 and (aOR 0.93, 95% CI: 0.9 to 1.0), respectively]. Participants reporting clinics as "too far" had double the odds of early gaps (aOR 2.2: 95% CI: 1.2 to 4.1).

DISCUSSION

Early gaps in ART persist, resulting in higher odds of detectable viremia, particularly in South Africa. Interventions targeting health management and access to care are critical to reducing early gaps.

Outcomes After Being Lost to Follow-up Differ for Pregnant and Postpartum Women When Compared With the General HIV Treatment Population in Rural South Africa

Supplemental Digital Content is Available in the Text.

Undetermined attrition prohibits full understanding of the coverage and effectiveness of HIV programs. Outcomes following loss to follow-up (LTFU) among antiretroviral therapy (ART) patients may differ according to their reasons for ART initiation.

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

BACKGROUND

Young adolescents with perinatally acquired human immunodeficiency virus (HIV) are at risk for poor care outcomes. We examined whether universal antiretroviral treatment (ART) eligibility policies (Treat All) improved rapid ART initiation after care enrollment among 10-14-year-olds in 7 sub-Saharan African countries.

METHODS

Regression discontinuity analysis and data for 6912 patients aged 10-14-years were used to estimate changes in rapid ART initiation (within 30 days of care enrollment) after adoption of Treat All policies in 2 groups of countries: Uganda and Zambia (policy adopted in 2013) and Burundi, Democratic Republic of the Congo, Kenya, Malawi, and Rwanda (policy adopted in 2016).

RESULTS

There were immediate increases in rapid ART initiation among young adolescents after national adoption of Treat All. Increases were greater in countries adopting the policy in 2016 than in those adopting it in 2013: 23.4 percentage points (pp) (95% confidence interval, 13.9-32.8) versus 11.2pp (2.5-19.9). However, the rate of increase in rapid ART initiation among 10-14-year-olds rose appreciably in countries with earlier treatment expansions, from 1.5pp per year before Treat All to 7.7pp per year afterward.

CONCLUSIONS

Universal ART eligibility has increased rapid treatment initiation among young adolescents enrolling in HIV care. Further research should assess their retention in care and viral suppression under Treat All.

Attrition in HIV care following HIV diagnosis: a comparison of the pre-UTT and UTT eras in South Africa

INTRODUCTION

Policies for Universal Test & Treat (UTT) and same-day initiation (SDI) of antiretroviral therapy (ART) were instituted in South Africa in September 2016 and 2017 respectively. However, there is limited evidence on whether these changes have improved patient retention after HIV diagnosis.

METHODS

We enrolled three cohorts of newly diagnosed HIV-infected adults from two primary health clinics in Johannesburg from April to November 2015 (Pre-UTT, N = 144), May-September 2017 (UTT, N = 178) and October-December 2017 (SDI, N = 88). A baseline survey was administered immediately after HIV diagnosis after which follow-up using clinical records (paper charts, electronic health records and laboratory data) ensued for 12 months. The primary outcome was patient loss to follow-up (being >90 days late for the last scheduled appointment) at 12 months post-HIV diagnosis. We modelled attrition across HIV policy periods with Cox proportional hazard regression.

RESULTS

Overall, 410 of 580 screened HIV-positive patients were enrolled. Overall, attrition at 12 months was 30% lower in the UTT guideline period (38.2%) compared to pre-UTT (47.2%, aHR 0.7, 95% CI: 0.5 to 1.0). However, the total attrition was similar between the SDI (47.7%) and pre-UTT cohorts (aHR 1.0, 95% CI: 0.7 to 1.5). Older age at HIV diagnosis (aHR 0.5 for ≥40 vs. 25 to 29 years, 95% CI: 0.3 to 0.8) and being in a non-marital relationship (aHR 0.5 vs. being single, 95% CI: 0.3 to 0.8) protected against LTFU at 12 months, whereas LTFU rates increased with longer travel time to the diagnosing clinic (aHR 1.8 for ≥30 minutes vs. ≤15 minutes, 95% CI: 1.1 to 3.1). In analyses adjusted for the time-varying ART initiation status, compared to the pre-ART period of care, the hazard of on-ART LTFU was 90% higher among participants diagnosed under the SDI policy compared to pre-UTT (aHR 1.9, 95% CI: 1.1 to 2.9).

