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Chao A, Spiegelman D, Khan S, Walsh F, Mazibuko S, Pasipamire M, Chai B, Reis R, Mlambo K, Delva W, Khumalo G, Zwane M, Fleming Y, Mafara E, Hettema A, Lejeune C, Bärnighausen T, Okello V. Mortality under early access to antiretroviral therapy vs. Eswatini's national standard of care: the MaxART clustered randomized stepped-wedge trial. HIV Med 2020; 21:429-440. [PMID: 32458567 DOI: 10.1111/hiv.12876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 03/18/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Current WHO guidelines recommend the treatment of all HIV-infected individuals with antiretroviral therapy (ART) to improve survival and quality of life, and decrease infection of others. MaxART is the first implementation trial of this strategy embedded within a government-managed health system, and assesses mortality as a secondary outcome. Because primary findings strongly supported scale-up of the 'treat all' strategy (hereafter Treat All), this analysis examines mortality as an additional indicator of its impact. METHODS MaxART was conducted in 14 Eswatinian health clinics through a clinic-based stepped-wedge design, by transitioning clinics from then-national standard of care (SoC) to the Treat All intervention. All-cause, disease-related, and HIV-related mortality were analysed using the Cox proportional hazards model, censoring SoC participants at clinic transition. Median follow-up time among study participants was 292 days. There were 36/2034 deaths in SoC (1.77%) and 49/1371 deaths in Treat All (3.57%). RESULTS Between September 2014 and August 2017, 3405 participants were enrolled. In SoC and Treat All interventions, respectively, the multivariable-adjusted 12-month all-cause mortality rates were 1.42% [95% confidence interval (CI): 0.66-2.17] and 1.60% (95% CI: 0.78-2.40), disease-related mortality rates were 1.02% (95% CI: 0.40-1.64) and 1.10% (95% CI: 0.46-1.73), and HIV-related mortality rates were 1.03% (95% CI: 0.40-1.65) and 0.99% (95% CI: 0.40-1.58). Treat All had no impact on all-cause [hazard ratio (HR) = 1.12, 95% CI: 0.58-2.18, P = 0.73], disease-related (HR = 1.04, 95% CI: 0.52-2.11, P = 0.90), or HIV-related mortality (HR = 0.93, 95% CI: 0.46-1.87, P = 0.83). CONCLUSION There was no immediate benefit of the Treat All strategy on mortality, nor evidence of harm. Longer follow-up of participants is needed to establish long-term consequences.
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Affiliation(s)
- A Chao
- Department of Biostatistics, Yale School of Public Health, Center for Methods in Implementation and Prevention Science (CMIPS), New Haven, CT, USA
| | - D Spiegelman
- Department of Biostatistics, Yale School of Public Health, Center for Methods in Implementation and Prevention Science (CMIPS), New Haven, CT, USA
| | - S Khan
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - F Walsh
- Clinton Health Access Initiative (CHAI), Boston, MA, USA
| | - S Mazibuko
- Eswatini National ART program (SNAP), Ministry of Health, Mbabane, Eswatini
| | - M Pasipamire
- Eswatini National ART program (SNAP), Ministry of Health, Mbabane, Eswatini
| | - B Chai
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - R Reis
- Leiden University Medical Center, Leiden University, Leiden, Netherlands.,Amsterdam Institute for Social Science, University of Amsterdam, Amsterdam, Netherlands.,Children's Institute, University of Cape Town, Cape Town, South Africa
| | - K Mlambo
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - W Delva
- The South African Department of Science and Technology - National Research Foundation (DST-NRF) Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.,Center for Statistics, Hasselt University, Diepenbeek, Belgium.,International Centre for Reproductive Health, Ghent University, Gent, Belgium.,Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - G Khumalo
- Eswatini National Network of People Living with HIV (SWANNEPHA), Mbabane, Eswatini
| | | | | | - E Mafara
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - A Hettema
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - C Lejeune
- Clinton Health Access Initiative (CHAI), Mbabane, Eswatini
| | - T Bärnighausen
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - V Okello
- Directorate Office, Ministry of Health, Mbabane, Eswatini
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