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

• Published in: Journal of the International AIDS Society 2020-03, Vol.23 (3), p.e25458-n/a
• Main Authors: Kerschberger, Bernhard, Schomaker, Michael, Jobanputra, Kiran, Kabore, Serge M, Teck, Roger, Mabhena, Edwin, Mthethwa‐Hleza, Simangele, Rusch, Barbara, Ciglenecki, Iza, Boulle, Andrew
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; Adolescent; Adult; AIDS; Analysis; Anti-HIV Agents - administration & dosage; Anti-HIV Agents - therapeutic use; Antiretroviral agents; Care and treatment; CD4 Lymphocyte Count; CD4-Positive T-Lymphocytes; Cohort analysis; Diagnosis; Disease transmission; Drug therapy; Eligibility Determination; Eswatini; Ethics; Evaluation; Female; Health facilities; Hemoglobin; Highly active antiretroviral therapy; HIV; HIV infection; HIV Infections - drug therapy; Human immunodeficiency virus; Humans; Kaplan-Meier Estimate; Laboratories; Male; Medical care; Middle Aged; Patient compliance; Patients; Pregnancy; Primary care; Proportional Hazards Models; Prospective Studies; Public health administration; Public Sector; Quality management; Retention; Standard of Care; Studies; Survival; Swaziland; treat all; viral failure; Young Adult
• ISSN: 1758-2652; 1758-2652
• DOI: 10.1002/jia2.25458

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