Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA.
Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
Lancet HIV. 2021 Dec;8(12):e755-e765. doi: 10.1016/S2352-3018(21)00186-7. Epub 2021 Oct 14.
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.
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.
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.
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.
National Institutes of Health.
普遍检测和治疗（UTT）适用于所有艾滋病毒感染者，仅在实验条件下通过整群随机试验进行了评估。在实际情况下，UTT 政策对艾滋病毒护理级联的公共卫生效果尚不清楚。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的真实世界效果。
我们使用赞比亚常规电子健康记录系统的数据，分析了在实施普遍治疗（即 2016 年 1 月 1 日至 2018 年 1 月 1 日）前的 1 年和实施后 1 年内新登记的抗逆转录病毒治疗（ART）初治成年人，在赞比亚 117 个诊所接受治疗，这些诊所得到了赞比亚传染病研究中心的支持。我们使用回归不连续性设计来估计在实施 UTT 时对当天开始接受 ART、1 个月内开始接受 ART 和 12 个月时保留在 ART 上（定义为登记后 9-15 个月就诊，至少接受 6 个月的 ART）的影响，假设在 UTT 实施前后就诊的患者在测量和未测量的特征上是平衡的。我们进行了工具变量分析，以估计在常规条件下当天开始接受 ART 对 12 个月时保留在 ART 上的影响。
共有 65673 名新登记的艾滋病毒感染者（40858 [62.2%]名女性，中位年龄 32 岁[IQR 26-39]，中位 CD4 计数 287 个细胞/μL [IQR 147-466]）符合纳入分析的条件；其中 31145 人在实施 UTT 前登记，34528 人在实施 UTT 后登记。普遍治疗的实施将当天开始接受 ART 的比例从 41.7%提高到 74.8%（风险差异[RD]33.1%，95%CI 30.5-35.7），1 个月内开始接受 ART 的比例从 69.6%提高到 87.0%（RD 17.4%，15.5-19.3），12 个月时保留在 ART 上的比例从 56.2%提高到 63.3%（RD 7.1%，4.3-9.9）。普遍治疗实施后，ART 开始率在患者亚组中变得更加一致，但亚组间 12 个月时保留在 ART 上的异质性没有改变。工具变量分析表明，常规环境下当天开始接受 ART 可使 12 个月时保留在 ART 上的比例增加 15.8%（95%CI 12.1-19.5）。
在赞比亚实施的 UTT 政策提高了快速开始和接受 ART 的速度，以及 12 个月时保留在 ART 上的速度，尽管总体保留在 ART 上的速度仍然不理想。UTT 政策减少了治疗开始方面的差异，但没有减少 12 个月时保留在 ART 上的差异。自然实验揭示了真实世界实施的预期和意外影响，并表明需要新的策略利用 UTT 的短期效果来培养长期治疗成功。
美国国立卫生研究院。
