Research priorities to inform “Treat All” policy implementation for people living with HIV in sub‐Saharan Africa: a consensus statement from the International epidemiology Databases to Evaluate AIDS (IeDEA)

Abstract

Introduction “Treat All” – the treatment of all people with HIV, irrespective of disease stage or CD4 cell count – represents a paradigm shift in HIV care that has the potential to end AIDS as a public health threat. With accelerating implementation of Treat All in sub‐Saharan Africa (SSA), there is a need for a focused agenda and research to identify and inform strategies for promoting timely uptake of HIV treatment, retention in care, and sustained viral suppression and addressing bottlenecks impeding implementation. Methods The Delphi approach was used to develop consensus around research priorities for Treat All implementation in SSA. Through an iterative process (June 2017 to March 2018), a set of research priorities was collectively formulated and refined by a technical working group and shared for review, deliberation and prioritization by more than 200 researchers, implementation experts, policy/decision‐makers, and HIV community representatives in East, Central, Southern and West Africa. Results and discussion The process resulted in a list of nine research priorities for generating evidence to guide Treat All policies, implementation strategies and monitoring efforts. These priorities highlight the need for increased focus on adolescents, men, and those with mental health and substance use disorders – groups that remain underserved in SSA and for whom more effective testing, linkage and care strategies need to be identified. The priorities also reflect consensus on the need to: (1) generate accurate national and sub‐national estimates of the size of key populations and describe those who remain underserved along the HIV‐care continuum; (2) characterize the timeliness of HIV care and short‐ and long‐term HIV care continuum outcomes, as well as factors influencing timely achievement of these outcomes; (3) estimate the incidence and prevalence of HIV‐drug resistance and regimen switching; and (4) identify cost‐effective and affordable service delivery models and strategies to optimize uptake and minimize gaps, disparities, and losses along the HIV‐care continuum, particularly among underserved populations. Conclusions Reflecting consensus among a broad group of experts, researchers, policy‐ and decision‐makers, PLWH, and other stakeholders, the resulting research priorities highlight important evidence gaps that are relevant for ministries of health, funders, normative bodies and research networks.

HIV viral suppression among pregnant and breastfeeding women in routine care in the Kinshasa province: a baseline evaluation of participants in CQI‐PMTCT study

“…If the same level of drug resistance were to be true in our sample, more than 20% of pregnant and breastfeeding women in care in Kinshasa would have drug resistance to potentially TDF and EFV. These findings support the call from a recent consensus statement on research priorities to inform “treat all” implementation in sub‐Saharan Africa for research to estimate the incidence and prevalence of drug resistance .…”

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

“…The high frequency of missing data may be a function of less frequent CD4 monitoring as this is no longer needed to determine treatment eligibility, despite the continued recommendation of baseline CD4 measurement in national guidelines [19]. Similar findings were observed in South Africa under changes in CD4 monitoring policy [32] and may be expected in other settings as Treat All implementation continues [33], potentially limiting opportunities to evaluate the impact of this policy. Among patients enrolling in care after Treat All, we also observed negligible differences among patients grouped by baseline CD4 count with respect to six-month retention in care.…”

Decreasing time to antiretroviral therapy initiation after HIV diagnosis in a clinic‐based observational cohort study in four African countries

“…These findings highlight the need to diagnose HIV earlier while improving access to immediate ART after diagnosis. In our study, most participants in the current era started ART within weeks of HIV diagnosis, so particular attention must be paid to identifying barriers and gaps in diagnosing HIV earlier in the course of infection . Other studies have similarly found that diagnosing individuals with HIV before disease progression is a major challenge in the care cascade .…”