Impact of "test and treat" recommendations on eligibility for antiretroviral treatment: Cross sectional population survey data from three high HIV prevalence countries

Background Latest WHO guidelines recommend starting HIV-positive individuals on antiretroviral therapy treatment (ART) regardless of CD4 count. We assessed additional impact of adopting new WHO guidelines. Methods We used data of individuals aged 15–59 years from three HIV population surveys conducted in 2012 (Kenya) and 2013 (Malawi and South Africa). Individuals were interviewed at home followed by rapid HIV and CD4 testing if tested HIV-positive. HIV-positive individuals were classified as “eligible for ART” if (i) had ever been initiated on ART or (ii) were not yet on ART but met the criteria for starting ART based on country’s guidelines at the time of the survey (Kenya–CD4< = 350 cells/μl and WHO Stage 3 or 4 disease, Malawi as for Kenya plus lifelong ART for all pregnant and breastfeeding women, South Africa as for Kenya plus ART for pregnant and breastfeeding women until cessation of breastfeeding). Findings Of 18,991 individuals who tested, 4,113 (21.7%) were HIV-positive. Using country’s ART eligibility guidelines at the time of the survey, the proportion of HIV-infected individuals eligible for ART was 60.0% (95% CI: 57.2–62.7) (Kenya), 73.4% (70.8–75.8) (South Africa) and 80.1% (77.3–82.6) (Malawi). Applying WHO 2013 guidelines (eligibility at CD4< = 500 and Option B+ for pregnant and breastfeeding women), the proportions eligible were 82.0% (79.8–84.1) (Kenya), 83.7% (81.5–85.6) (South Africa) and 87.6% (85.0–89.8) (Malawi). Adopting “test and treat” would mean a further 18.0% HIV-positive individuals (Kenya), 16.3% (South Africa) and 12.4% (Malawi) would become eligible. In all countries, about 20% of adolescents (aged 15–19 years), became eligible for ART moving from WHO 2013 to “test and treat” while no differences by sex were observed. Conclusion Countries that have already implemented 2013 WHO recommendations, the burden of implementing “test and treat” would be small. Youth friendly programmes to help adolescents access and adhere to treatment will be needed.

[1]  K. Cohen,et al.  A comparison of self-report and antiretroviral detection to inform estimates of antiretroviral therapy coverage, viral load suppression and HIV incidence in Kwazulu-Natal, South Africa , 2017, BMC Infectious Diseases.

[2]  Jon Cohen.  Swaziland makes major strides against its AIDS epidemic , 2017 .

[3]  M. Davies,et al.  Living and dying to be counted: What we know about the epidemiology of the global adolescent HIV epidemic , 2017, Journal of the International AIDS Society.

[4]  H. Rees,et al.  Increased Access to Antiretroviral Therapy Is Associated with Reduced Maternal Mortality in Johannesburg, South Africa: An Audit from 2003-2012 , 2016, PloS one.

[5]  T. F. Rinke de Wit,et al.  Long-Term Antiretroviral Treatment Adherence in HIV-Infected Adolescents and Adults in Uganda: A Qualitative Study , 2016, PloS one.

[6]  M. Fox,et al.  Insights into Adherence among a Cohort of Adolescents Aged 12–20 Years in South Africa: Reported Barriers to Antiretroviral Treatment , 2016, AIDS Research and Treatment.

[7]  J. Etard,et al.  Who Needs to Be Targeted for HIV Testing and Treatment in KwaZulu-Natal? Results From a Population-Based Survey , 2016, Journal of acquired immune deficiency syndromes.

[8]  Reed J. D. Sorensen,et al.  Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: the Global Burden of Disease Study 2015 , 2016, The lancet. HIV.

[9]  N. Ford,et al.  Closer to 90–90–90. The cascade of care after 10 years of ART scale-up in rural Malawi: a population study , 2016, Journal of the International AIDS Society.

[10]  L. Kuhn,et al.  Impact of a youth-friendly HIV clinic: 10 years of adolescent outcomes in Port-au-Prince, Haiti , 2016, Journal of the International AIDS Society.

[11]  C. Barker,et al.  The HIV Treatment Gap: Estimates of the Financial Resources Needed versus Available for Scale-Up of Antiretroviral Therapy in 97 Countries from 2015 to 2020 , 2015, PLoS medicine.

[12]  H. Lane,et al.  Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. , 2015, The New England journal of medicine.

[13]  J. Etard,et al.  Cascade of HIV care and population viral suppression in a high-burden region of Kenya , 2015, AIDS.

[14]  Reuben Granich,et al.  Trends in AIDS Deaths, New Infections and ART Coverage in the Top 30 Countries with the Highest AIDS Mortality Burden; 1990–2013 , 2015, PloS one.

[15]  S. Hussen,et al.  Transition of youth living with HIV from pediatric to adult-oriented healthcare: a review of the literature. , 2014, Future virology.

[16]  R. Ferrand,et al.  Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges. , 2014, The Lancet. Infectious diseases.

[17]  M. Davies,et al.  Provider-Initiated HIV Testing and Counselling for Children , 2014, PLoS medicine.

[18]  K. D. de Cock,et al.  Antiretroviral Treatment Scale-up Among Persons Living With HIV in Kenya: Results From a Nationally Representative Survey , 2014, Journal of acquired immune deficiency syndromes.

[19]  H. Mujuru,et al.  Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study , 2014, PLoS medicine.

[20]  Kenneth H Mayer,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. , 2014, The Lancet. Infectious diseases.

[21]  P. Easterbrook,et al.  The impact and cost of the 2013 WHO recommendations on eligibility for antiretroviral therapy , 2014, AIDS.

[22]  T. F. Rinke de Wit,et al.  Averted HIV infections due to expanded antiretroviral treatment eligibility offsets risk of transmitted drug resistance: a modeling study , 2014, AIDS.

[23]  M. Newell,et al.  Reduction in Early Mortality on Antiretroviral Therapy for Adults in Rural South Africa Since Change in CD4+ Cell Count Eligibility Criteria , 2014, Journal of acquired immune deficiency syndromes.

[24]  E. Abrams,et al.  Retention of HIV-Infected Children on Antiretroviral Treatment in HIV Care and Treatment Programs in Kenya, Mozambique, Rwanda, and Tanzania , 2013, Journal of acquired immune deficiency syndromes.

[25]  T. Bärnighausen,et al.  High Coverage of ART Associated with Decline in Risk of HIV Acquisition in Rural KwaZulu-Natal, South Africa , 2013, Science.

[26]  S. Makombe,et al.  Determinants and Consequences of Failure of Linkage to Antiretroviral Therapy at Primary Care Level in Blantyre, Malawi: A Prospective Cohort Study , 2012, PloS one.

[27]  J. Moatti,et al.  The Macroeconomic Consequences of Renouncing to Universal Access to Antiretroviral Treatment for HIV in Africa: A Micro-Simulation Model , 2012, PloS one.

[28]  J. Kahn,et al.  Expanding ART for Treatment and Prevention of HIV in South Africa: Estimated Cost and Cost-Effectiveness 2011-2050 , 2012, PloS one.

[29]  Lei Wang,et al.  Prevention of HIV-1 infection with early antiretroviral therapy. , 2011, The New England journal of medicine.

[30]  Matthias Egger,et al.  Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis , 2009, AIDS.

[31]  Matthew G Law,et al.  Relation between HIV viral load and infectiousness: a model-based analysis , 2008, The Lancet.

[32]  Till Bärnighausen,et al.  Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models. , 2014, The Lancet. Global health.

[33]  Global AIDS update. , 1992, World health forum.