Background Multistage stepwise HIV testing and treatment initiation procedures can result in lost opportunities to provide timely antiretroviral therapy (ART). Incomplete patient engagement along the continuum of HIV care translates into high levels of preventable mortality. We aimed to evaluate the ability of a simplified test and treat structural intervention to reduce mortality. Methods and Findings In the “pre-intervention 2010” (from January 2010 to December 2010) and “pre-intervention 2011” (from January 2011 to December 2011) phases, patients who screened HIV-positive at health care facilities in Zhongshan and Pubei counties in Guangxi, China, followed the standard-of-care process. In the “post-intervention 2012” (from July 2012 to June 2013) and “post-intervention 2013” (from July 2013 to June 2014) phases, patients who screened HIV-positive at the same facilities were offered a simplified test and treat intervention, i.e., concurrent HIV confirmatory and CD4 testing and immediate initiation of ART, irrespective of CD4 count. Participants were followed for 6–18 mo until the end of their study phase period. Mortality rates in the pre-intervention and post-intervention phases were compared for all HIV cases and for treatment-eligible HIV cases. A total of 1,034 HIV-positive participants (281 and 339 in the two pre-intervention phases respectively, and 215 and 199 in the two post-intervention phases respectively) were enrolled. Following the structural intervention, receipt of baseline CD4 testing within 30 d of HIV confirmation increased from 67%/61% (pre-intervention 2010/pre-intervention 2011) to 98%/97% (post-intervention 2012/post-intervention 2013) (all p < 0.001 [i.e., for all comparisons between a pre- and post-intervention phase]), and the time from HIV confirmation to ART initiation decreased from 53 d (interquartile range [IQR] 27–141)/43 d (IQR 15–113) to 5 d (IQR 2–12)/5 d (IQR 2–13) (all p < 0.001). Initiation of ART increased from 27%/49% to 91%/89% among all cases (all p < 0.001) and from 39%/62% to 94%/90% among individuals with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). Mortality decreased from 27%/27% to 10%/10% for all cases (all p < 0.001) and from 40%/35% to 13%/13% for cases with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). The simplified test and treat intervention was significantly associated with decreased mortality rates compared to pre-intervention 2011 (adjusted hazard ratio [aHR] 0.385 [95% CI 0.239–0.620] and 0.380 [95% CI 0.233–0.618] for the two post-intervention phases, respectively, for all newly
References
[1]
World Health Organization (2011) The Treatment 2.0 framework for action: catalysing the next phase of treatment, care and support. Geneva: World Health Organization.
[2]
Castilla J, Sobrino P, De La Fuente L, Noguer I, Guerra L, et al. (2002) Late diagnosis of HIV infection in the era of highly active antiretroviral therapy: consequences for AIDS incidence. AIDS 16: 1945–1951. pmid:12351955 doi: 10.1097/00002030-200209270-00012
[3]
Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ (2011) The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis 52: 793–800. doi: 10.1093/cid/ciq243. pmid:21367734
[4]
Girardi E, Sabin CA, Monforte AD (2007) Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing. J Acquir Immune Defic Syndr 46: S3–S8. pmid:17713423 doi: 10.1097/01.qai.0000286597.57066.2b
[5]
Mocroft A, Kirk O, Aldins P, Chies A, Blaxhult A, et al. (2008) Loss to follow-up in an international, multicentre observational study. HIV Med 9: 261–269. doi: 10.1111/j.1468-1293.2008.00557.x. pmid:18400074
