Most countries have formally adopted the World Health Organization’s 2015 recommendation of universal HIV treatment (Treat All). Although effects of universal treatment eligibility interventions have been examined in large trials and using modeled data, there are few rigorous assessments of the real-world impact of Treat All on antiretroviral treatment (ART) uptake across different contexts.
We used longitudinal data for 814,603 patients enrolling in HIV care during 2004-2018 in six sub-Saharan African countries participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium (Burundi, Kenya, Malawi, Rwanda, Uganda, and Zambia). Using a quasi-experimental regression discontinuity design, we assessed the change in the proportion of individuals initiating treatment within 30 days of enrollment in HIV care (rapid ART initiation) after country-level adoption of Treat All policies. A modified multivariable Poisson model was used to identify factors associated with failure to initiate ART rapidly among persons enrolling in HIV care under Treat All.
In all countries, national adoption of Treat All was associated with large increases in rapid ART initiation. The greatest increase in rapid ART initiation immediately after Treat All policy adoption was observed in Rwanda, from 44.4% to 78.9% of patients (34.5 percentage points (pp); 95% CI: 27.2-41.7 pp), Kenya (25.7pp, 95% CI: 21.8 to 29.5pp), and Burundi (17.7pp, 95% CI: 6.5 to 28.9pp), while the rate of rapid ART initiation accelerated sharply following Treat All policy adoption in Malawi, Uganda, and Zambia. Under Treat All, younger patients (16-24 years) and men were at increased risk of not rapidly initiating ART (compared to older patients and women, respectively). However, rapid ART initiation following enrollment increased for all groups as more time elapsed since Treat All adoption.
Adoption of Treat All policies had a strong effect on increasing rates of rapid ART initiation and increases followed different trajectories across the six countries. Adoption and implementation of Treat All policies should be accelerated, with particular care to identify and address possible inequities in access to treatment by subgroups at higher risk of not rapidly initiating treatment following diagnosis and care enrollment.