Association of Implementation of a Universal Testing and Treatment Intervention With HIV Diagnosis, Receipt of Antiretroviral Therapy, and Viral Suppression in East Africa

Petersen, Maya; Balzer, Laura B.; Kwarsiima, D; Sang, Norton; Chamie, Gabriel; Ayieko, James; Kabami, Jane; Owaraganise, Asiphas; Liegler, Teri; Mwangwa, Florence; Kadede, Kevin; Jain, Vivek; Plenty, Albert; Brown, Lillian B.; Lavoy, Geoff; Schwab, Joshua; Black, Douglas; Laan, Mark van der; Bukusi, Elizabeth A.; Cohen, Craig R.; Clark, Tamara D.; Charlebois, Edwin D.; Kamya, Moses R.; Havlir, Diane V.

doi:10.1001/jama.2017.5705

Cited by 127 publications

(158 citation statements)

References 34 publications

Supporting

Mentioning

152

Contrasting

Unclassified

Order By: Relevance

“…Similar results were observed even when excluding patients who were not eligible for ART prior to Treat All implementation, indicating that the change was not solely due to the new guideline and its implementation at the sites, but rather in improved programme capacity to rapidly initiate ART. These data are consistent with successful implementation of earlier ART guidelines in Rwanda leading to rapid increases in median CD4 count at ART initiation, as well as global data showing rapid increases in ART uptake as treatment thresholds increased .…”

Section: Discussionsupporting

confidence: 83%

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

et al. 2019

View full text Add to dashboard Cite

Introduction Nearly all countries in sub‐Saharan Africa have adopted policies to provide antiretroviral therapy ( ART ) to all persons living with HIV (Treat All), though HIV care outcomes of these programmes are not well‐described. We estimated changes in ART initiation and retention in care following Treat All implementation in Rwanda in July 2016. Methods We conducted an interrupted time series analysis of adults enrolling in HIV care at ten Rwandan health centres from July 2014 to September 2017. Using segmented linear regression, we assessed changes in levels and trends of 30‐day ART initiation and six‐month retention in care before and after Treat All implementation. We compared modelled outcomes with counterfactual estimates calculated by extrapolating baseline trends. Modified Poisson regression models identified predictors of outcomes among patients enrolling after Treat All implementation. Results Among 2885 patients, 1803 (62.5%) enrolled in care before and 1082 (37.5%) after Treat All implementation. Immediately after Treat All implementation, there was a 31.3 percentage point increase in the predicted probability of 30‐day ART initiation (95% CI 15.5, 47.2), with a subsequent increase of 1.1 percentage points per month (95% CI 0.1, 2.1). At the end of the study period, 30‐day ART initiation was 47.8 percentage points (95% CI 8.1, 87.8) above what would have been expected under the pre‐Treat All trend. For six‐month retention, neither the immediate change nor monthly trend after Treat All were statistically significant. While 30‐day ART initiation and six‐month retention were less likely among patients 15 to 24 versus >24 years, the predicted probability of both outcomes increased significantly for younger patients in each month after Treat All implementation. Conclusions Implementation of Treat All in Rwanda was associated with a substantial increase in timely ART initiation without negatively impacting care retention. These early findings support Treat All as a strategy to help achieve global HIV targets.

show abstract

Section: Discussionsupporting

confidence: 83%

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

et al. 2019

View full text Add to dashboard Cite

show abstract

“…A large meta-analysis has also highlighted the benefits of decentralizing care and task shifting, demonstrating a more favorable effect for community-based vs. clinic-based ART programs on engagement in care in low- and middle-income countries 28 . Although both community- and clinic-based interventions demonstrated similar effects on adherence, virologic suppression, and mortality in this meta-analysis, interim data from the contemporary SEARCH study in east Africa suggest that community-based testing and treatment may lead to even greater improvements in ART coverage and viral suppression that meet 90-90-90 goals 29 . RHD control programs typically receive limited funding due to competing public health priorities, so cost-effectiveness and local sustainability are important.…”

