Understanding the effects of Universal Test and Treat on longitudinal HIV care continuum outcomes among South African youth: a retrospective cohort study

Abstract

IntroductionLittle is known about when youth living with HIV (YLHIV) are most susceptible to disengagement from HIV care. The longitudinal HIV care continuum is an underutilized tool that can provide a holistic understanding of population-level HIV care trajectories and be used to compare treatment outcomes across groups. We aimed to explore effects of the Universal Test and Treat policy (UTT) on longitudinal care outcomes among South African youth living with HIV (YLHIV) and identify temporally precise opportunities for re-engaging this priority population.MethodsUsing medical record and census data, we conducted a retrospective cohort study among youth aged 18-24 newly diagnosed with HIV between August 2015 and December 2018 in nine health care facilities in rural South Africa. We used weighted Fine and Grey sub-distribution proportional hazards models to characterize longitudinal care continuum outcomes in the population overall and stratified by treatment era of diagnosis. We estimated the proportion of individuals in each stage of the continuum over time and the mean time spent in each stage in the first year following diagnosis. Estimates for the two groups were compared using differences (diagnosis pre-UTT=referent).ResultsA total of 420 YLHIV were included. By the end of the first year following diagnosis, just 23% of individuals had no 90-or-more-day lapse in care and were virally suppressed. Those diagnosed in the UTT era spent less time as ART-naïve (mean difference=-19.3 days; 95% CI: - 27.7, -10.9) and more time virally suppressed (mean difference=17.7; 95% CI: 1.0, 34.4) compared to those diagnosed pre-UTT adoption. Most individuals who were diagnosed in the UTT era and experienced a 90-or-more-day lapse in care disengaged between diagnosis and linkage to care or ART initiation and viral suppression.ConclusionsImplementation of UTT yielded modest improvements in time spent on ART and virally suppressed among South African YLHIV. However, meeting UNAIDS’ 95-95-95 targets remains a challenge in this priority population. Retention in care and re-engagement interventions that can be implemented between diagnosis and linkage to care (e.g., longitudinal counseling following diagnosis) or ART initiation and viral suppression may be particularly important to improving treatment outcomes among South African YLHIV.

Impact of increasing CD4 count threshold eligibility for antiretroviral therapy initiation on advanced HIV disease and tuberculosis prevalence and incidence in South Africa: an interrupted time series analysis

“…[6] After implementing these policies, access to ART increased, and a higher proportion of PLHIV in South Africa and other LMICs initiated ART at higher CD4 counts. [7][8][9] Consequently, a higher proportion of people receiving ART have achieved viral suppression [10,11], and population-level HIV incidence has reduced. [12] The life expectancy of PLHIV has also improved [13], and the burden of opportunistic co-infections such as TB has reduced.…”

Correlates of viral suppression among sexual minority men and transgender women living with HIV in Mpumalanga, South Africa

“…Among those who know their status, 64.7% to 82.1% are on ART, while 34.4% to 55.0% are virally suppressed [ 6 ]. Recent estimates indicate better progress towards 95-95-95 targets—an improvement that is largely due to South Africa’s implementation of the universal “test-and-treat” policy in 2016, which gave access to treatment for all PLHIV, and the introduction of single dose regimens [ 7 , 8 ]. However, HIV treatment progress for SMM and transgender women in South Africa is suboptimal [ 4 ].…”