‘Treat all’ led to more rapid HIV treatment uptake in Africa
New analysis reveals real-world impact of the national roll-out of ‘treat all’ guidelines on antiretroviral treatment uptake in sub-Saharan Africa.
Roll-out of the ‘treat all’ public health policy across six African countries led to 81.6% of people living with HIV starting antiretroviral treatment (ART) within 30 days of confirming their HIV-positive result.
The findings come from a study published in the online journal PLOS Medicine, which investigated the impact of national adoption of universal treatment guidelines in Burundi, Kenya, Malawi, Rwanda, Uganda and Zambia.
Since 2015, the World Health Organization (WHO) has recommended all people living with HIV start treatment as soon as possible regardless of how compromised their immune system is, as measured by their CD4 count. ‘Rapid’ ART initiation is defined as starting treatment within 30 days, but the WHO now recommends treatment is started within seven days, and where possible, on the same day as the HIV-positive confirmation.
As of mid-2018, 85% of low- and middle-income countries have moved to adopt the WHO recommendation, but little is known about the real-world impact of the policy on actual treatment uptake in these countries.
Patient data in the periods immediately before and after treat-all roll-out were analysed, including 816,403 people living with HIV in the six countries participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium.
Following the introduction of treat-all policies, 59.2% of the patients started treatment on the same day as enrolment in HIV care, and 67.1% started within seven days. Rapid ART initiation under treat all was highest in Malawi (88.9%) and Rwanda (86.9%), and lowest in Burundi (77.9%). Over 60% of the people initiating treatment were women, although this proportionately levelled off in some countries, and the median ages of the patients ranged from 32 to 36 years.
Overall, there was a 25.99 percentage point (pp) increase in people accessing treatment under treat all, from 55.7% to 81.6%. These increases were most significant in populations over 25 where the percentage increase was 26.5 points compared to those aged 16 to 24, where treatment uptake increased by 22.9 percentage points.
Immediate and significant increases in the number of patients accessing treatment were observed between the study periods in four out of six of the countries. In Rwanda, the number of patients accessing treatment rose by 34.5 percentage points, from 44.4% to 78.9%. In Kenya, Burundi and Malawi, the percentage points increase was more moderate at 25.7 pp, 17.7 pp and 12.5 pp respectively.
No immediate increases were observed in Zambia (0.4 pp) or Uganda (−4.2 pp) for treat-all roll-out. But each additional month following the roll-out was associated with 2.2 pp and 2.6 pp increases in the proportion of patients initiating ART in Uganda and Zambia, respectively.
Among patients enrolled in treat all, young adults aged 16 to 24 and men were more likely to not rapidly start treatment. But this decreased over time, with more men and young people initiating ART within the 30-day period recommended by the WHO. The authors note that as further data becomes available, research should focus on whether sex and age disparities in ART initiation decrease over time.
The research also found no differences in the rapid rates of ART initiation across CD4 counts. If this had been reported, then concerns held by some that treat all could ‘crowd out’ the sickest people among the increasing numbers of healthy people also accessing treatment could have been validated. This is consistent with data from elsewhere, but the authors note that there could be variations at the country or site level, but this will be increasingly difficult to assess as fewer patients actually receive a CD4 test in the era of treat all.
Future research should also concentrate on rates and time to viral load suppression among those rapidly initiating ART, and crucially, care retention. “Additional analyses utilizing real-world service delivery data from diverse country contexts and quasi-experimental designs will be important for deriving generalizable effect estimates of the individual- and population-level benefits of treat all policies,” note the authors.