Retention in Care Trajectories of HIV-Positive Individuals Participating in a Universal Test-and-Treat Program in Rural South Africa (ANRS 12249 TasP Trial)

Gosset, Andréa; Protopopescu, Camélia; Larmarange, Joseph; Orne-Gliemann, Joanna; McGrath, Nuala; Pillay, Deenan; Dabis, François; Iwuji, Collins; Boyer, Sylvie

doi:10.1097/qai.0000000000001938

Cited by 37 publications

(35 citation statements)

References 38 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…However, point estimates of retention tended to be lower than under SOC, than previous retention estimates from this setting before the introduction of Treat‐All and than in a streamlined combination intervention trial in Eastern Africa . Similarly to another Treat‐All trial in South Africa , 6% of patients never returned for a clinic visit after ART initiation (vs. 3% under SOC). A broad range of supportive interventions may improve retention (e.g.…”

Section: Discussioncontrasting

confidence: 57%

“…The association was more pronounced for patients presenting with advanced HIV disease, and the effect of CD4 cell count varied with time under SOC, with higher hazard early during treatment. Notably, under Treat‐All, outcomes for patients with high CD4 cell counts were similar to those for patients with 201 to 350 cells/mm 3 , a pattern confirmed by two other Treat‐All trials but in contrast to findings from the Western Cape, South Africa, where attrition was increased for CD4 >500 cells/mm 3 .…”

Section: Discussionsupporting

confidence: 55%

“…Overall retention was comparable to ART programmes in low‐ and middle‐income countries and two Treat‐All trials in Southern Africa . However, point estimates of retention tended to be lower than under SOC, than previous retention estimates from this setting before the introduction of Treat‐All and than in a streamlined combination intervention trial in Eastern Africa .…”

Section: Discussionmentioning

confidence: 60%

“…The impact of changing ART eligibility criteria in RLS is poorly understood because of the lack of recent programme data , the gap between supporting health policies and efficient operationalization and inconclusive treatment outcome data from ongoing Treat‐All trials . Eswatini (formerly Swaziland) is one of the few countries that piloted the Treat‐All policy before it became a WHO recommendation in 2016 .…”

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

et al. 2020

View full text Add to dashboard Cite

Introduction The Treat‐All policy – antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria – increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat‐All in resource‐limited settings. We aimed to describe and compare programmatic outcomes between Treat‐All and standard of care (SOC) in the public sectors of Eswatini. Methods This is a prospective cohort study of ≥16‐year‐old HIV‐positive patients initiated on first‐line ART under Treat‐All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan‐Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all‐cause attrition and viral failure. Results Of the 3170 patients, 1888 (59.6%) initiated ART under Treat‐All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat‐All (71%) than SOC (75%) (p = 0.002), it was similar in covariate‐adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat‐All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat‐All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat‐All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3. Under Treat‐All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine. Conclusions Compared to SOC, Treat‐All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.

show abstract

Section: Discussioncontrasting

confidence: 57%

Section: Discussionsupporting

confidence: 55%

Section: Discussionmentioning

confidence: 60%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

et al. 2020

View full text Add to dashboard Cite

show abstract

“…This result could partly explain why the trial did not demonstrate a significant difference in the cumulative HIV incidence between trial arms: 2.11% in the intervention arm and 2.27% in the control arm (adjusted hazard ratio: 1.01 [95% CI: 0.87 to 1.17], p = 0.89) . Despite a higher proportion of HIV positive individuals becoming aware of their HIV status as a result of the trial, a high proportion of those initiating ART achieving virological suppression , high levels of treatment adherence and good retention into care , low linkage to care was observed . As a result, ART initiation remained similar between arms: all ART initiations within trial clinics represent 17% (662/3940) of the PLHIV population in the intervention arm, compared with 12% (554/4623) in the control arm.…”

Section: Discussionmentioning

confidence: 96%

Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa

et al. 2019

Self Cite

View full text Add to dashboard Cite

Introduction The universal test‐and‐treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa. Methods The TasP cluster‐randomized trial (2012 to 2016) implemented six‐monthly repeat home‐based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 × 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level. Results 8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited. Conclusions PVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART‐initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90‐90‐90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context‐specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH‐27‐0512‐3974 (South African National Clinical Trials Register).

show abstract

Attrition in HIV care following HIV diagnosis: a comparison of the pre‐UTT and UTT eras in South Africa

Onoya

Hendrickson

Sineke

et al. 2021

J. Intern. AIDS Soc.

View full text Add to dashboard Cite

Introduction Policies for Universal Test & Treat (UTT) and same‐day initiation (SDI) of antiretroviral therapy (ART) were instituted in South Africa in September 2016 and 2017 respectively. However, there is limited evidence on whether these changes have improved patient retention after HIV diagnosis. Methods We enrolled three cohorts of newly diagnosed HIV‐infected adults from two primary health clinics in Johannesburg from April to November 2015 (Pre‐UTT, N = 144), May‐September 2017 (UTT, N = 178) and October‐December 2017 (SDI, N = 88). A baseline survey was administered immediately after HIV diagnosis after which follow‐up using clinical records (paper charts, electronic health records and laboratory data) ensued for 12 months. The primary outcome was patient loss to follow‐up (being >90 days late for the last scheduled appointment) at 12 months post‐HIV diagnosis. We modelled attrition across HIV policy periods with Cox proportional hazard regression. Results Overall, 410 of 580 screened HIV‐positive patients were enrolled. Overall, attrition at 12 months was 30% lower in the UTT guideline period (38.2%) compared to pre‐UTT (47.2%, aHR 0.7, 95% CI: 0.5 to 1.0). However, the total attrition was similar between the SDI (47.7%) and pre‐UTT cohorts (aHR 1.0, 95% CI: 0.7 to 1.5). Older age at HIV diagnosis (aHR 0.5 for ≥40 vs. 25 to 29 years, 95% CI: 0.3 to 0.8) and being in a non‐marital relationship (aHR 0.5 vs. being single, 95% CI: 0.3 to 0.8) protected against LTFU at 12 months, whereas LTFU rates increased with longer travel time to the diagnosing clinic (aHR 1.8 for ≥30 minutes vs. ≤15 minutes, 95% CI: 1.1 to 3.1). In analyses adjusted for the time‐varying ART initiation status, compared to the pre‐ART period of care, the hazard of on‐ART LTFU was 90% higher among participants diagnosed under the SDI policy compared to pre‐UTT (aHR 1.9, 95% CI: 1.1 to 2.9). Conclusions Overall, nearly two‐fifths of HIV positive patients are likely to disengage from care by 12 months after HIV diagnosis under the new SDI policy. Furthermore, the increase in on‐ART patient attrition after the introduction of the SDI policy is cause for concern. Further research is needed to determine the best way for rapidly initiating patients on ART and also reducing long‐term attrition from care.

show abstract

Retention in Care Trajectories of HIV-Positive Individuals Participating in a Universal Test-and-Treat Program in Rural South Africa (ANRS 12249 TasP Trial)

Abstract: Supplemental Digital Content is Available in the Text.

Cited by 37 publications

References 38 publications

HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa

Attrition in HIV care following HIV diagnosis: a comparison of the pre‐UTT and UTT eras in South Africa

Contact Info

Product

Resources

About