Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa

Abstract

Prompt uptake of antiretroviral treatment (ART) is essential to ensure the success of universal test and treat (UTT) strategies to prevent HIV transmission in high-prevalence settings. We describe ART initiation rates and associated factors within an ongoing UTT cluster-randomized trial in rural South Africa. HIV-positive individuals were offered immediate ART in the intervention arm vs. national guidelines recommended initiation (CD4≤350 cells/mm3) in the control arm. We used data collected up to July 2015 among the ART-eligible individuals linked to TasP clinics before January 2015. ART initiation rates at one (M1), three (M3) and six months (M6) from baseline visit were described by cluster and CD4 count strata (cells/mm3) and other eligibility criteria: ≤100; 100–200; 200–350; CD4>350 with WHO stage 3/4 or pregnancy; CD4>350 without WHO stage 3/4 or pregnancy. A Cox model accounting for covariate effect changes over time was used to assess factors associated with ART initiation. The 514 participants had a median [interquartile range] follow-up duration of 1.08 [0.69; 2.07] months until ART initiation or last visit. ART initiation rates at M1 varied substantially (36.9% in the group CD4>350 without WHO stage 3/4 or pregnancy, and 55.2–71.8% in the three groups with CD4≤350) but less at M6 (from 85.3% in the first group to 96.1–98.3% in the three other groups). Factors associated with lower ART initiation at M1 were a higher CD4 count and attending clinics with both high patient load and higher cluster HIV prevalence. After M1, having a regular partner was the only factor associated with higher likelihood of ART initiation. These findings suggest good ART uptake within a UTT setting, even among individuals with high CD4 count. However, inadequate staffing and healthcare professional practices could result in prioritizing ART initiation in patients with the lowest CD4 counts.

Socio‐economic status and time trends associated with early ART initiation following primary HIV infection in Montreal, Canada: 1996 to 2015

“…Boyer et al . recently described early ART initiation rates and associated factors in 514 HIV‐infected individuals enrolled in a universal test and treat cluster randomized trial in South Africa . They reported an early ART initiation rate of 88% from 2012 to 2015, which is consistent with our result for a similar time period.…”

Comparative assessment of five trials of universal HIV testing and treatment in sub‐Saharan Africa

“…The proportion of adults who had no secondary school education ranged from 13% in the South African communities of PopART (unpublished data) to 71% in the SEARCH communities 28. While all trials are conducted in areas which suffer from generalized HIV epidemics, the baseline prevalence of HIV also varied and was estimated to be 30% TasP trial sites 29, 29% in BCPP 30, 29% in Max ART 31, 22% in the South African sites of the PopART (unpublished data), 21% in the Zambian sites of PopART (unpublished data), 20% in SEARCH Kenyan communities 32, and is less than 10% in the SEARCH Ugandan communities 32. Finally, important disparities are observed across trials in relation to the extent of development of the HIV health systems at baseline.…”

“…Besides characterizing the trial populations with standard socio‐demographic information, these trials also collect experiences and perceptions of a sample of trial participants, community members and services providers. Such qualitative research provides evidence to understand the acceptability of the UTT strategies by the general population 29, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69. Overall, the analysis of the various themes addressed within these five trials will contribute to understanding the impact of UTT strategies in various contexts as well as inform the generalization of such a strategy to new contexts.…”

Predictors of timely linkage‐to‐ART within universal test and treat in the HPTN 071 (PopART) trial in Zambia and South Africa: findings from a nested case‐control study

“…There is evidence on factors associated with initiation of ART, usually among individuals who have already linked‐to‐care at least once since HIV diagnosis and from contexts where ART eligibility criteria applied . More scarce are data from settings providing immediate treatment or UTT, with the latter not only making ART immediately available for all who have already presented to health‐facilities, but first seeking to test everyone in the community (universal testing) . Although a UTT approach substantially simplifies treatment by removing ART initiation criteria, providers must still negotiate all the steps along the cascade of care, to link clients to care following HIV detection in the community and achieve timely initiation of ART.…”