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Observational Study
. 2018 Sep;23(9):968-979.
doi: 10.1111/tmi.13122. Epub 2018 Jul 26.

Do HIV treatment eligibility expansions crowd out the sickest? Evidence from rural South Africa

Sheryl A Kluberg  1 , Matthew P Fox  1   2   3 , Michael LaValley  4 , Deenan Pillay  5   6 , Till Bärnighausen  5   7 , Jacob Bor  1   2   3   5
Affiliations
Observational Study

Do HIV treatment eligibility expansions crowd out the sickest? Evidence from rural South Africa

Sheryl A Kluberg et al. Trop Med Int Health. 2018 Sep.

Abstract
in English, French

Objective: The 2015 WHO recommendation to initiate all HIV patients on antiretroviral therapy (ART) at diagnosis could potentially overextend health systems and crowd out sicker patients, mitigating the policy's impact. We evaluate whether South Africa's prior eligibility expansion from CD4 ≤ 200 to CD4 ≤ 350 cells/μl reduced ART uptake in the sickest patients.

Methods: Using data on all patients presenting to the Hlabisa HIV Treatment and Care Programme in KwaZulu-Natal from April 2010 to June 2012 (n = 13 809), we assessed the impact of the August 2011 eligibility expansion on the number of patients seeking care, number initiating ART and time from HIV diagnosis to ART initiation among patients always eligible (CD4 0-200), newly eligible (CD4 201-350) and not yet eligible by CD4 count (>350). We used interrupted time series methods to control for long-run trends and isolate the effect of the policy.

Results: Expanding ART eligibility led to an increased number of patients initiating ART per month [+95.5; 95% CI (-1.3; 192.3)]. Newly eligible patients (CD4 201-350) initiated treatment 47% faster than before (95% CI 19%; 82%), while the sickest patients (CD4 ≤ 200) saw no decline in the monthly number of patients initiating treatment or the rate of treatment uptake.

Conclusion: The Hlabisa programme successfully extended ART to patients with CD4 ≤ 350 cells/μl, while ensuring that the sickest patients did not experience delays in ART initiation. Treatment programmes must be vigilant to maintain quality of care for the sickest as countries move to treat all patients irrespective of CD4 count.

Objectif: La recommandation 2015 de l'OMS d'initier tous les patients VIH à la thérapie antirétrovirale (ART) dès le diagnostic pourrait potentiellement surpasser les systèmes de santé et évincer les patients plus malades, atténuant ainsi l'impact de la politique. Nous avons voulu évaluer si l'expansion préalable de l’éligibilité en l'Afrique du Sud, passant de CD4 ≤ 200 à CD4 ≤350 cellules/μL, réduisait l'adoption de l'ART chez les patients les plus malades.

Méthodes: En utilisant des données sur tous les patients du programme Hlabisa de traitement et de soins du VIH dans le KwaZulu‐Natal d'avril 2010 à juin 2012 (n = 13 809), nous avons évalué l'impact de l'expansion de l’éligibilité en août 2011 sur le nombre de patients recherchant des soins, le nombre débutant l'ART et le temps écoulé entre le diagnostic du VIH et le début de l'ART parmi les patients toujours éligibles (CD4<200), nouvellement éligibles (201<CD4<350) et non encore éligibles (CD4>350). Nous avons utilisé des méthodes de séries temporelles interrompues pour contrôler pour les tendances à long terme et isoler l'effet de la politique.

Résultats: L'expansion de l’éligibilité a entraîné une augmentation du nombre de patients débutant l'ART [+95.5; IC95% (−1.3; 192.3)]. Les patients nouvellement éligibles (201 < CD4 < 350) ont débuté le traitement 47% plus vite qu'avant (IC95%: 19%; 82%), tandis que les patients les plus malades (CD4 ≤200) n'ont pas vu diminuer le nombre mensuel débutant le traitement ou le taux de l'adoption du traitement.

Conclusion: Le programme Hlabisa a étendu l'ART avec succès chez les patients avec CD4 ≤350 cellules/μL tout en veillant à ce que les patients les plus malades ne subissent pas de retards dans l'initiation de l'ART. Les programmes de traitement doivent être vigilants afin de maintenir la qualité des soins pour les personnes les plus malades à mesure que les pays commencent à traiter tous les patients sans tenir compte du nombre de CD4.

Keywords: Afrique du Sud; HIV/AIDS; South Africa; adultes; adults; antiretroviral therapy; continuity of care; continuité des soins; directives; guidelines; thérapie antirétrovirale.

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Figures

Figure 1
Figure 1
Observed monthly count of new diagnoses over time at the Hlabisa HIV Treatment and Care Programme clinics in KwaZulu‐Natal, South Africa, along with curve of predicted values and 95% confidence limits. Predicted values based on the following model: Count = β 0  + β 1 (study month) + β 2 (guideline change) + β 3 (holiday) Figure is stratified by CD4 count at clinical presentation. Grey bar indicates month of policy implementation.
Figure 2
Figure 2
Observed monthly count of new ART initiators over time at the Hlabisa HIV Treatment and Care Programme clinics in KwaZulu‐Natal, South Africa, along with curve of predicted values and 95% confidence limits. Predicted values based on the following model: Count = β 0  + β 1 (study month) + β 2 (guideline change) + β 3 (holiday) Figure is stratified by CD4 count at clinical presentation. Grey bar indicates month of policy implementation. ART, antiretroviral therapy.
Figure 3
Figure 3
Kaplan–Meier curves showing the cumulative probability of treatment initiation before (solid) and after (dashed) the guideline change, adjusted for holiday, sex and age using inverse probability of treatment weighting. Figure is stratified by CD4 count at clinical presentation. ART, antiretroviral therapy.
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References

    1. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach June 2013 [Internet]. Geneva, Switzerland: World Health Organization; 2013. (Available from: http://www.who.int/hiv/pub/guidelines/arv2013/art/statartadolescents/en/) [13 May 2014]. - PubMed
    1. Danel C, Moh R, Gabillard D et al A trial of early antiretrovirals and isoniazid preventive therapy in Africa. N Engl J Med 2015: 373: 808–822. - PubMed
    1. Okulicz JF, Le TD, Agan BK et al Influence of the timing of antiretroviral therapy on the potential for normalization of immune status in human immunodeficiency virus 1‐infected individuals. JAMA Intern Med 2015: 175: 88–99. - PMC - PubMed
    1. Lundgren JD, Babiker AG, Gordin F et al Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med 2015: 373: 795–807. - PMC - PubMed
    1. Grinsztejn B, Hosseinipour MC, Ribaudo HJ et al Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV‐1 infection: results from the phase 3 HPTN 052 randomised controlled trial. Lancet Infect Dis 2014: 14: 281–290. - PMC - PubMed

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