Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA.
Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
Clin Infect Dis. 2021 Sep 15;73(6):e1273-e1281. doi: 10.1093/cid/ciab222.
The World Health Organization's Treat-All guidance recommends CD4 testing before initiating antiretroviral therapy (ART), and routine viral load (VL) monitoring (over CD4 monitoring) for patients on ART.
We used regression discontinuity analyses to estimate changes in CD4 testing and VL monitoring among 547 837 ART-naive patients enrolling in human immunodeficiency virus (HIV) care during 2006-2018 at 225 clinics in 26 countries where Treat-All policies were adopted. We examined CD4 testing within 12 months before and VL monitoring 6 months after ART initiation among adults (≥20 years), adolescents (10-19 years), and children (0-9 years) in low/lower-middle-income countries (L/LMICs) and high/upper-middle-income countries (H/UMICs).
Treat-All adoption led to an immediate decrease in pre-ART CD4 testing among adults in L/LMICs, from 57.0% to 48.1% (-8.9 percentage points [pp]; 95% CI: -11.0, -6.8), and a small increase in H/UMICs, from 90.1% to 91.7% (+1.6pp; 95% CI: 0.2, 3.0), with no changes among adolescents or children; decreases in pre-ART CD4 testing accelerated after Treat-All adoption in L/LMICs. In L/LMICs, VL monitoring after ART initiation was low among all patients in L/LMICs before Treat-All; while there was no immediate change at Treat-All adoption, VL monitoring trends significantly increased afterwards. VL monitoring increased among adults immediately after Treat-All adoption, from 58.2% to 61.1% (+2.9pp; 95% CI: 0.5, 5.4), with no significant changes among adolescents/children.
While on-ART VL monitoring has improved in L/LMICs, Treat-All adoption has accelerated and disparately worsened suboptimal pre-ART CD4 monitoring, which may compromise care outcomes for individuals with advanced HIV.
世界卫生组织的“全面治疗”指南建议在开始抗逆转录病毒治疗（ART）之前进行 CD4 检测，并对接受 ART 的患者进行常规病毒载量（VL）监测（而非 CD4 监测）。
我们使用回归间断分析估计了 2006 年至 2018 年期间，在 26 个实施“全面治疗”政策的国家/地区的 225 个诊所中，547837 名首次接受抗逆转录病毒治疗的 HIV 感染者在接受治疗前 12 个月内进行 CD4 检测和在开始 ART 后 6 个月内进行 VL 监测的情况。我们在中低收入国家（LMICs）和高/中收入国家（UMICs）的成年人（≥20 岁）、青少年（10-19 岁）和儿童（0-9 岁）中检查了 ART 前的 CD4 检测和 ART 后 6 个月的 VL 监测。
“全面治疗”的实施立即导致中低收入国家成年人接受 ART 前的 CD4 检测率下降，从 57.0%降至 48.1%（-8.9 个百分点[pp]；95%CI：-11.0，-6.8），而高/中收入国家的这一比例略有上升，从 90.1%升至 91.7%（+1.6pp；95%CI：0.2，3.0），青少年和儿童的这一比例则没有变化；中低收入国家实施“全面治疗”后，ART 前 CD4 检测率的下降速度加快。在中低收入国家，“全面治疗”实施前，所有患者的 ART 后 VL 监测率都很低；尽管在实施“全面治疗”时没有立即发生变化，但此后 VL 监测趋势显著增加。在中低收入国家，“全面治疗”实施后，ART 后立即增加了成年人的 VL 监测，从 58.2%升至 61.1%（+2.9pp；95%CI：0.5，5.4），青少年/儿童的这一比例没有显著变化。
虽然中低收入国家的 ART 后 VL 监测有所改善，但“全面治疗”的实施加速了 ART 前 CD4 监测的不理想情况，并使其恶化，这可能会影响晚期 HIV 感染者的护理结果。
