Uptake and effect of universal test-and-treat on twelve months retention and initial virologic suppression in routine HIV program in Kenya

Abstract

Early combination antiretroviral therapy (cART), as recommended in WHO’s universal test-and-treat (UTT) policy, is associated with improved linkage to care, retention, and virologic suppression in controlled studies. We aimed to describe UTT uptake and effect on twelve-month non-retention and initial virologic non-suppression (VnS) among HIV infected adults starting cART in routine HIV program in Kenya. Individual-level HIV service delivery data from 38 health facilities, each representing 38 of the 47 counties in Kenya were analysed. Adults (>15 years) initiating cART between the second-half of 2015 (2015HY2) and the first-half of 2018 (2018HY1) were followed up for twelve months. UTT was defined based on time from an HIV diagnosis to cART initiation and was categorized as same-day, 1–14 days, 15–90 days, and 91+ days. Non-retention was defined as individuals lost-to-follow-up or reported dead by the end of the follow up period. Initial VnS was defined based on the first available viral load test with >400 copies/ml. Hierarchical mixed-effects survival and generalised linear regression models were used to assess the effect of UTT on non-retention and VnS, respectively. Of 8592 individuals analysed, majority (n = 5864 [68.2%]) were female. Same-day HIV diagnosis and cART initiation increased from 15.3% (2015HY2) to 52.2% (2018HY1). The overall non-retention rate was 2.8 (95% CI: 2.6–2.9) per 100 person-months. When compared to individuals initiated cART 91+ days after a HIV diagnosis, those initiated cART on the same day of a HIV diagnosis had the highest rate of non-retention (same-day vs. 91+ days; aHR, 1.7 [95% CI: 1.5–2.0], p<0.001). Of those included in the analysis, 5986 (69.6%) had a first viral load test done at a median of 6.3 (IQR, 5.6–7.6) months after cART initiation. Of these, 835 (13.9%) had VnS. There was no association between UTT and VnS (same-day vs. 91+ days; aRR, 1.0 [95% CI: 0.9–1.2], p = 0.664). Our findings demonstrate substantial uptake of the UTT policy but poor twelve-month retention and lack of an association with initial VnS from routine HIV settings in Kenya. These findings warrant consideration for multi-pronged program interventions alongside UTT policy for maximum intended benefits in Kenya.

Real-world impact of integrating HIV assisted partner services into 31 facilities in Kenya: a single-arm, hybrid type 2 implementation-effectiveness study

“…Utilising the denominator of those with viral load results available, over 90% of all three groups were virally suppressed, which is higher than Kenya national programme data (85% virally suppressed among those with available viral load results. 25 A study evaluating national programme data from Kenya showed that male individuals were half as likely to get a viral test compared with female individuals. 26 The incomplete assessment of viral load adds uncertainty to our results; however, male individuals with newly diagnosed HIV also have slightly lower confirmed retention on ART at 12 months (86%) compared with male individuals with known HIV-positive status (90%) and female individuals (88%) at 12 months, and retention in care declined in all groups over time.…”

The effect of the Universal Test and Treat policy uptake on CD4 count testing and incidence of opportunistic infections among people living with HIV infection in Cameroon: a retrospective analysis of routine data

“…This sharp increase from 2016 corresponded with the introduction of the test and treat-all strategy. Substantial uptake of the UTT policy has been reported across several sub-Saharan African countries [ [20] , [21] , [22] , [23] , [24] , [25] ]. This successful implementation of the UTT policy has been facilitated intuitively from the removal of the CD4 eligibility threshold for ART initiation, but also by experiences gained from the Option B+ approach that preceded UTT, the extraordinary financial support and pressures from different stakeholders (from governments, civil society groups, researchers, and donors) to accelerate the implementation of UTT [ 26 , 27 ].…”

Changes in access to viral load testing, incidence rates of viral load suppression and rebound following the introduction of the ‘universal test and treat’ guidelines in Cameroon: A retrospective follow-up analysis

“…The Cox regression model was used to screen for factors independently associated with VLS or VLR. These factors were selected based on a previous study in Kenya by Kimanga et al [ 16 ]. Hazard ratios with their corresponding 95% confidence intervals (95%CI) and p-values were obtained from the final multivariable Cox model.…”