The effect of “universal test and treat” program on HIV treatment outcomes and patient survival among a cohort of adults taking antiretroviral treatment (ART) in low income settings of Gurage zone, South Ethiopia

Abstract

Background Through universal “test and treat approach” (UTT) it is believed that HIV new infection and AIDS related death will be reduced at community level and through time HIV can be eliminated. With this assumption the UTT program was implemented since 2016. However, the effect of this program in terms of individual patient survival and treatment outcome was not assessed in relation to the pre-existing defer treatment approach. Objective To assess the effects of UTT program on HIV treatment outcomes and patient survival among a cohort of adult HIV infected patients taking antiretroviral treatment in Gurage zone health facilities. Methods Institution based retrospective cohort study was conducted in facilities providing HIV care and treatment. Eight years (2012–2019) HIV/AIDS treatment records were included in the study. Five hundred HIV/AIDS treatment records were randomly selected and reviewed. Data were abstracted using standardized checklist by trained health professionals; then it was cleaned, edited and entered by Epi info version 7 and analyzed by STATA. Cox model was built to estimate survival differences across different study variables. Results A total of 500 patients were followed for 1632.6 person-year (PY) of observation. The overall incidence density rate (IDR) of death in the cohort was 3 per-100-PY. It was significantly higher for differed treatment program, which is 3.8 per-100-PY compared to 2.4 per-100-PY in UTT program with a p value of 0.001. The relative risk of death among differed cases was 1.58 times higher than the UTT cases. The cumulative probability of survival at the end of 1st, 2nd, 3rd, and 4th years was 98%, 90.2%, 89.2% and 88% respectively with difference between groups. The log rank test and Kaplan–Meier survival curve indicated patients enrolled in the UTT program survived longer than patients enrolled in the differed treatment program (log rank X2 test = 4.1, p value = 0.04). Age, residence, base line CD4 count, program of enrolment, development of new OIS and treatment failure were predicted mortality from HIV infection. Conclusion Mortality was significantly reduced after UTT. Therefore, intervention to further reduce deaths has to focus on early initiation of treatment and strengthening UTT programs.

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

“…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.…”

“…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".…”

Patient and programmatic characteristics, retention and predictors of attrition among patients starting antiretroviral therapy (ART) before and after the implementation of HIV “Treat All” in Zimbabwe

“…To date, the few studies assessing the real-life effects of “Treat All” have shown inconsistent findings regarding its effect on retention. Some have shown patients starting under “Treat All” likely to do better[11,12], others worse [6,7] while others showed no difference [8–10]. In our study, patients who started ART during HIV “Treat All” had lower retention and a higher risk of attrition.…”

Universal test and treat in relation to HIV disease progression: results from a stepped‐wedge trial in Eswatini

“…Of note, while the primary analysis showed a nonsignificant trend of UTT being associated with increased HIV‐related death, which is potentially concerning, a more detailed analysis of mortality in this trial found no association [11], and when the analysis was limited to sicker clients, the aHR dropped below 1. In addition, a recent study in Ethiopia reported a significant reduction of mortality with UTT [17]. Differentiated models of service delivery, in which stable clients after 12 months on ART are given multi‐month refills with reduced appointment frequency to allow a greater focus on sicker clients, have been implemented in Eswatini (piloted in some study facilities starting in 2014; national guidelines and standard operating procedures developed in 2016) and may have helped to mitigate any negative impact of UTT on sicker clients.…”