CONCLUSIONS

Overall, nearly two-fifths of HIV positive patients are likely to disengage from care by 12 months after HIV diagnosis under the new SDI policy. Furthermore, the increase in on-ART patient attrition after the introduction of the SDI policy is cause for concern. Further research is needed to determine the best way for rapidly initiating patients on ART and also reducing long-term attrition from care.

Toward Universal HIV Treatment in Haiti: Time Trends in ART Retention After Expanded ART Eligibility in a National Cohort From 2011 to 2017

BACKGROUND

The World Health Organization (WHO) recommends universal antiretroviral therapy (ART) for persons living with HIV (PLWH), but evidence about effects of expanded ART access on ART retention in low-resource settings is limited.

SETTING

Haiti's Ministry of Health endorsed universal ART for pregnant women in March 2013 (Option B+) and for all PLWH in July 2016. This study included 51,579 ART patients from 2011 to 2017 at 94 hospitals and clinics in Haiti.

METHODS

This observational, retrospective cohort study described time trends in 6-month ART retention using secondary data, and compared results during 3 periods using an interrupted time series model: pre-Option B+ (period 1: 1/11-2/13), Option B+ (period 2: 3/13-6/16), and Test and Start (T&S, period 3: 7/16-9/17).

RESULTS

From the pre-Option B+ to the T&S period, the monthly count of new ART patients increased from 366/month to 877/month, and the proportion with same-day ART increased from 6.3% to 42.1% (P < 0.001). The proportion retained on ART after 6 months declined from 78.4% to 75.0% (P < 0.001). In the interrupted time series model, ART retention improved by a rate of 1.4% per quarter during the T&S period after adjusting for patient characteristics (adjusted incidence rate ratio = 1.014; 95% confidence interval: 1.002 to 1.026, P < 0.001). However, patients with same-day ART were 14% less likely to be retained compared to those starting ART >30 days after HIV diagnosis (adjusted incidence rate ratio = 0.86; 95% confidence interval: 0.84-0.89, P < 0.001).

CONCLUSIONS

Achieving targets for HIV epidemic control will require increasing ART retention and reducing the disparity in retention for those with same-day ART.

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Background

In September 2016, South Africa (SA) began implementing the universal-test-and-treat (UTT) policy in hopes of attaining the UNAIDS 90-90-90 targets by 2020. The SA National Department of Health provided a further directive to initiate antiretroviral therapy (ART) on the day of HIV diagnosis in September 2017. We conducted a qualitative study to determine the progress in implementing UTT and examine health providers' perspectives on the implementation of the same-day initiation (SDI) policy, six months after the policy change.

Methods

We conducted in-depth interviews with three professional nurses, and four HIV lay counsellors of five primary health clinics in the Gauteng province, between October and December 2017. In September 2018, we also conducted a focus group discussion with ten professional nurses/clinic managers from ten clinic facilities. The interviews and focus groups covered the adoption and implementation of UTT and SDI policies. Interviews were conducted in English, Sotho or Zulu and audio-recorded with participant consent. Audio-recordings were transcribed verbatim, translated to English and analysed thematically using NVivo 11.

Results

The data indicates inconsistencies across facilities and incongruities between counsellor and nursing provider perspectives regarding the SDI policy implementation. While nurses highlighted the clinical benefits of early ART initiation, they expressed concerns that immediate ART may be overwhelming for some patients, who may be unprepared and likely to disengage from care soon after the initial acceptance of ART. Accordingly, the SDI implementation was slow due to limited patient demand, provider ambivalence to the policy implementations, as well as challenges with infrastructure and human resources. The process for assessing patient readiness was poorly defined by health providers across facilities, inconsistent and counsellor dependent. Providers were also unclear on how to ensure that patients who defer treatment return for ongoing counselling.

