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

Tymejczyk, Olga; Brazier, Ellen; Yiannoutsos, Constantin T.; Vinikoor, Michael J.; Lettow, Monique van; Nalugoda, Fred; Urassa, Mark; Sinayobye, Jean d’Amour; Rebeiro, Peter F; Wools‐Kaloustian, Kara; Davies, Mary‐Ann; Zaniewski, Elizabeth; Anderegg, Nanina; Liu, Grace S; Ford, Nathan; Nash, Denis

doi:10.1371/journal.pmed.1002822

Cited by 59 publications

(63 citation statements)

References 26 publications

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“…Importantly, this was a secondary data analysis of studies conducted in 2013 or earlier and the prevalence and characteristics of people with advanced HIV may have changed. Nevertheless, although most countries have adopted 'treat all' there may be delays in implementation at the level of all facilities and our results would thus remain relevant for settings where 'treat all' has not yet been fully implemented [29]. Finally, as stated in the methods, the surveys were not representative at country level and subgroup analysis was not planned at the design stage analysis, therefore, our results should be interpreted with caution.…”

Section: Discussionmentioning

confidence: 84%

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)

Chihana

Huerga²,

Cutsem

et al. 2019

Global Health Action

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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.

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Section: Discussionmentioning

confidence: 84%

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)

Chihana

Huerga²,

Cutsem

et al. 2019

Global Health Action

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“…To date, studies on whether HIV "Treat All" has improved ART initiation among adolescents are inconclusive. Positive effects have been shown in some studies, while others have shown that they are still at risk of not initiating ART [23,[27][28][29]. To our knowledge, no evidence-based strategies are currently being implemented in Zimbabwe on a broader scale under "Treat All" to promote ART initiation among adolescents and young adults.…”

Section: Plos Onementioning

confidence: 99%

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

et al. 2020

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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).

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“…19 The MOH has also become a leader in progressive antiretroviral therapy programmes, such as Option B+ and universal treatment. [20][21][22] Given this ongoing success in treating chronic infectious disease as well as the resources invested in these programmes, and Malawi's growing burden of chronic NCDs, integrated care for chronic diseases is an attractive solution. Applying lessons from HIV care delivery to NCDs is well described, and an integrated approach is increasingly recognised as a possible delivery model, particularly for primary care, with much of the literature focused on calling for various integrated approaches.…”

Section: Introductionmentioning

confidence: 99%

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

Wroe

Kalanga²,

Dunbar³

et al. 2020

BMJ Open

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ObjectivesNon-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).DesignThis is a retrospective cohort study.SettingThe study includes an HIV–NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi.ParticipantsAll 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.InterventionsPatients 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 measuresRoutine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis.ResultsNCD 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.ConclusionsThe 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.

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

Cited by 59 publications

References 26 publications

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)

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)

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

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

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