HIV Treatment Outcomes Among Patients Initiated on Antiretroviral Therapy Pre and Post-Universal Test and Treat Guidelines in South Africa

Kamban Hirasen; Matthew P Fox; Cheryl J Hendrickson; Tembeka Sineke; Dorina Onoya

doi:10.2147/TCRM.S227290

HIV Treatment Outcomes Among Patients Initiated on Antiretroviral Therapy Pre and Post-Universal Test and Treat Guidelines in South Africa

Ther Clin Risk Manag. 2020 Mar 4:16:169-180. doi: 10.2147/TCRM.S227290. eCollection 2020.

Authors

Kamban Hirasen¹, Matthew P Fox^{1

2

3}, Cheryl J Hendrickson¹, Tembeka Sineke¹, Dorina Onoya¹

Affiliations

¹ Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
² Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
³ Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.

Abstract

Introduction: Officially rolled out on 01 September 2016, South Africa's Universal Test and Treat (UTT) policy calls for first-line antiretroviral treatment (ART) initiation among all known HIV-positive patients, irrespective of CD4 cell count. We evaluate treatment outcomes of patients initiated on first-line ART directly before and after the implementation of UTT.

Methods: We analysed prospectively collected clinical cohort data among ART-naïve adult patients within two HIV clinics in Johannesburg, South Africa. We compare two groups: 1) an unexposed pre-UTT group initiating treatment from 01 December 2014 to 31 May 2015; and 2) an exposed UTT group initiating treatment from 01 December 2016 to 31 May 2017. Primary treatment outcomes included lost to follow-up (LTFU) (>90 days late for the last scheduled visit with no subsequent clinical visit). Cox proportional hazards models were used to estimate the association between pre-UTT vs UTT initiation on LTFU by 12 months.

Results: We included 2410 patients. A total of 1267 (52.6%) patients initiated ART before UTT implementation and 1143 (47.4%) after the change in policy. LTFU (adjusted Hazard Ratio (aHR): 1.51; 95% Confidence Interval (CI): 1.16-1.98) between groups and specifically among those initiating with a CD4 cell count ≤500 cells/mm³ (aHR: 1.59; 95% CI: 1.21-2.10) was higher among patients initiating ART under UTT.

Conclusion: LTFU under UTT proved higher than that of previous periods. Patients initiating first-line therapy under the treat-all policy may often start treatment in better health, subsequently not perceiving a direct benefit to treatment which may deter patients from consistent engagement in HIV treatment programmes.

Keywords: South Africa; antiretroviral therapy; lost to follow-up; resource-limited settings; universal access; virologic suppression.

Grants and funding

This study has been made possible by the generous support of the American people and the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) under the terms of Cooperative Agreements AID-674-A-12-00029 and 72067419CA00004 to the Health Economics and Epidemiology Research Office. The contents are the responsibility of the authors and do not necessarily reflect the views of PEPFAR, USAID or the United States government.