Conclusions

Our results highlight important gaps in the drive to achieve the ART initiation target and demonstrate the need for further engagement with health care providers around the implementation of same-day ART initiation, particularly with regards to infrastructural/capacity needs and the management of patient readiness for lifelong ART on the day of HIV diagnosis. Additionally, there is a need for improved promotion of the SDI provision both in health care settings and in media communications to increase patient demand for early and lifelong ART.

Getting to 90-90-90: Experiences from the MaxART Early Access to ART for All (EAAA) Trial in Eswatini

PURPOSE OF REVIEW

The MaxART Consortium-led by the Eswatini Ministry of Health-implemented multiple interventions between 2012 and 2017 to achieve UNAIDS 90-90-90 targets. We summarize key findings from community outreach strategies in support of the first 90 goal, and from the Early Access to ART for All (EAAA) trial on the implementation of a "Treat All" strategy to achieve the second and third 90 goals within a government-managed public health system.

RECENT FINDINGS

The MaxART Consortium demonstrated that "Fast Track," a problem-solving approach, was effective at increasing testing coverage in the community. Compared with baseline data at 3 months prior to the start of the Fast Track, there was a 273% proportional increase in HIV tests conducted among adolescent males, adolescent females, and adult men, and 722% over baseline for adolescent males. The MaxART EAAA trial further showed that implementation of the Treat All policy was associated with significant two-fold shorter time from enrollment into care to ART initiation than under the standard CD4+ cell threshold-based treatment guidelines. Finally, through the MaxART trial, Eswatini was able to identify areas for further investment, including addressing the system-side barriers to routine viral load monitoring, and designing and implementing innovative community-based approaches to reach individuals who were not more routinely accessing HIV testing and counseling services. As low- and middle-income countries adopt the Treat All approach in their national HIV care and treatment guidelines, further implementation science research is needed to understand and address the system-level barriers to achieving the benefits of Treat All for HIV-infected individuals and those at risk.

Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD-HIV model

OBJECTIVES

Non-communicable diseases (NCDs) account for one-third of disability-adjusted life years in Malawi, and access to care is exceptionally limited. Integrated services with HIV are widely recommended, but few examples exist globally. We report descriptive outcomes from an Integrated Chronic Care Clinic (IC3).

DESIGN

This is a retrospective cohort study.

SETTING

The study includes an HIV-NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi.

PARTICIPANTS

All new patients, including 6233 HIV-NCD diagnoses, enrolled between January 2015 and December 2017 were included. This included 3334 patients with HIV (59.7% women) and 2990 patients with NCD (67.3% women), 10% overall under age 15 years.

INTERVENTIONS

Patients were seen at their nearest health centre, with a hospital team visiting routinely to reinforce staffing. Data were collected on paper forms and entered into an electronic medical record.

PRIMARY AND SECONDARY OUTCOME MEASURES

Routine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis.

RESULTS

NCD diagnoses were 1693 hypertension, 668 asthma, 486 epilepsy, 149 diabetes and 109 severe mental illness. By December 2018, 8.3% of patients with NCD over 15 years were also on HIV treatment. One-year retention was 85% for HIV and 72% for NCDs, with default in 8.4% and 25.5% and deaths in 4.0% and 1.4%, respectively. Clinical outcomes showed statistically significant improvement for hypertension, diabetes, asthma and epilepsy. Of the 1807 (80%) of patients with HIV with viral load results, 85% had undetectable viral load.

CONCLUSIONS

The IC3 model, built on an HIV platform, facilitated rapid decentralisation and access to NCD services in rural Malawi. Clinical outcomes and retention in care are favourable, suggesting that integration of chronic disease care at the primary care level poses a way forward for the large dual burden of HIV and chronic NCDs.

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.