[6]
Tran DA, Shakeshaft A, Ngo AD, Rule J, Wilson DP, et al. (2012) Structural barriers to timely initiation of antiretroviral treatment in Vietnam: findings from six outpatient clinics. PLoS ONE 7: e51289. doi: 10.1371/journal.pone.0051289. pmid:23240013
[7]
Thanawuth N, Chongsuvivatwong V (2008) Late HIV diagnosis and delay in CD4 count measurement among HIV-infected patients in southern Thailand. AIDS Care 20: 43–50. doi: 10.1080/09540120701439303. pmid:18278614
[8]
Fleishman JA, Yehia BR, Moore RD, Korthuis PT, Gebo KA, et al. (2012) Establishment, retention, and loss to follow-up in outpatient HIV care. J Acquir Immune Defic Syndr 60: 249–259. doi: 10.1097/QAI.0b013e318258c696. pmid:22531758
[9]
Mugglin C, Estill J, Wandeler G, Bender N, Egger M, et al. (2012) Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis. Trop Med Int Health 17: 1509–1520. doi: 10.1111/j.1365-3156.2012.03089.x. pmid:22994151
[10]
Hoffmann CJ, Lewis JJ, Dowdy DW, Fielding KL, Grant AD, et al. (2013) Mortality associated with delays between clinic entry and ART initiation in resource-limited settings: results of a transition-state model. J Acquir Immune Defic Syndr 63: 105–111. doi: 10.1097/QAI.0b013e3182893fb4. pmid:23392457
[11]
Kiertiburanakul S, Boettiger D, Lee MP, Omar SF, Tanuma J, et al. (2014) Trends of CD4 cell count levels at the initiation of antiretroviral therapy over time and factors associated with late initiation of antiretroviral therapy among Asian HIV-positive patients. J Int AIDS Soc 17: 18804. doi: 10.7448/IAS.17.1.18804. pmid:24598459
[12]
Zhang F, Dou Z, Ma Y, Zhang Y, Zhao Y, et al. (2011) Effect of earlier initiation of antiretroviral treatment and increased treatment coverage on HIV-related mortality in China: a national observational cohort study. Lancet Infect Dis 11: 516–524. doi: 10.1016/S1473-3099(11)70097-4. pmid:21600849
[13]
Brinkhof MW, Pujades-Rodriguez M, Egger M (2009) Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis. PLoS ONE 4: e5790. doi: 10.1371/journal.pone.0005790. pmid:19495419
[14]
Tang H, Mao Y, Shi CX, Han J, Wang L, et al. (2014) Baseline CD4 cell counts of newly diagnosed HIV cases in China: 2006–2012. PLoS ONE 9: e96098. doi: 10.1371/journal.pone.0096098. pmid:24901790
[15]
Ministry of Health Working Group on Clinical AIDS Treatment (2012) China free antiretroviral treatment manual. Beijing: People’s Medical Publishing House.
[16]
Govindasamy D, Meghij J, Kebede Negussi E, Clare Baggaley R, Ford N, et al. (2014) Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings—a systematic review. J Int AIDS Soc 17: 19032. doi: 10.7448/IAS.17.1.19032. pmid:25095831
[17]
Patten GE, Wilkinson L, Conradie K, Isaakidis P, Harries AD, et al. (2013) Impact on ART initiation of point-of-care CD4 testing at HIV diagnosis among HIV-positive youth in Khayelitsha, South Africa. J Int AIDS Soc 16: 18518. doi: 10.7448/IAS.16.1.18518. pmid:23830642
[18]
National Center for AIDS/STD Control and Prevention (2012) 2011 annual report of national AIDS/STD statistics on epidemics and program implementation. Beijing: National Center for AIDS/STD Control and Prevention.
[19]
Chinese Center for Disease Control and Prevention (2009) [National guidelines for detection of HIV/AIDS, 2009 revision.] Beijing: Chinese Center for Disease Control and Prevention.
[20]
Cochrane Effective Practice and Organisation of Care Review Group (2002) Data collection checklist. Ottawa: Cochrane Collaboration.
