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

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:

• universal access
• antiretroviral therapy
• lost to follow-up
• virologic suppression
• resource-limited settings
• South Africa

Acknowledgments

We extend our gratitude to the Directors and staff of Themba Lethu HIV Clinic and Witkoppen Health and Welfare Centre. We thank the Gauteng Provincial and National Department of Health for providing care to the patients at Themba Lethu HIV Clinic and Witkoppen Health and Welfare Centre as part of the National Programme. Finally, we sincerely thank the patients attending Themba Lethu HIV Clinic and Witkoppen Health and Welfare Centre for the use of their clinical data and their continued trust in the treatment and care provided at these clinics.

Author Contributions

All authors contributed to data analysis, drafting or revising the article, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests.

Additional information

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.