Prevalence of HIV-associated esophageal candidiasis in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Esophageal candidiasis (OC) is a common AIDS-defining opportunistic infection. Antiretroviral therapy (ART) reduces the occurrence of OC and other opportunistic infections among persons living with HIV (PLHIV). We sought to determine and compare the prevalence of OC in the ART and pre-ART era among PLHIV in sub-Saharan Africa (SSA).

METHODS

We searched PubMed, Embase, Web of Science, and the African Journals Online databases to select studies in English and French reporting the prevalence of HIV-associated OC in SSA from January 1980 to June 2020. Reviews, single-case reports, and case series reporting < 10 patients were excluded. A random-effect cumulative meta-analysis was performed using STATA 16.0, and trend analysis performed using GraphPad Prism 8.0.

RESULTS

Thirteen eligible studies from 9 SSA countries including a total of 113,272 patients were qualitatively synthesized, and 9 studies were included in the meta-analysis. Overall pooled prevalence of HIV-associated OC was 12% (95% confidence interval (CI): 8 to 15%, I 2 = 98.61%, p <. 001). The prevalence was higher in the pre-ART era compared to the ART era, but not to statistical significance (34.1% vs. 8.7%, p = 0.095). In those diagnosed by endoscopy, the prevalence was higher compared to patients diagnosed by non-endoscopic approaches, but not to statistical significance (35.1% vs. 8.4%, p = .071). The prevalence of OC significantly decreased over the study period (24 to 16%, p < .025).

CONCLUSION

The prevalence of OC among PLHIV in the ART era in SSA is decreasing. However, OC remains a common problem. Active endoscopic surveillance of symptomatic patients and further empirical studies into the microbiology, optimal antifungal treatment, and impact of OC on quality of life of PLHIV in SSA are recommended.

Rapid antiretroviral therapy initiation in the Botswana Combination Prevention Project: a quasi-experimental before and after study

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.

High levels of viral load monitoring and viral suppression under Treat All in Rwanda - a cross-sectional study

INTRODUCTION

Aiming to reach UNAIDS 90-90-90 targets, nearly all sub-Saharan African countries have expanded antiretroviral therapy (ART) to all people living with HIV (PLWH) (Treat All). Few published data exist on viral load testing and viral suppression under Treat All in this region. We assessed proportions of patients with available viral load test results and who were virally suppressed, as well as factors associated with viral suppression, among PLWH in 10 Rwandan health centres after Treat All implementation.

METHODS

Cross-sectional study during 2018 of adults (≥15 years) engaged in HIV care at 10 Rwandan health centres. Outcomes were being on ART (available ART initiation date in the study database, with no ART discontinuation prior to 1 January 2018), retained on ART (≥2 post-ART health centre visits ≥90 days apart during 2018), available viral load test results (viral load measured in 2018 and available in study database) and virally suppressed (most recent 2018 viral load <200 copies/mL). We used modified Poisson regression models accounting for clustering by health centre to determine factors associated with being virally suppressed.

RESULTS

Of 12,238 patients, 7050 (58%) were female and 1028 (8%) were aged 15 to 24 years. Nearly all patients (11,933; 97%) were on ART, of whom 11,198 (94%) were retained on ART. Among patients retained on ART, 10,200 (91%) had available viral load results; of these 9331 (91%) were virally suppressed. Viral suppression was less likely among patients aged 15 to 24 compared to >49 years (adjusted prevalence ratio (aPR): 0.83, 95% CI 0.76 to 0.90 and those with pre-ART CD4 counts of <200 compared to ≥500 cells/mm3 (aPR: 0.92, 95% CI 0.90 to 0.93). There was no statistically significant difference in viral suppression among patients who entered after Treat All implementation compared to those who enrolled before 2010 (aPR 0.98, 95% CI 0.94 to 1.03).

CONCLUSIONS

In this large cohort of Rwandan PLWH receiving HIV care after Treat All implementation, patients in study health centres have surpassed the third UNAIDS 90-90-90 target. To ensure all PLWH fully benefit from ART, additional efforts should focus on improving ART adherence among younger persons.

