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Changes in rapid HIV treatment initiation after national "treat all" policy adoption in 6 sub-Saharan African countries: Regression discontinuity analysis

dc.contributor.authorRebeiro, Peter F.
dc.contributor.authorTymejczyk, Olga
dc.contributor.authorBrazier, Ellen
dc.contributor.authorYiannoutsos, Constantin T.
dc.contributor.authorVinikoor, Michael
dc.contributor.authorvan Lettow, Monique
dc.date.accessioned2020-03-25T18:16:39Z
dc.date.available2020-03-25T18:16:39Z
dc.date.issued2019-06
dc.identifier.citationTymejczykO, BrazierE, Yiannoutsos CT,VinikoorM, van LettowM, NalugodaF, et al.(2019)Changesin rapidHIV treatmentinitiationafter national“treatall” policyadoptionin 6 sub-SaharanAfricancountries:Regressiondiscontinuity analysis.PLoSMed 16(6):e1002822.en_US
dc.identifier.issn1549-1277
dc.identifier.urihttps://ir.vanderbilt.edu/xmlui/handle/1803/9864
dc.descriptionOnly Vanderbilt University affiliated authors are listed on VUIR. For a full list of authors, access the version of record at https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1002822&type=printableen_US
dc.description.abstractBackground Most countries have formally adopted the World Health Organization's 2015 recommendation of universal HIV treatment ("treat all"). However, there are few rigorous assessments of the real-world impact of treat all policies on antiretroviral treatment (ART) uptake across different contexts. Methods and findings We used longitudinal data for 814,603 patients enrolling in HIV care between 1 January 2004 and 10 July 2018 in 6 countries participating in the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium: Burundi (N = 11,176), Kenya (N = 179,941), Malawi (N = 84,558), Rwanda (N = 17,396), Uganda (N = 96,286), and Zambia (N = 425,246). Using a quasi-experimental regression discontinuity design, we assessed the change in the proportion initiating ART within 30 days of enrollment in HIV care (rapid ART initiation) after country-level adoption of the treat all policy. A modified Poisson model was used to identify factors associated with failure to initiate ART rapidly under treat all. In each of the 6 countries, over 60% of included patients were female, and median age at enrollment ranged from 32 to 36 years. In all countries studied, national adoption of treat all was associated with large increases in rapid ART initiation. Significant increases in rapid ART initiation immediately after treat all policy adoption were observed in Rwanda, from 44.4% to 78.9% of patients (34.5 percentage points [pp], 95% CI 27.2 to 41.7; p < 0.001), Kenya (25.7 pp, 95% CI 21.8 to 29.5; p < 0.001), Burundi (17.7 pp, 95% CI 6.5 to 28.9; p = 0.002), and Malawi (12.5 pp, 95% CI 7.5 to 17.5; p < 0.001), while no immediate increase was observed in Zambia (0.4 pp, 95% CI -2.9 to 3.8; p = 0.804) and Uganda (-4.2 pp, 95% CI -9.0 to 0.7; p = 0.090). The rate of rapid ART initiation accelerated sharply following treat all policy adoption in Malawi, Uganda, and Zambia; slowed in Kenya; and did not change in Rwanda and Burundi. In post hoc analyses restricted to patients enrolling under treat all, young adults (16-24 years) and men were at increased risk of not rapidly initiating ART (compared to older patients and women, respectively). However, rapid ART initiation following enrollment increased for all groups as more time elapsed since treat all policy adoption. Study limitations include incomplete data on potential ART eligibility criteria, such as clinical status, pregnancy, and enrollment CD4 count, which precluded the assessment of rapid ART initiation specifically among patients known to be eligible for ART before treat all. Conclusions Our analysis indicates that adoption of treat all policies had a strong effect on increasing rates of rapid ART initiation, and that these increases followed different trajectories across the 6 countries. Young adults and men still require additional attention to further improve rapid ART initiation.en_US
dc.description.sponsorshipResearch reported in this publication was supported by the National Institute of Allergy and Infectious Diseases [www.niaid.nih.gov] of the National Institutes of Health under Award Numbers U01AI096299 (OT, EB, JDS, GL, DN; IeDEA Central Africa) and U01AI069924 (MD, EZ, NA, MV, MvL); IeDEA Southern Africa); the National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute on Drug Abuse [www.drugabuse.gov], the National Cancer Institute, and the National Institute of Mental Health under Award Number U01AI069911 (CTY, KWK, MU, FN); IeDEA East Africa); the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Cancer Institute, the National Institute of Allergy and Infectious Diseases, National Institute of Mental Health, and the Office of the Director, the National Institutes of Health [www.nih.gov/institutes-nih/nih-office-director], under Award Number U01AI069923 (Caribbean, Central and South America network for HIV epidemiology [CCASAnet]; PFR), and National Institute of Allergy and Infectious Diseases under Award Number K01-AI131895 (PFR). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.en_US
dc.language.isoen_USen_US
dc.publisherPLOS MEDICINEen_US
dc.source.urihttps://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1002822&type=printable
dc.subjectIMPLEMENTATIONen_US
dc.subjectEPIDEMIOLOGYen_US
dc.subjectINFERENCEen_US
dc.subjectDESIGNSen_US
dc.titleChanges in rapid HIV treatment initiation after national "treat all" policy adoption in 6 sub-Saharan African countries: Regression discontinuity analysisen_US
dc.typeArticleen_US
dc.identifier.doi10.1371/journal.pmed.1002822
dc.rights.holderCopyright: © 2019 Tymejczyk et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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