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
Year: 2021
Type: article
Study design: Observational Study
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.
Source: Clinical Infectious Diseases
DOI: 10.1093/cid/ciab222
Institutions: City University of New York, University of Bern, Indiana University Indianapolis, Indiana University School of Medicine, Université de Bordeaux, Inserm, Institut de Recherche pour le Développement, Johns Hopkins University, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Fundação Oswaldo Cruz, National Center for Global Health and Medicine
Language: English
Subfield: Infectious Diseases
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,052
Funders: National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, National Institute on Aging, National Heart, Lung, and Blood Institute, National Institute of Mental Health, National Institute on Drug Abuse, National Cancer Institute, National Institute of Allergy and Infectious Diseases, Fogarty International Center, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Child Health and Human Development, U.S. National Library of Medicine, Eunice Kennedy Shriver National Institute of Child Health and Human Development
Awards: G1265315430, G1825977350, G1859885209, G240136927, G2466661058, G2517021052, G2602991252, G2606189360, G295270083, G3090742097, G325158278, G3475612999, G3527861497, G3544296662, G4118374008, G4136037232, G4176875957, G4275245238, G4346769292, G4536063133, G4592013985, G5012601499, G5355865466, G5785870036, G596821015, G5984172584, G617683515, G6246704175, G6256613848, G6607000333, G6796974715, G6965689831, G7300457456, G7927980121, G8717451453, G8800573163, Emory Specialized Center of Research Excellence (SCORE) on Sex Differences, North American AIDS Cohorts on Collaboration and Design (NAACCORD), Central Africa International Epidemiology databases to Evaluate AIDS, Caribbean, Central, and South America network for HIV Epidemiology (CCASAnet), G97119092
OpenAlex ID: W3135724712