Who is seeking antiretroviral treatment for HIV now? Characteristics of patients presenting in Kenya and South Africa in 2017‐2018

Abstract

Introduction Many African countries have had at least two years’ experience with universal treatment eligibility for HIV. The literature contains few descriptions, though, of populations starting treatment since adoption of universal eligibility. Using baseline data from a clinical trial of same‐day ART initiation, we describe the populations presenting for HIV testing or care at study clinics in Kenya and South Africa in 2017‐18, during the era of same‐day initiation. Methods The Simplified Algorithm for Treatment Eligibility (SLATE) trials in Kenya (SLATE I) and South Africa (SLATE II) were multicenter, non‐blinded, individually randomized, pragmatic trials evaluating simple, standardized algorithms to determine eligibility for same‐day initiation of ART without relying on laboratory results, point of care tests or multiple clinic visits. In Kenya, enrolment occurred during July 2017 to April 2018. In South Africa, enrolment occurred during March to September 2018. We describe demographic, socioeconomic and clinical characteristics of patients randomized to the same‐day initiation arm for both studies. Results and Discussion A total of 240 and 296 participants were enrolled in Kenya and South Africa. The majority were female (59% and 64% respectively), with a median age of 35 years. In both countries, most subjects were newly diagnosed with HIV on the day of enrolment (62%, 55%), believed they already had adequate knowledge to begin ART (78%, 68%), and preferred to start ART immediately (same‐day) (98% in both countries). About 40% of all patients had at least one symptom related to tuberculosis (cough, fever, night sweats, weight loss) and/or cryptococcal meningitis (continuous headache). More than a third of patients (37%, 36%) presented with advanced disease (CD4 <200 cells/mm3), a fifth presented with very advanced disease (CD4 < 100), and approximately 1 in 20 presented with very advanced disease and were asymptomatic. Conclusions Despite >2 years of universal eligibility for ART in Kenya and South Africa, in 2017‐2018 more than half of HIV‐positive patients presenting at public sector clinics were not yet aware of their status, and more than a third presented for care with advanced HIV disease. These proportions remain similar to those observed before the introduction of universal eligibility.

Prevalence of TB symptoms, diagnosis and treatment among people living with HIV (PLHIV) not on ART presenting at outpatient clinics in South Africa and Kenya: baseline results from a clinical trial

“…Further details of the baseline characteristics of the cohorts have been reported previously. 10 TB symptom prevalence The prevalence of any TB symptoms was 38% (95% CI 32% to 44%) in SLATE I in Kenya, 35% (30%-41%) in SLATE I in South Africa and 47% (42%-53%) in SLATE II (table 1). In both studies and both countries, among people with any symptom, cough (66% combined) and weight loss (72% combined) were the most common symptoms reported.…”

“…The baseline characteristics of these patients have previously been described. 10 Patient and public involvement Patients were not involved in the design, recruitment or conduct of the SLATE trials. We conducted a qualitative study at the end of SLATE II to help gain a deeper understanding of patient perceptions of initiating ART per standard of care compared with SDI using the SLATE algorithm.…”

A clinical algorithm for same-day HIV treatment initiation in settings with high TB symptom prevalence in South Africa: The SLATE II individually randomized clinical trial

“…No important imbalances with respect to the characteristics of the enrolled sample were noted. Additional details about the study cohort have been reported elsewhere [ 23 ].…”

“…At study enrollment, approximately half of standard (52%, n = 155) and intervention (47%, n = 140) arm patients presented with one or more TB symptoms. Details of the intervention arm patients are reported elsewhere [23]. Overall, 392 (66%) of study patients were willing and able to produce a sputum sample and were tested for TB at study enrollment, including 163 (55%) standard arm patients and 229 (77%) in the intervention arm.…”

“…Although some patients had multiple symptoms or severe illness, most reported only one symptom of short duration. Despite the frequency of TB symptoms observed, the vast majority of those with TB symptoms (91%) tested negative for active TB disease [ 12 ]. These results, as well as findings from the TEMPRANO trial [ 13 ], the CASCADE trial [ 10 ], and others [ 14 ], demonstrate the benefits of early ART among those with TB symptoms and suggest that rapid ART initiation among patients later found to have TB disease and treated for TB does not appear to be of serious concern.…”