Anti-retroviral therapy after "Treat All" in Harare, Zimbabwe: What are the changes in uptake, time to initiation and retention?

Abstract

Background: In Zimbabwe, Harare was the first province to implement "Treat All" for people living with human immunodeficiency virus (PLHIV). Since its roll out in July 2016, no study has been conducted to assess the changes in key programme indicators. We compared antiretroviral therapy (ART) uptake, time to ART initiation from diagnosis, and retention before and during "Treat All". Methods: We conducted an ecological study to assess ART uptake among all PLHIV newly diagnosed before and during "Treat All". We conducted a cohort study to assess time to ART initiation and retention in care among all PLHIV newly initiated on ART from all electronic patient management system-supported sites (n=50) before and during "Treat All". Results: ART uptake increased from 65% (n=4619) by the end of quarter one, 2014 to 85% (n=5152) by the end of quarter four, 2018. A cohort of 2289 PLHIV was newly initiated on ART before (April-June 2015) and 1682 during "Treat all" (April-June 2017). Their age and gender distribution was similar. The proportion of PLHIV in early stages of disease was significantly higher during "Treat all" (73.2% vs. 55.6%, p<0.001). The median time to ART initiation was significantly lower during "Treat All" (31 vs. 88 days, p<0.001). Cumulative retention at three, six and 12 months was consistently lower during "Treat all" and was significant at six months (74.9% vs.78.1% p=0.022). Conclusion: Although there were benefits of early ART initiation during "Treat All", the programme should consider strategies to improve retention.

Keywords: ART outcomes; HIV; Operational research; SORT IT; test and treat; time to treatment; universal test and treat.

Figure 1.. Trends ^# in quarterly ART uptake^ among newly diagnosed PLHIV before (January 2014–June 2016) and during (July 2016–December 2018) “Treat All” *, Harare, Zimbabwe.

PLHIV: People Living with Human Immunodeficiency Virus; ART: Antiretroviral therapy ^aggregate numbers for each quarter were extracted to calculate ART uptake, source of data is district health information system (DHIS-2) *” Treat All” means all individuals with confirmed HIV diagnosis are eligible for ART irrespective of WHO clinical stage or CD4 count. ^#During 2014, the CD4 count eligibility criteria was raised from <350 to <500 cells/mm ³ . As more people in pre-ART care were eligible for ART, there was an increase in new ART initiations which resulted in corresponding increase in ART uptake. Similarly, there was an increase in new ART initiations which resulted in corresponding increase in ART uptake after “Treat All”.