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Published on: October 31, 2010
Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African
Elizabeth Zaniewski1, Ellen Brazier2, Cam Ha Dao Ostinelli1
1Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
Insights
The Treat-All policy expanded antiretroviral therapy (ART) eligibility but decreased pre-ART CD4 testing in some Southern African nations. Continued laboratory support is crucial for effective HIV disease management and ART program evaluation.
Area of Science:
- Public Health
- Infectious Diseases
- Health Policy
Background:
- The Treat-All policy aimed to increase access to antiretroviral therapy (ART) for people living with HIV (PLHIV).
- Understanding the impact of this policy on laboratory testing practices is essential for effective HIV program implementation in Southern Africa.
Purpose of the Study:
- To evaluate the effect of the Treat-All policy on laboratory testing for CD4 counts and viral load monitoring among ART-naïve PLHIV in Southern Africa.
Main Methods:
- A regression discontinuity design was employed using HIV cohort data from six Southern African countries (Lesotho, Malawi, Mozambique, South Africa, Zambia, Zimbabwe).
- The study analyzed data from over 230,000 ART-naïve PLHIV aged five years and older, initiating ART within two years of national Treat-All adoption (2016-2017).
Main Results:
- Pre-ART CD4 testing decreased significantly in Malawi and Mozambique following Treat-All adoption.
- Pre-ART CD4 testing increased in Zambia, while viral load monitoring remained largely unaffected, except for a notable increase among females in South Africa.
Conclusions:
- While expanding ART eligibility, the Treat-All policy led to reduced pre-ART CD4 testing in some regions, potentially impacting advanced HIV disease management.
- Sustained investment in CD4 and viral load laboratory capacity is vital for optimizing ART outcomes and ensuring consistent evaluation of ART programs across Southern Africa.
Objective:
To determine whether Treat-All policy impacted laboratory testing practices of antiretroviral therapy (ART) programs in Southern Africa.
Study Design And Setting:
We used HIV cohort data from Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in a regression discontinuity design to estimate changes in pre-ART CD4 testing and viral load monitoring following national Treat-all adoption that occurred during 2016 to 2017. This study included more than 230,000 ART-naïve people living with HIV (PLHIV) aged five years or older who started ART within two years of national Treat-All adoption.
Results:
We found pre-ART CD4 testing decreased following adoption of Treat-All recommendations in Malawi (-21.4 percentage points (pp), 95% confidence interval, CI: -26.8, -16.0) and in Mozambique (-8.8pp, 95% CI: -14.9, -2.8), but increased in Zambia (+2.7pp, 95% CI: +0.4, +5.1). Treat-All policy had no effect on viral load monitoring, except among females in South Africa (+7.1pp, 95% CI: +1.1, +13.0).
Conclusion:
Treat-All policy expanded ART eligibility, but led to reductions in pre-ART CD4 testing in some countries that may weaken advanced HIV disease management. Continued and expanded support of CD4 and viral load laboratory capacity is needed to further improve treatment successes and allow for uniform evaluation of ART implementation across Southern Africa.
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