Background

Universal testing and treatment (UTT) for all people living with HIV has only been assessed under experimental conditions in cluster-randomised trials. The public health effectiveness of UTT policies on the HIV care cascade under real-world conditions is not known. We assessed the real-world effectiveness of universal HIV treatment policies that were implemented in Zambia on Jan 1, 2017.

Methods

We used data from Zambia's routine electronic health record system to analyse antiretroviral therapy (ART)-naive adults who newly enrolled in HIV care up to 1 year before and after the implementation of universal treatment (ie, Jan 1, 2016, to Jan 1, 2018) at 117 clinics supported by the Centre for Infectious Disease Research in Zambia. We used a regression discontinuity design to estimate the effects of implementing UTT on same-day ART initiation, ART initiation within 1 month, and retention on ART at 12 months (defined as clinic attendance 9–15 months after enrolment and at least 6 months on ART), under the assumption that patients presenting immediately before and after UTT implementation were balanced on both measured and unmeasured characteristics. We did an instrumental variable analysis to estimate the effect of same-day ART initiation under routine conditions on 12-month retention on ART.

Findings

65 673 newly enrolled patients with HIV (40 858 [62·2%] female, median age 32 years [IQR 26–39], median CD4 count 287 cells per μL [IQR 147–466]) were eligible for inclusion in the analyses; 31 145 enrolled before implementation of UTT, and 34 528 enrolled after UTT. Implementation of universal treatment increased same-day ART initiation from 41·7% to 74·8% (risk difference [RD] 33·1%, 95% CI 30·5–35·7), ART initiation by 1 month from 69·6% to 87·0% (RD 17·4%, 15·5–19·3), and 12-month retention on ART from 56·2% to 63·3% (RD 7·1%, 4·3–9·9). ART initiation rates became more uniform across patient subgroups after implementation of universal treatment, but heterogeneity in 12-month retention on ART between subgroups was unchanged. Instrumental variable analyses indicated that same-day ART initiation in routine settings led to a 15·8% increase (95% CI 12·1–19·5) in 12-month retention on ART.

Interpretation

UTT policies implemented in Zambia increased the rapidity and uptake of ART, as well as retention on ART at 12 months, although overall retention on ART remained suboptimal. UTT policies reduced disparities in treatment initiation, but not 12-month retention on ART. Natural experiments reveal both the anticipated and unanticipated effects of real-world implementation and indicate the need for new strategies leveraging the short-term effects of UTT to cultivate long-term treatment success.

Funding

National Institutes of Health.

中文翻译：

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在赞比亚实施普遍和快速的 HIV 治疗对开始抗逆转录病毒治疗和保留护理的影响：使用回归不连续性的自然实验

背景

仅在整群随机试验的实验条件下对所有艾滋病病毒感染者的普遍检测和治疗 (UTT) 进行了评估。UTT 政策在现实世界条件下对 HIV 护理级联的公共卫生有效性尚不清楚。我们评估了 2017 年 1 月 1 日在赞比亚实施的普遍艾滋病毒治疗政策在现实世界中的有效性。

方法

我们使用来自赞比亚常规电子健康记录系统的数据来分析在实施普遍治疗前后长达 1 年（即 2016 年 1 月 1 日至 2016 年 1 月 1 日）新加入 HIV 护理的未接受过抗逆转录病毒疗法 (ART) 的成年人。 2018 年）在赞比亚传染病研究中心支持的 117 家诊所。我们使用不连续性回归设计来评估实施 UTT 对当日 ART 启动、1 个月内 ART 启动和 ART 保留 12 个月（定义为入组后 9-15 个月就诊以及入组后至少 6 个月就诊）的影响ART），假设患者在 UTT 实施之前和之后在测量和未测量特征上保持平衡。

发现

65 673 名新入组的 HIV 患者（40 858 [62·2%] 女性，中位年龄 32 岁 [IQR 26–39]，中位 CD4 计数 287 个细胞/μL [IQR 147–466]）有资格纳入分析; 31 145 人在 UTT 实施前注册，34 528 人在 UTT 实施后注册。普遍治疗的实施使当天启动 ART 从 41·7% 增加到 74·8%（风险差异 [RD] 33·1%，95% CI 30·5–35·7），ART 在 1 个月内启动从 69 ·6% 至 87·0%（RD 17·4%，15·5–19·3），ART 的 12 个月保留率从 56·2% 至 63·3%（RD 7·1%，4· 3–9·9). 在实施普遍治疗后，各患者亚组的 ART 启动率变得更加统一，但各亚组之间 ART 12 个月保留的异质性没有改变。

解释

赞比亚实施的 UTT 政策提高了 ART 的速度和采用率，以及 12 个月时 ART 的保留率，尽管 ART 的总体保留率仍然不理想。UTT 政策减少了治疗开始的差异，但没有减少 ART 的 12 个月保留。自然实验揭示了现实世界实施的预期和意外效果，并表明需要利用 UTT 的短期效果来培养长期治疗成功的新策略。

资金

美国国立卫生研究院。