Section: Discussionmentioning

confidence: 73%

Rheumatic Heart Disease Treatment Cascade in Uganda

Longenecker

Morris

Aliku

et al. 2017

Circ: Cardiovascular Quality and Outcomes

View full text Add to dashboard Cite

Background Rheumatic heart disease (RHD) is a leading cause of premature death and disability in low-income countries; however, few receive optimal benzathine penicillin G (BPG) therapy to prevent disease progression. We aimed to comprehensively describe the treatment cascade for RHD in Uganda in order to identify appropriate targets for intervention. Methods and Results Using data from the Uganda RHD Registry (n=1,504), we identified the proportion of patients in the following care categories: (1) diagnosed and alive as of June 1, 2016, (2) retained in care, (3) appropriately prescribed BPG, and (4) optimally adherent to BPG (>80% of prescribed doses). We used logistic regression to investigate factors associated with retention and optimal adherence. Overall, median (IQR) age was 23 (15–38) years; 69% were female; and 82% had clinical RHD. Median follow-up time was 2.4 (0.9–4.0) years. Retention in care was the most significant barrier to achieving optimal BPG adherence with only 56.9% (95% CI 54.1–59.7%) of living subjects having attended clinic in the prior 56 weeks. Among those retained in care, however, we observed high rates of BPG prescription [91.6% (95% CI 89.1–93.5%)] and optimal adherence (91.4% [95% CI 88.7–93.5]). Younger age, latent disease status, and access to care at a regional center were the strongest independent predictors of retention and optimal adherence. Conclusions Our study suggests that improving retention in care—possibly by decentralizing RHD services—would have the greatest impact on uptake of antibiotic prophylaxis among patients with RHD in Uganda.

show abstract

“…Twenty‐three studies reported Population‐wide Viral Suppression and only three performed a statistical comparison of Population‐wide Viral Suppression across a demographic or risk strata of interest. A study in Kenya and Uganda found that groups aged 15 to 24 and 25 to 34 had statistically lower Population‐wide Viral Suppression compared to groups aged greater than 44 (RD −9.2%; 95% CI −3.6 to −14.9) [36]. The authors found that groups spending one month or longer away from their community had lower risks of Population‐wide Viral Suppression compared to groups spending less than one month away from their community, but this finding was not statistically significant (RD 2·6%; 95% CI −0.6 to 5.9%).…”

Section: Resultsmentioning

confidence: 99%

Evidence of sociodemographic heterogeneity across the HIV treatment cascade and progress towards 90‐90‐90 in sub‐Saharan Africa – a systematic review and meta‐analysis

et al. 2020

View full text Add to dashboard Cite

Introduction Heterogeneity of sociodemographics and risk behaviours across the HIV treatment cascade could influence the public health impact of universal ART in sub‐Saharan Africa if those not virologically suppressed are more likely to be part of a risk group contributing to onward infections. Sociodemographic and risk heterogeneity across the treatment cascade has not yet been comprehensively described or quantified and we seek to systematically review and synthesize research on this topic among adults in Africa. Methods We conducted a systematic review of peer‐reviewed literature in Embase and MEDLINE databases as well as grey literature sources published in English between 2014 and 2018. We included studies that included people living with HIV (PLHIV) aged ≥15 years, and reported a 90‐90‐90 outcome: awareness of HIV‐positive status, ART use among those diagnosed or viral suppression among those on ART. We summarized measures of association between sociodemographics, within each outcome, and as a composite measure of population‐wide viral suppression. Results and discussion From 3533 screened titles, we extracted data from 92 studies (50 peer‐reviewed, 42 grey sources). Of included studies, 32 reported on awareness, 53 on ART use, 32 on viral suppression and 23 on population‐wide viral suppression. The majority of studies were conducted in South Africa, Uganda, and Malawi and reported data for age and gender. When stratified, PLHIV ages 15 to 24 years had lower median achievement of the treatment cascade (60‐49‐81), as compared to PLHIV ≥25 years (70‐63‐91). Men also had lower median achievement of the treatment cascade (66‐72‐85), compared to women (79‐76‐89). For population‐wide viral suppression, women aged ≥45 years had achieved the 73% target, while the lowest medians were among 15‐ to 24‐year‐old men (37%) and women (49%). Conclusions Considerable heterogeneity exists by age and gender for achieving the HIV 90‐90‐90 treatment goals. These results may inform delivery of HIV testing and treatment in sub‐Saharan Africa, as targeting youth and men could be a strategic way to maximize the population‐level impact of ART.

show abstract

Association of Implementation of a Universal Testing and Treatment Intervention With HIV Diagnosis, Receipt of Antiretroviral Therapy, and Viral Suppression in East Africa

Abstract: clinicaltrials.gov Identifier: NCT01864683.

Cited by 127 publications

References 34 publications

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

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

Rheumatic Heart Disease Treatment Cascade in Uganda

Evidence of sociodemographic heterogeneity across the HIV treatment cascade and progress towards 90‐90‐90 in sub‐Saharan Africa – a systematic review and meta‐analysis

Contact Info

Product

Resources

About