Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
Dignitas International, Zomba, Malawi.
J Int AIDS Soc. 2019 Feb;22(2):e25239. doi: 10.1002/jia2.25239.
Since June 2016, the national HIV programme in Malawi has adopted Universal Test and Treat (UTT) guidelines requiring that all persons who test HIV positive will be referred to start antiretroviral therapy (ART). Although there is strong evidence from clinical trials that early initiation of ART leads to reduced morbidity and mortality, the impact of UTT on retention on ART in real-life programmatic settings in Africa is not yet known.
We conducted a retrospective cohort study in Zomba district, Malawi to compare ART outcomes of patients who initiated ART under 2016 UTT guidelines and those who started ART prior to rollout of UTT (pre-UTT). We analysed data from 32 rural and urban health facilities of various sizes. Cox proportional hazards modelling was used to determine the independent risk factors of attrition from ART at 12 months. All analyses were adjusted for clustering by health facility using a robust standard errors approach.
Among 1492 patients (mean age 34.4 years, 933 (63%) female) who initiated ART during the study period, 501 were enrolled in the pre-UTT cohort and 911 during UTT. At 12 months, retention on ART in the UTT cohort was higher than in the pre-UTT cohort 83.0% (95% confidence interval (CI): 81.0% to 85.0%) versus 76.2% (95% CI 73.9% to 78.5%). Adolescents, aged 10 to 19 years (adjusted hazard ratio (aHR) 1.53; 95% CI 1.01 to 2.32), and women who were pregnant or breastfeeding at ART initiation (aHR 1.87; 95% CI 1.30 to 2.38) were at higher risk of attrition in the combined pre-UTT and UTT cohort.
Retention on ART was nearly 6% higher after UTT introduction. Young adults and women who were pregnant or breastfeeding at the start of ART were at increased risk of attrition, emphasizing the need for targeted interventions for these groups to achieve the 90-90-90 UNAIDS targets in the UTT era.
自 2016 年 6 月以来，马拉维国家艾滋病毒规划采用了普遍检测和治疗（UTT）准则，要求所有艾滋病毒检测呈阳性的人都将被转介开始接受抗逆转录病毒治疗（ART）。尽管临床试验有强有力的证据表明早期开始 ART 可降低发病率和死亡率，但 UTT 对非洲实际规划环境中保留在 ART 治疗中的影响尚不清楚。
我们在马拉维宗巴区进行了一项回顾性队列研究，以比较根据 2016 年 UTT 准则开始 ART 的患者和在 UTT 推出前开始 ART（前 UTT）的患者的 ART 结局。我们分析了来自 32 个不同规模的农村和城市卫生机构的数据。使用 Cox 比例风险模型确定 12 个月时从 ART 流失的独立风险因素。所有分析均通过稳健标准误差方法按卫生机构进行了聚类调整。
在研究期间开始接受 ART 的 1492 名患者（平均年龄 34.4 岁，933 名[63%]女性）中，501 名患者被纳入前 UTT 队列，911 名患者被纳入 UTT 队列。在 12 个月时，UTT 队列的 ART 保留率高于前 UTT 队列 83.0%（95%置信区间（CI）：81.0%至 85.0%）与 76.2%（95% CI 73.9%至 78.5%）。青少年（10 至 19 岁）（调整后的危险比（aHR）1.53；95%CI 1.01 至 2.32）和开始 ART 时怀孕或正在哺乳的女性（aHR 1.87；95%CI 1.30 至 2.38）在前 UTT 和 UTT 联合队列中发生流失的风险更高。
UTT 推出后，ART 保留率提高了近 6%。开始 ART 时处于青春期的成年人和正在怀孕或哺乳的妇女流失的风险增加，这强调需要针对这些群体采取有针对性的干预措施，以在 UTT 时代实现 90-90-90 的艾滋病规划署目标。