International epidemiology databases to evaluate AIDS (IeDEA) in sub-Saharan Africa, 2012-2019

PURPOSE

The objectives of the International epidemiology databases to evaluate AIDS (IeDEA) are to (i) evaluate the delivery of combination antiretroviral therapy (ART) in children, adolescents and adults in sub-Saharan Africa, (ii) to describe ART regimen effectiveness, durability and tolerability, (iii) to examine HIV-related comorbidities and coinfections and (iv) to examine the pregnancy-related and HIV-related outcomes of women on ART and their infants exposed to HIV or ART in utero or via breast milk.

PARTICIPANTS

IeDEA is organised in four regions (Central, East, Southern and West Africa), with 240 treatment and care sites, six data centres at African, European and US universities, and almost 1.4 million children, adolescents and adult people living with HIV (PLWHIV) enrolled.

FINDINGS TO DATE

The data include socio-demographic characteristics, clinical outcomes, opportunistic events, treatment regimens, clinic visits and laboratory measurements. They have been used to analyse outcomes in PLWHIV-1 or PLWHIV-2 who initiate ART, including determinants of mortality, of switching to second-line and third-line ART, drug resistance, loss to follow-up and the immunological and virological response to different ART regimens. Programme-level estimates of mortality have been corrected for loss to follow-up. We examined the impact of coinfection with hepatitis B and C, and the epidemiology of different cancers and of (multidrug resistant) tuberculosis, renal disease and of mental illness. The adoption of 'Treat All', making ART available to all PLWHIV regardless of CD4+ cell count or clinical stage was another important research topic.

FUTURE PLANS

IeDEA has formulated several research priorities for the 'Treat All' era in sub-Saharan Africa. It recently obtained funding to set up sentinel sites where additional data are prospectively collected on cardiometabolic risks factors as well as mental health and liver diseases, and is planning to create a drug resistance database.

HIV testing and ART initiation in people who inject drugs and are placed on methadone in Kachin State, Myanmar

Setting

People who inject drugs (PWID) enrolled for methadone maintenance therapy (MMT) and never previously tested for human immunodeficiency virus (HIV) in Myitkyina Drug Dependency Treatment Hospital, Myitkyina, Kachin State, Myanmar.

Objectives

To compare before (2016) and after (2018) adoption of 'Test and Treat' guidelines for antiretroviral therapy (ART): 1) the demographic profile of PWID, 2) HIV testing uptake and ART initiation in those diagnosed HIV-positive, and 3) time taken for events.

Design

This was a cohort study using secondary programme data.

Results

In 2016 and 2018, there were respectively 141 and 146 PWID: all were male except for one female and age distribution between the 2 years was similar. In 2018, significantly more PWID were HIV-tested than in 2016 (85% vs. 45%; P ≤ 0.001). Among those tested, the proportions who were HIV-positive were similar (37% in 2016 and 38% in 2018). In 2018, significantly fewer HIV-positive PWID were started on ART than in 2016 (19% vs. 48%; P = 0.01). Median times between enrolment on MMT and HIV testing (2 vs. 1 day) and between being diagnosed HIV-positive and started on ART (31 vs. 17 days) for 2016 and 2018 were not significantly different.

Conclusion

ART uptake decreased in 2018 compared with 2016, and ways to rectify this are urgently needed.

Distribution of advanced HIV disease from three high HIV prevalence settings in Sub-Saharan Africa: a secondary analysis data from three population-based cross-sectional surveys in Eshowe (South Africa), Ndhiwa (Kenya) and Chiradzulu (Malawi)

