Evaluation of the clinical outcomes of the Test and Treat strategy to implement Treat All in Nigeria: Results from the Nigeria Multi-Center ART Study

Abstract

In December 2016, the Nigerian Federal Ministry of Health updated its HIV guidelines to a Treat All approach, expanding antiretroviral therapy (ART) eligibility to all individuals with HIV infection, regardless of CD4+ cell count, and recommending ART be initiated within two weeks of HIV diagnosis (i.e., the Test and Treat strategy). The Test and Treat policy was first piloted in 32 local government areas (LGAs). The primary objective of this study was to evaluate the clinical outcomes of adult patients initiated on ART within two weeks of HIV diagnosis during this pilot. We conducted a retrospective cohort analysis of patients who initiated ART within two weeks of new HIV diagnosis between October 2015 and September 2016 in eight randomly selected LGAs participating in the Test and Treat pilot study. 2,652 adults were newly diagnosed and initiated on ART within two weeks of HIV diagnosis. Of these patients, 8% had documentation of a 12-month viral load measurement, and 13% had documentation of a six-month viral load measurement. Among Test and Treat patients with a documented viral load, 79% were suppressed (≤400 copies/ml) at six months and 78% were suppressed at 12 months. By 12 months post-ART initiation, 34% of the patients who initiated ART under the Test and Treat strategy were lost to follow-up. The median CD4 cell count among patients initiating ART within two weeks of HIV diagnosis was 323 cells/mm 3 (interquartile range, 161–518). While randomized controlled trials have demonstrated that Test and Treat strategies can improve patient retention and increase viral suppression compared to standard of care, these findings indicate that the effectiveness of Test and Treat in some settings may be far lower than the efficacy demonstrated in randomized controlled trials. Significant attention to the way Test and Treat strategies are implemented, monitored, and improved particularly related to early retention, can help expand access to ART for all patients.

Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe’s National Antiretroviral Therapy Programme between 2012 and 2015

“…On top of the change in the CD4 cut off point, test and treat was also introduced to specific sub-populations (children under 5 years, TB/HIV co-infected, HBV/HIV co-infected, the HIV-positive partner in HIV sero-discordant relationship and pregnant and breastfeeding mothers (Option B+). Similar findings were reported in previous studies, which showed that patients who started ART at a higher CD4 were at risk of attrition[8, 9]. Patients starting ART at high CD4 are less sick and have low risk perception which might affect adherence to long term therapy [55].…”

Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe’s national antiretroviral therapy programme between 2012 and 2015

“…On top of the change in the CD4 cut-off point, test and treat was also introduced to specific sub-populations (children under 5 years, TB/HIV co-infected, HBV/HIV co-infected, the HIV-positive partner in HIV sero-discordant relationship and pregnant and breastfeeding mothers (Option B+). Similar findings were reported in previous studies, which showed that patients who started ART at a higher CD4 were at risk of attrition [8,9]. Patients starting ART at high CD4 are less sick and have low risk perception which might affect adherence to long term therapy [64].…”

“…Early ART initiation as measured by shorter time duration between HIV testing and ART initiation has been shown to reduce risk of attrition [6,7]. Other studies have however shown that those who initiate ART at a higher baseline CD4 may also be prone to attrition [8,9].…”

Predictors of first-line antiretroviral therapy failure among adults and adolescents living with HIV/AIDS in a large prevention and treatment program in Nigeria

“…Nigeria adopted in 2015 a ‘test and treat’ policy of ART initiation in all PLWH regardless of CD4, clinical stage, age or population [ 6 ]. Although additional work is needed to completely achieve this goal, efforts have been made to scale-up treatment access and the number of PLWH receiving ART almost doubled between 2015 and 2018 [ 7 ].…”