Providing antiretroviral therapy to all who are <scp>HIV</scp> positive: the clinical, public health and programmatic benefits of <i>Treat All</i>

Ford, Nathan; Vitória, Marco; Doherty, Meg

doi:10.1002/jia2.25078

Cited by 22 publications

(24 citation statements)

References 12 publications

(11 reference statements)

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“…Accordingly, in 2015 the World Health Organization (WHO) recommended immediate provision of ART to all people living with HIV (PLWH) (“Treat All”) . In sub‐Saharan Africa, the epicentre of the global HIV epidemic, nearly all countries have adopted these guidelines . However, to date, limited data from this region exist describing HIV care outcomes after national implementation of Treat All.…”

Section: Introductionmentioning

confidence: 99%

Early outcomes after implementation of treat all in Rwanda: an interrupted time series study

et al. 2019

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Introduction Nearly all countries in sub‐Saharan Africa have adopted policies to provide antiretroviral therapy ( ART ) to all persons living with HIV (Treat All), though HIV care outcomes of these programmes are not well‐described. We estimated changes in ART initiation and retention in care following Treat All implementation in Rwanda in July 2016. Methods We conducted an interrupted time series analysis of adults enrolling in HIV care at ten Rwandan health centres from July 2014 to September 2017. Using segmented linear regression, we assessed changes in levels and trends of 30‐day ART initiation and six‐month retention in care before and after Treat All implementation. We compared modelled outcomes with counterfactual estimates calculated by extrapolating baseline trends. Modified Poisson regression models identified predictors of outcomes among patients enrolling after Treat All implementation. Results Among 2885 patients, 1803 (62.5%) enrolled in care before and 1082 (37.5%) after Treat All implementation. Immediately after Treat All implementation, there was a 31.3 percentage point increase in the predicted probability of 30‐day ART initiation (95% CI 15.5, 47.2), with a subsequent increase of 1.1 percentage points per month (95% CI 0.1, 2.1). At the end of the study period, 30‐day ART initiation was 47.8 percentage points (95% CI 8.1, 87.8) above what would have been expected under the pre‐Treat All trend. For six‐month retention, neither the immediate change nor monthly trend after Treat All were statistically significant. While 30‐day ART initiation and six‐month retention were less likely among patients 15 to 24 versus >24 years, the predicted probability of both outcomes increased significantly for younger patients in each month after Treat All implementation. Conclusions Implementation of Treat All in Rwanda was associated with a substantial increase in timely ART initiation without negatively impacting care retention. These early findings support Treat All as a strategy to help achieve global HIV targets.

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Section: Introductionmentioning

confidence: 99%

Early outcomes after implementation of treat all in Rwanda: an interrupted time series study

et al. 2019

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“…Despite the wide‐scale adoption of Treat‐All in RLS , studies accounting for this policy change under routine conditions are lacking. This study began two years before publication of the WHO Treat‐All guidelines, and thus has the potential to inform implementation of this policy in similar rural settings.…”

Section: Discussionmentioning

confidence: 99%

“…HIV programmes need to maximize retention on and adherence to ART during treatment expansion to take advantage of the clinical, programmatic and public health benefits of Treat-All and achieve the second and third 90s of the UNAIDS 90-90-90 targets [5,6]. However, challenges in ART programming may be exacerbated with Treat-All, questioning the feasibility of universal ART in resource-limited settings (RLS) [7][8][9][10][11][12][13][14][15].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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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.

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“…Continued efforts also are needed to reach persons with HIV infection who are not on ART to understand and address barriers to ART initiation. Further, the full individual and public health benefits of Treat All can only be realized by overcoming program challenges for early HIV diagnosis and linkage to ART, rapid ART initiation, and support of ART adherence and retention among all persons with HIV infection ( 10 ). India is actively working to improve each of these areas through efforts that include implementation of patient-centered service delivery models to maximize the number of persons with HIV infection receiving ART and to improve quality of care.…”

Section: Discussionmentioning

confidence: 99%

Implementation of the Treat All Policy Among Persons with HIV Infection Enrolled in Care But Not on Antiretroviral Therapy — India, May 2017–June 2018

Mitruka¹,

Bamrotiya²,

Agarwal³

et al. 2018

MMWR Morb. Mortal. Wkly. Rep.

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Providing antiretroviral therapy to all who are HIV positive: the clinical, public health and programmatic benefits of Treat All

Cited by 22 publications

References 12 publications

Early outcomes after implementation of treat all in Rwanda: an interrupted time series study

Early outcomes after implementation of treat all in Rwanda: an interrupted time series study

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

Implementation of the Treat All Policy Among Persons with HIV Infection Enrolled in Care But Not on Antiretroviral Therapy — India, May 2017–June 2018

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