Background: Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality.Objective: We aimed to quantify population-level estimates of advanced HIV from three high HIV prevalence settings in Sub-Saharan Africa.Methods: Three cross-sectional surveys were conducted in (Ndhiwa (Kenya): September-November 2012), (Chiradzulu (Malawi): February-May 2013) and (Eshowe (South Africa): July-October 2013). Eligible individuals 15-59 years old who consented were interviewed at home followed by rapid HIV test and CD4 count test if tested HIV-positive. Advanced HIV was defined as CD4 < 200 cells/µl. We used logistic regression to identify patient characteristics associated with advanced HIV.Results: Among 18,991 (39.2% male) individuals, 4113 (21.7%) tested HIV-positive; 385/3957 (9.7% (95% Confidence Interval [CI]: 8.8-10.7)) had advanced HIV, ranging from 7.8% (95%CI 6.4-9.5) Chiradzulu (Malawi) to 11.8% (95%CI 9.8-14.2) Ndhiwa (Kenya). The proportion of PLHIV with advanced disease was higher among men 15.3% (95% CI 13.2-17.5) than women 7.5% (95%CI 6.6-8.6) p < 0.001. Overall, 62.7% of all individuals with advanced HIV were aware of their HIV status and 40.3% were currently on ART. Overall, 65.6% of individuals not on ART had not previously been diagnosed with HIV, while only 29.6% of those on ART had been on ART for ≥6 months. Individuals with advanced HIV disease were more likely to be men (adjusted Odds Ratio [aOR]; 2.1 (95%CI 1.7-2.6), and more likely not to be on ART (aOR; 1.7 (95%CI 1.3-2.1).Conclusion: In our study, about 1 in 10 PLHIV had advanced HIV with nearly 40% of them unaware of their HIV status. However, a substantial proportion of patients with advanced HIV were established on ART. Our findings suggest the need for a dual focus on alternative testing strategies to identify PLHIV earlier as well as improving ART retention.

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.

Decreasing time to antiretroviral therapy initiation after HIV diagnosis in a clinic-based observational cohort study in four African countries

INTRODUCTION

World Health Organization (WHO) guidelines have shifted over time to recommend earlier initiation of antiretroviral therapy (ART) and now encourage ART initiation on the day of HIV diagnosis, if possible. However, barriers to ART access may delay initiation in resource-limited settings. We characterized temporal trends and other factors influencing the interval between HIV diagnosis and ART initiation among participants enrolled in a clinic-based cohort across four African countries.

METHODS

The African Cohort Study enrols adults engaged in care at 12 sites in Uganda, Kenya, Tanzania and Nigeria. Participants provide a medical history, complete a physical examination and undergo laboratory assessments every six months. Participants with recorded dates of HIV diagnosis were categorized by WHO guideline era (<2006, 2006 to 2009, 2010 to 2012, 2013 to 2015, ≥2016) at the time of diagnosis. Cox proportional hazard modelling was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CI) for time to ART initiation.

RESULTS AND DISCUSSION

From January 2013 to September 2019, a total of 2888 adults living with HIV enrolled with known diagnosis dates. Median time to ART initiation decreased from 22.0 months (interquartile range (IQR) 4.0 to 77.3) among participants diagnosed prior to 2006 to 0.5 months (IQR 0.2 to 1.8) among those diagnosed in 2016 and later. Comparing those same periods, CD4 nadir increased from a median of 166 cells/mm3 (IQR: 81 to 286) to 298 cells/mm3 (IQR: 151 to 501). In the final adjusted model, participants diagnosed in each subsequent WHO guideline era had increased rates of ART initiation compared to those diagnosed before 2006. CD4 nadir ≥500 cells/mm3 was independently associated with a lower rate of ART initiation as compared to CD4 nadir <200 cells/mm3 (HR: 0.32; 95% CI: 0.28 to 0.37). Age >50 years at diagnosis was independently associated with shorter time to ART initiation as compared to 18 to 29 years (HR: 1.38; 95% CI: 1.19 to 1.61).

CONCLUSIONS

Consistent with changing guidelines, the interval between diagnosis and ART initiation has decreased over time. Still, many adults living with HIV initiated treatment with low CD4, highlighting the need to diagnose HIV earlier while improving access to immediate ART after diagnosis.

