HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

Abstract

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.

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

“…In the current study, adolescents and young adults had comparable retention with adults contrary to other studies. The finding is contrary to other programmatic HIV "Treat All" studies to date [6,7,[9][10][11]. Zimbabwe has employed strategies to retain adolescents in care, mainly through its home-grown community adolescent's treatment supporters (CATS) model.…”

“…To date, the few studies assessing the real-life effects of “Treat All” have shown inconsistent findings regarding its impact on retention. Some studies have shown patients starting under “Treat All” likely to do better [ 11 , 12 ], others worse [ 6 , 7 ] while others showed no difference [ 8 – 10 ]. Several factors can explain the conflicting findings in these studies.…”

“…The health care workers might be unable to prepare and provide adequate counselling on the importance of adhering to lifelong ART to these asymptomatic patients who might not appreciate its benefits hence defaulting treatment [38]. In a study conducted in Eswatini, the percentage of patients who never returned after the first same-day ART initiation visit doubled (from 3 to 6%) during the "Treat All" period [10]. In clinical trials, same-day ART initiation has shown either no difference or a positive effect on retention [34][35][36][37].…”

“…Compared to other implementation studies conducted to date comparing outcomes before and after "Treat All" [6][7][8][9][10][11][12][13], our study sample size was large. The pilot districts were distributed across all the regions of the country.…”

“…Multiple studies have assessed the realworld effects of "Treat All" on ART initiation, linkage, virologic suppression, and retention. However, these studies have reported inconsistent results [6][7][8][9][10][11][12][13]. None of these previous studies has assessed if predictors for attrition changed since the transition to "Treat All".…”