NIAID Now | June 26, 2019
When countries began providing HIV treatment to all people diagnosed with the virus, regardless of their immune health, the proportion of people who started treatment within a month of enrolling in HIV care jumped sharply in some nations, a study has found.
World Health Organization (WHO) guidelines on when people with HIV should start taking antiretroviral therapy (ART) used to be based on their CD4+ T-cell count, a measure of immune health. Four years ago, WHO recommended that all people diagnosed with HIV should start ART at any CD4+ T-cell count. Since then, at least 84 percent of low- and middle-income countries have formally adopted this “Treat All” policy.
Scientists funded by NIAID wanted to know whether the implementation of Treat All has changed how quickly people diagnosed with HIV begin taking ART. This is important from a public health perspective because starting ART soon after HIV diagnosis can curb the spread of the virus. Daily ART can reduce the amount of HIV in the blood, or the viral load, to levels that are undetectable with standard tests. Achieving and maintaining a durably undetectable viral load both preserves the health of the person living with HIV and prevents sexual transmission of the virus to an HIV-negative partner.
To help determine the impact of Treat All, the researchers looked at data on more than 810,000 people who enrolled in HIV care between 2004 and 2018 in Burundi, Kenya, Malawi, Rwanda, Uganda and Zambia. These countries began implementing Treat All between July and December 2016. The scientists estimated the effects of national adoption of Treat All policies on the percentage of people who began taking ART within 30 days of enrollment in HIV care, which the investigators called “rapid ART initiation.” The data came from HIV clinics participating in the NIAID-supported International epidemiology Databases to Evaluate AIDS (IeDEA) consortium.
Some analyses of the rate of change in a health behavior smooth differences over time and cannot evaluate a sudden change. In contrast, the investigators used a novel statistical approach to evaluate specific changes in the proportion of people with HIV who started treatment rapidly before and after the change in national HIV treatment policies. The researchers found statistically significant increases in rapid ART initiation immediately following adoption of Treat All in four of the six countries, from a 12.5 percentage point increase in Malawi to a 34.5 percentage point increase in Rwanda. In Uganda and Zambia, rapid ART initiation under Treat All did not increase immediately but rose sharply over time, by 2.2 percentage points per month in Uganda and 2.6 percentage points per month in Zambia. These higher levels of rapid ART initiation persisted well after national policy changes, suggesting the improvements can be sustained.
Descriptive analyses showed that, overall, 55.7 percent of people enrolling in HIV care rapidly initiated ART in the period before Treat All went into effect, while 81.6 percent rapidly initiated ART after—an increase of 25.9 percentage points.
While the rates of rapid ART initiation improved for all sub-groups examined, the researchers found that certain groups were less likely than others to rapidly start ART after Treat All policies went into effect. Teenagers and young adults ages 16 to 24 years were less likely to rapidly start ART than adults ages 25 and older, and men were less likely to do so than women.
This study is among the first to provide evidence outside of a controlled research setting that national adoption of Treat All policies leads to strong, sustained improvements in rapid ART initiation after enrollment in HIV care.
Reference: O Tymejczyk et al. Changes in rapid HIV treatment initiation after national “treat all” policy adoption in 6 sub-Saharan African countries: Regression discontinuity analysis. PLoS Medicine DOI: 10.1371/journal.pmed.1002822 (2019).