Supporting Diagnosis and Management of HIV/AIDS Patients Through Point-of-Care Technology Development

The HIV pandemic disproportionately impacts sub-Saharan Africa where in 2017, 71% of people living with HIV resided, 65% of new infections and 75% of deaths were reported. Prevention, screening and treatment strategies have led to progress in addressing this disease. HIV diagnostics have been crucial for prevention and treatment but more progress is required to reduce HIV infection. The Center for Innovation in Point-of-Care Technologies for HIV/AIDS at Northwestern University (C-THAN) is a vital partner in the National Institute of Biomedical Imaging and Bioengineering Point-of-Care Technologies Research Network. C-THAN's mission is to develop and commercialize a pipeline of point-of-care technologies critical for improved prevention and management of HIV in low- and middle-income countries with specific emphasis on sub-Saharan Africa.

Anti-retroviral therapy scale-up and its impact on sex-stratified tuberculosis notification trends in Uganda

INTRODUCTION

In order to end the tuberculosis (TB) epidemic by 2035, countries must achieve a 10% annual decline in tuberculosis incidence rates by 2025. Provision of antiretroviral therapy (ART) has been associated with population level decreases in TB notification rates. We aimed to assess whether the progressive scale-up of ART provision over the past nine years has had an effect on population level trends of TB notification in Uganda stratified by sex and HIV status.

METHODS

The study area consisted of Kampala and eight surrounding districts. Annual TB notifications and mid-year populations were used to calculate notification rates per 100,000 population from the study area. Numbers alive and retained on ART were used to calculate ART coverage, overall and by sex. TB notification rates (TBNRs) overall and stratified by sex and HIV status were calculated for the period 2009 to 2017. Trends in TBNRs before and after rollout of universal ART for pregnant women in 2013 were examined using Poisson regression models. To gain insight into the trends in CD4+ T-cell counts at ART initiation over the study period, we performed a sub analysis of patient level data from the Infectious Diseases Institute clinic.

RESULTS

From 2009 to 2017, ART coverage increased by 27.6% among men and by 35.4% among women. TBNRs declined during the same period. Overall, the average annual percentage decline in TBNRs was -3.5% (95%CI -3.7% to -3.3%), (-2.3% (95%CI -2.6% to -1.9%) in men and -5.4% (95%CI -5.7% to -5.0%) in women). ART coverage increased after 2013 but this was not associated with an accelerated decline in overall TBNRs among HIV-positive persons -3.6% before 2013 and -5.2% after 2013; p = 0.33. The proportion of patients initiating ART with CD4+ T-cell count ≤ 200 cells/mL did not decrease significantly after 2013 (42.2% to 32.2%, p = 0.05).

CONCLUSIONS

Although ART scale-up was temporally associated with a decline in TB notification rates, the achieved rates of decline are below those required to achieve the End TB Targets. Additional investments in tuberculosis control should include efforts to promote earlier care seeking and ART initiation among HIV-positive persons.

How to Evolve the Response to the Global HIV Epidemic With New Metrics and Targets Based on Pre-Treatment CD4 Counts

PURPOSE OF THE REVIEW

Early diagnosis and treatment of HIV following seroconversion improves individual and population health. Using published data on pre-treatment CD4 cell counts, we benchmarked the level of immunodeficiency at HIV diagnosis and ART initiation in the "real world" against those of the treatment and control arms of landmark controlled trials that successfully reduced HIV-related deaths (INSIGHT/START) and onward HIV transmission (HPTN 052).

RECENT FINDINGS

The median CD4 count in the treatment vs. control arms of the INSIGHT/START trial and HPTN 052 were 650 vs. 408 cells/μL and 442 vs. 221 cells/μL, respectively. In the real world, recent global estimates of the median CD4 count at start of ART range from 234 to 350 cells/μL, and only 25% of those initiating ART do so early (i.e., with CD4 > 500 cells/μL). Recent global data on trends in the median CD4 count at diagnosis and ART initiation are not encouraging. We identify a critical need for new targets and metrics for persons newly diagnosed with HIV, newly enrolling in HIV care, and newly initiating ART, based on pre-treatment CD4 counts, to help increase the focus of implementation efforts on achieving earlier diagnosis, linkage to care, and ART initiation.