[21]
Michie S, van Stralen MM, West R (2011) The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 6: 42. doi: 10.1186/1748-5908-6-42. pmid:21513547
[22]
Mao Y, Wu Z, Poundstone K, Wang C, Qin Q, et al. (2010) Development of a unified web-based national HIV/AIDS information system in China. Int J Epidemiol 39 (Suppl 2): 79–89. doi: 10.1093/ije/dyq213
[23]
May M, Gompels M, Delpech V, Porter K, Post F, et al. (2011) Impact of late diagnosis and treatment on life expectancy in people with HIV-1: UK Collaborative HIV Cohort (UK CHIC) Study. BMJ 343: d6016. doi: 10.1136/bmj.d6016. pmid:21990260
[24]
Schwarcz S, Hsu L, Dilley JW, Loeb L, Nelson K, et al. (2006) Late diagnosis of HIV infection: trends, prevalence, and characteristics of persons whose HIV diagnosis occurred within 12 months of developing AIDS. J Acquir Immune Defic Syndr 43: 491–494. pmid:17031318 doi: 10.1097/01.qai.0000243114.37035.de
[25]
Nakagawa F, Lodwick RK, Smith CJ, Smith R, Cambiano V, et al. (2012) Projected life expectancy of people with HIV according to timing of diagnosis. AIDS 26: 335–343. doi: 10.1097/QAD.0b013e32834dcec9. pmid:22089374
[26]
Katz IT, Essien T, Marinda ET, Gray GE, Bangsberg DR, et al. (2011) Antiretroviral therapy refusal among newly diagnosed HIV-infected adults. AIDS 25: 2177–2181. doi: 10.1097/QAD.0b013e32834b6464. pmid:21832935
[27]
Musheke M, Bond V, Merten S (2013) Deterrents to HIV-patient initiation of antiretroviral therapy in urban Lusaka, Zambia: a qualitative study. AIDS Patient Care STDS 27: 231–241. doi: 10.1089/apc.2012.0341. pmid:23530573
[28]
MacPherson P, MacPherson EE, Mwale D, Bertel Squire S, Makombe SD, et al. (2012) Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi. J Int AIDS Soc 15: 18020. doi: 10.7448/IAS.15.2.18020. pmid:23336700
[29]
Zhang F, Haberer JE, Wang Y, Zhao Y, Ma Y, et al. (2007) The Chinese free antiretroviral treatment program: challenges and responses. AIDS 21: S143–S148. doi: 10.1097/01.aids.0000304710.10036.2b. pmid:18172383
[30]
Danel C, Gabillard D, Le Carrou J, Anglaret X, Moh R, et al. (2015) Early ART and IPT in HIV-infected African adults with high CD4 count (Temprano Trial). Abstract 115LB. CROI 2015; 23–26 Feb 2015; Seattle, Washington, US.
[31]
National Institute of Allergy and Infectious Diseases (2015) Starting antiretroviral treatment early improves outcomes for HIV-infected individuals: NIH-funded trial results likely will impact global treatment guidelines.
[32]
Joint United Nations Programme on HIV/AIDS (2015) Implications of the START study data: questions and answers.
[33]
World Health Organization (2013) Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection—recommendations for a public health approach. Geneva: World Health Organization.
[34]
World Health Organization (2013) Global update on HIV treatment 2013: results, impact and opportunities. Geneva: World Health Organization.
[35]
US Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents (2012) Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Washington (District of Columbia): US Department of Health and Human Services.
[36]
Cohen MS, Smith MK, Muessig KE, Hallett TB, Powers KA, et al. (2013) Antiretroviral treatment of HIV-1 prevents transmission of HIV-1: where do we go from here? Lancet 382: 1515–1524. doi: 10.1016/S0140-6736(13)61998-4. pmid:24152938
[37]
McNairy ML, Cohen M, El-Sadr WM (2013) Antiretroviral therapy for prevention is a combination strategy. Curr HIV/AIDS Rep 10: 152–158. doi: 10.1007/s11904-013-0152-1. pmid:23371351
[38]
Montaner JS, Hogg R, Wood E, Kerr T, Tyndall M, et al. (2006) The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. Lancet 368: 531–536. pmid:16890841 doi: 10.1016/s0140-6736(06)69162-9
[39]
Montaner JS, Lima VD, Barrios R, Yip B, Wood E, et al. (2010) Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet 376: 532–539. doi: 10.1016/S0140-6736(10)60936-1. pmid:20638713
[40]
Joint United Nations Programme on HIV/AIDS (2013) Global report: UNAIDS report on the global AIDS epidemic 2013. Geneva: Joint United Nations Programme on HIV/AIDS.
