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Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention

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 th...

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Autores principales: Wu, Zunyou, Zhao, Yan, Ge, Xianmin, Mao, Yurong, Tang, Zhenzhu, Shi, Cynthia X., Chen, Chi, Li, Yong, Qiu, Xuejun, Nong, Guide, Huang, Shanhui, Luo, Shen, Wu, Shaohui, He, Wenzhen, Zhang, Mingjie, Shen, Zhiyong, Jin, Xia, Li, Jian, Brookmeyer, Ron, Detels, Roger, Montaner, Julio, Wang, Yu
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2015
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562716/
https://www.ncbi.nlm.nih.gov/pubmed/26348214
http://dx.doi.org/10.1371/journal.pmed.1001874
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author Wu, Zunyou
Zhao, Yan
Ge, Xianmin
Mao, Yurong
Tang, Zhenzhu
Shi, Cynthia X.
Chen, Chi
Li, Yong
Qiu, Xuejun
Nong, Guide
Huang, Shanhui
Luo, Shen
Wu, Shaohui
He, Wenzhen
Zhang, Mingjie
Shen, Zhiyong
Jin, Xia
Li, Jian
Brookmeyer, Ron
Detels, Roger
Montaner, Julio
Wang, Yu
author_facet Wu, Zunyou
Zhao, Yan
Ge, Xianmin
Mao, Yurong
Tang, Zhenzhu
Shi, Cynthia X.
Chen, Chi
Li, Yong
Qiu, Xuejun
Nong, Guide
Huang, Shanhui
Luo, Shen
Wu, Shaohui
He, Wenzhen
Zhang, Mingjie
Shen, Zhiyong
Jin, Xia
Li, Jian
Brookmeyer, Ron
Detels, Roger
Montaner, Julio
Wang, Yu
author_sort Wu, Zunyou
collection PubMed
description 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/mm(3) 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/mm(3) 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 diagnosed HIV cases [both p < 0.001], and aHR 0.369 [95% CI 0.226–0.603] and 0.361 [95% CI 0.221–0.590] for newly diagnosed treatment-eligible HIV cases [both p < 0.001]). The unit cost of an additional patient receiving ART attributable to the intervention was US$83.80. The unit cost of a death prevented because of the intervention was US$234.52. CONCLUSIONS: Our results demonstrate that the simplified HIV test and treat intervention promoted successful engagement in care and was associated with a 62% reduction in mortality. Our findings support the implementation of integrated HIV testing and immediate access to ART irrespective of CD4 count, in order to optimize the impact of ART.
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spelling pubmed-45627162015-09-10 Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention Wu, Zunyou Zhao, Yan Ge, Xianmin Mao, Yurong Tang, Zhenzhu Shi, Cynthia X. Chen, Chi Li, Yong Qiu, Xuejun Nong, Guide Huang, Shanhui Luo, Shen Wu, Shaohui He, Wenzhen Zhang, Mingjie Shen, Zhiyong Jin, Xia Li, Jian Brookmeyer, Ron Detels, Roger Montaner, Julio Wang, Yu PLoS Med Research Article 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/mm(3) 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/mm(3) 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 diagnosed HIV cases [both p < 0.001], and aHR 0.369 [95% CI 0.226–0.603] and 0.361 [95% CI 0.221–0.590] for newly diagnosed treatment-eligible HIV cases [both p < 0.001]). The unit cost of an additional patient receiving ART attributable to the intervention was US$83.80. The unit cost of a death prevented because of the intervention was US$234.52. CONCLUSIONS: Our results demonstrate that the simplified HIV test and treat intervention promoted successful engagement in care and was associated with a 62% reduction in mortality. Our findings support the implementation of integrated HIV testing and immediate access to ART irrespective of CD4 count, in order to optimize the impact of ART. Public Library of Science 2015-09-08 /pmc/articles/PMC4562716/ /pubmed/26348214 http://dx.doi.org/10.1371/journal.pmed.1001874 Text en © 2015 Wu et al http://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.
spellingShingle Research Article
Wu, Zunyou
Zhao, Yan
Ge, Xianmin
Mao, Yurong
Tang, Zhenzhu
Shi, Cynthia X.
Chen, Chi
Li, Yong
Qiu, Xuejun
Nong, Guide
Huang, Shanhui
Luo, Shen
Wu, Shaohui
He, Wenzhen
Zhang, Mingjie
Shen, Zhiyong
Jin, Xia
Li, Jian
Brookmeyer, Ron
Detels, Roger
Montaner, Julio
Wang, Yu
Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention
title Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention
title_full Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention
title_fullStr Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention
title_full_unstemmed Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention
title_short Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention
title_sort simplified hiv testing and treatment in china: analysis of mortality rates before and after a structural intervention
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562716/
https://www.ncbi.nlm.nih.gov/pubmed/26348214
http://dx.doi.org/10.1371/journal.pmed.1001874
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