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

Abstract

IntroductionHPTN 071 (PopART) is a three‐arm community randomized trial in Zambia and South Africa evaluating the impact of a combination HIV prevention package, including universal test and treat (UTT), on HIV incidence. This nested study examined factors associated with timely linkage‐to‐care and ART initiation (TLA) (i.e. within six‐months of referral) in the context of UTT within the intervention communities of the HPTN 071 (PopART) trial.MethodsOf the 7572 individuals identified as persons living with HIV (PLWH) (and not on antiretroviral treatment (ART)) during the first year of the PopART intervention provided by Community HIV‐care Providers (CHiPs) through door‐to‐door household visits, individuals who achieved TLA (controls) and those who did not (cases), stratified by gender and community, were randomly selected to be re‐contacted for interview. Standardized questionnaires were administered to explore factors potentially associated with TLA, including demographic and behavioural characteristics, and participants’ opinions on HIV and related services. Odds ratios comparing cases and controls were estimated using a multi‐variable logistic regression.ResultsData from 705 participants (333 cases/372 controls) were analysed. There were negligible differences between cases and controls by demographic characteristics including age, marital or socio‐economic position. Prior familiarity with the CHiPs encouraged TLA (aOR of being a case: 0.58, 95% CI: 0.39 to 0.86, p = 0.006).Participants who found clinics overcrowded (aOR: 1.51, 95% CI: 1.08 to 2.12, p = 0.006) or opening hours inconvenient (aOR: 1.63, 95% CI: 1.06 to 2.51, p = 0.02) were less likely to achieve TLA, as were those expressing stronger feelings of shame about having HIV (p trend = 0.007). Expressing “not feeling ready” (aOR: 2.75, 95% CI: 1.89 to 4.01, p < 0.001) and preferring to wait until they felt sick (aOR: 2.00, 95% CI: 1.27 to 3.14, p = 0.02) were similarly indicative of being a case. Worrying about being seen in the clinic or about how staff treated patients was not associated with TLA.While the association was not strong, we found that the greater the number of self‐reported lifetime sexual partners the more likely participants were to achieve TLA (p trend = 0.06). There was some evidence that participants with HIV‐positive partners on ART were less likely to be cases (aOR: 0.75, 95% CI: 0.53 to 1.06, p = 0.07).DiscussionThe lack of socio‐demographic differences between cases and controls is encouraging for a “universal” intervention that seeks to ensure high coverage across whole communities. Making clinics more “patient‐friendly” could enhance treatment uptake further. The finding that those with higher risk behaviour are more actively engaging with UTT holds promise for treatment‐as‐prevention.

Rapid initiation of antiretroviral therapy for people living with HIV

“…We excluded several studies as they assessed the effect of ART initiation related to CD4 threshold rather than initiating ART soon after HIV diagnosis (Achhra 2017; Danel 2015; Iwuji 2017; Sabapathy 2017; Larmarange 2016; Plazy 2016; Temprano 2015). We further excluded studies that specifically assessed timing of ART in participants who had oppurtunistic infections such as cryptococcal meningitis or tuberculosis meningitis (Bisson 2013; Blanc 2011; Boulware 2014; Degu 2012; Grant 2010; Havlir 2011; Laurelliard 2013; Makadzange 2010).…”

“…They only included PLWH with cryptococcal meningitis.Plazy 2016Wrong intervention. ART initiation was not based on time since diagnosis, but on CD4 count.Sabapathy 2017Wrong intervention. ART initiation was not based on time since diagnosis, but on CD4 count.Temprano 2015Wrong intervention.…”

Feasibility of antiretroviral therapy initiation under the treat‐all policy under routine conditions: a prospective cohort study from Eswatini

“…Patients diagnosed on the same day as enrolment for HIV care were less likely to initiate treatment in both interventions, possibly related to internalized stigma when receiving an HIV diagnosis .…”

“…Patients diagnosed on the same day as enrolment for HIV care were less likely to initiate treatment in both interventions, possibly related to internalized stigma when receiving an HIV diagnosis [37,38]. Data suggested that patients under Treat-All who have had secondary education may be more likely to initiate ART.…”

Questionable assumptions mar modelling of Kenya home‐based testing campaigns

“…The authors appraise the assumptions made by the model and question whether the modelled HBCT programme in western Kenya could be improved [2].As the authors are aware, high prevalence settings often require active outreach to identify a meaningful proportion of the infected population [3]. However, timely linkage to care following diagnosis remains a challenge [4]. Several studies are looking at innovative means of addressing this, including the use of peer navigators [5], mHealth initiatives [6], and same-day ART start [7].Meanwhile, a different -but still valid -question concerns how best to use an existing programme, in this case through repeating it to test more people.…”