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

Abstract

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.

Go to: Introduction HIV remains one of the biggest contributors to mortality and morbidity in the world with most deaths occurring in the Sub-Saharan Africa (SSA)[1]. Despite freely available treatment for HIV/AIDS over the past decade, only (66.0%) of people living with HIV in eastern and southern part of SSA were on treatment in 2017 [2]. The World Health Organisation (WHO) 2013 treatment guidelines for starting HIV-positive people on antiretroviral therapy (ART) were CD4< = 500 cells/μl and for pregnant women to commence ART regardless of CD4 cell count [3]. In 2015 the WHO guidelines changed to starting every HIV-positive person on ART regardless of CD4 cell count[4] (the so-called “test and treat” approach) although some countries have not yet implemented these recommendations.

With only half the population of HIV-positive individuals on treatment, containing the spread of HIV remains a challenge with only small declines in incidence[5]. However, more evidence is becoming available on the benefits of undetectable viral load and early ART initiation on mortality and morbidity[6–8] and on lowering the risk of transmission[9–13], bringing hope on how further spreading of the disease can be contained through a “test and treat” approach.

However, adopting the new WHO guidelines may have challenges such as costs associated with more people on ART, infrastructure, human resources and how to monitor everyone started on ART to ensure that they adhere to medication[4]. This makes it difficult for countries to transition if they do not know what to expect if they move to test and treat.

To plan properly for transitioning to the new WHO guidelines, countries need to know the number, proportion, age and sex distribution of the additional HIV-positive individuals that will need to start ART. Most studies on the impact of change in ART guidelines on eligibility have been based on mathematical modeling [14, 15] which can easily over or underestimate results depending on the model assumptions. Other studies however, have used population data, for example in Kenya, a study that estimated the impact of change in treatment guidelines using nationally representative Kenya AIDS indicator survey data fell short of measuring the differential impact of the new WHO guidelines on age and sex[16]. Our aim therefore, was to measure the impact of a “test and treat” policy on eligibility, stratified by sex and age, using population data from three countries (Kenya, Malawi and South Africa) at different stages of implementing previous WHO guidelines.