Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis. (9th March 2021)

• Record Type: Journal Article
• Authors: Brazier, Ellen; Tymejczyk, Olga; Zaniewski, Elizabeth; Egger, Matthias; Wools-Kaloustian, Kara; Yiannoutsos, Constantin T; Jaquet, Antoine; Althoff, Keri N; Lee, Jennifer S; Caro-Vega, Yanink; Luz, Paula M; Tanuma, Junko; Niyongabo, Théodore; Nash, Denis
• Is Part Of: Clinical infectious diseases. Volume 73:Number 6(2021)
• Page Start: e1273
• Page End: e1281
• Publication Date: 2021-03-09
• Subjects: HIV care -- pre-ART CD4 testing -- viral load monitoring -- Treat-All; Communicable diseases -- Periodicals; 616.905
• DOI: 10.1093/cid/ciab222
• Languages: English
• ISSNs: 1058-4838

Abstract

Abstract: Background: The World Health Organization's Treat-All guidance recommends CD4 testing before initiating antiretroviral therapy (ART), and routine viral load (VL) monitoring (over CD4 monitoring) for patients on ART. Methods: We used regression discontinuity analyses to estimate changes in CD4 testing and VL monitoring among 547 837 ART-naive patients enrolling in human immunodeficiency virus (HIV) care during 2006–2018 at 225 clinics in 26 countries where Treat-All policies were adopted. We examined CD4 testing within 12 months before and VL monitoring 6 months after ART initiation among adults (≥20 years), adolescents (10–19 years), and children (0–9 years) in low/lower-middle-income countries (L/LMICs) and high/upper-middle-income countries (H/UMICs). Results: Treat-All adoption led to an immediate decrease in pre-ART CD4 testing among adults in L/LMICs, from 57.0% to 48.1% (−8.9 percentage points [pp]; 95% CI: −11.0, −6.8), and a small increase in H/UMICs, from 90.1% to 91.7% (+1.6pp; 95% CI: 0.2, 3.0), with no changes among adolescents or children; decreases in pre-ART CD4 testing accelerated after Treat-All adoption in L/LMICs. In L/LMICs, VL monitoring after ART initiation was low among all patients in L/LMICs before Treat-All; while there was no immediate change at Treat-All adoption, VL monitoring trends significantly increased afterwards. VL monitoring increased among adults immediately after Treat-All adoption, from 58.2% to 61.1% (+2.9pp; 95% CI: 0.5, 5.4), with no significant changes among adolescents/children. Conclusions: While on-ART VL monitoring has improved in L/LMICs, Treat-All adoption has accelerated and disparately worsened suboptimal pre-ART CD4 monitoring, which may compromise care outcomes for individuals with advanced HIV. Abstract : Adoption of Treat-All policies led to decreases in pre-antiretroviral therapy (ART) CD4 testing among adult ART initiators in low/lowermiddle income countries, with no immediate increase in viral load monitoring after ART initiation, potentially compromising appropriate care of individuals with advanced HIV.