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Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis

BACKGROUND: 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. METHODS: We used regression discontinuity analyses to estimate changes in CD4 testin...

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Autores principales: Brazier, Ellen, Tymejczyk, Olga, Zaniewski, Elizabeth, Egger, Matthias, Wools-Kaloustian, Kara, Yiannoutsos, Constantin T, Jaquet, Antoine, Althoff, Keri N, Lee, Jennifer S, Caro-Vega, Yanink, Luz, Paula M, Tanuma, Junko, Niyongabo, Théodore, Nash, Denis
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442775/
https://www.ncbi.nlm.nih.gov/pubmed/33693517
http://dx.doi.org/10.1093/cid/ciab222
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author Brazier, Ellen
Tymejczyk, Olga
Zaniewski, Elizabeth
Egger, Matthias
Wools-Kaloustian, Kara
Yiannoutsos, Constantin T
Jaquet, Antoine
Althoff, Keri N
Lee, Jennifer S
Caro-Vega, Yanink
Luz, Paula M
Tanuma, Junko
Niyongabo, Théodore
Nash, Denis
author_facet Brazier, Ellen
Tymejczyk, Olga
Zaniewski, Elizabeth
Egger, Matthias
Wools-Kaloustian, Kara
Yiannoutsos, Constantin T
Jaquet, Antoine
Althoff, Keri N
Lee, Jennifer S
Caro-Vega, Yanink
Luz, Paula M
Tanuma, Junko
Niyongabo, Théodore
Nash, Denis
author_sort Brazier, Ellen
collection PubMed
description BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.
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spelling pubmed-84427752021-09-16 Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis Brazier, Ellen Tymejczyk, Olga Zaniewski, Elizabeth Egger, Matthias Wools-Kaloustian, Kara Yiannoutsos, Constantin T Jaquet, Antoine Althoff, Keri N Lee, Jennifer S Caro-Vega, Yanink Luz, Paula M Tanuma, Junko Niyongabo, Théodore Nash, Denis Clin Infect Dis Online Only Articles BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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. Oxford University Press 2021-03-09 /pmc/articles/PMC8442775/ /pubmed/33693517 http://dx.doi.org/10.1093/cid/ciab222 Text en © The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. https://creativecommons.org/licenses/by-nc-nd/4.0/This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
spellingShingle Online Only Articles
Brazier, Ellen
Tymejczyk, Olga
Zaniewski, Elizabeth
Egger, Matthias
Wools-Kaloustian, Kara
Yiannoutsos, Constantin T
Jaquet, Antoine
Althoff, Keri N
Lee, Jennifer S
Caro-Vega, Yanink
Luz, Paula M
Tanuma, Junko
Niyongabo, Théodore
Nash, Denis
Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis
title Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis
title_full Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis
title_fullStr Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis
title_full_unstemmed Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis
title_short Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis
title_sort effects of national adoption of treat-all guidelines on pre-antiretroviral therapy (art) cd4 testing and viral load monitoring after art initiation: a regression discontinuity analysis
topic Online Only Articles
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442775/
https://www.ncbi.nlm.nih.gov/pubmed/33693517
http://dx.doi.org/10.1093/cid/ciab222
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