Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa.
BACKGROUND:Loss to follow-up is high among HIV patients not yet receiving antiretroviral therapy (ART). Clinical trials have demonstrated the clinical efficacy of early ART; however, these trials may miss an important real-world consequence of providing ART at diagnosis: its impact on retention in c...
| Main Authors: | , , , , , , |
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| Format: | Article |
| Language: | English |
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Public Library of Science (PLoS)
2017-11-01
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| Series: | PLoS Medicine |
| Online Access: | http://europepmc.org/articles/PMC5705070?pdf=render |
| _version_ | 1818201990369378304 |
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| author | Jacob Bor Matthew P Fox Sydney Rosen Atheendar Venkataramani Frank Tanser Deenan Pillay Till Bärnighausen |
| author_facet | Jacob Bor Matthew P Fox Sydney Rosen Atheendar Venkataramani Frank Tanser Deenan Pillay Till Bärnighausen |
| author_sort | Jacob Bor |
| collection | DOAJ |
| description | BACKGROUND:Loss to follow-up is high among HIV patients not yet receiving antiretroviral therapy (ART). Clinical trials have demonstrated the clinical efficacy of early ART; however, these trials may miss an important real-world consequence of providing ART at diagnosis: its impact on retention in care. METHODS AND FINDINGS:We examined the effect of immediate (versus deferred) ART on retention in care using a regression discontinuity design. The analysis included all patients (N = 11,306) entering clinical HIV care with a first CD4 count between 12 August 2011 and 31 December 2012 in a public-sector HIV care and treatment program in rural South Africa. Patients were assigned to immediate versus deferred ART eligibility, as determined by a CD4 count < 350 cells/μl, per South African national guidelines. Patients referred to pre-ART care were instructed to return every 6 months for CD4 monitoring. Patients initiated on ART were instructed to return at 6 and 12 months post-initiation and annually thereafter for CD4 and viral load monitoring. We assessed retention in HIV care at 12 months, as measured by the presence of a clinic visit, lab test, or ART initiation 6 to 18 months after initial CD4 test. Differences in retention between patients presenting with CD4 counts just above versus just below the 350-cells/μl threshold were estimated using local linear regression models with a data-driven bandwidth and with the algorithm for selecting the bandwidth chosen ex ante. Among patients with CD4 counts close to the 350-cells/μl threshold, having an ART-eligible CD4 count (<350 cells/μl) was associated with higher 12-month retention than not having an ART-eligible CD4 count (50% versus 32%), an intention-to-treat risk difference of 18 percentage points (95% CI 11 to 23; p < 0.001). The decision to start ART was determined by CD4 count for one in four patients (25%) presenting close to the eligibility threshold (95% CI 20% to 31%; p < 0.001). In this subpopulation, having an ART-eligible CD4 count was associated with higher 12-month retention than not having an ART-eligible CD4 count (91% versus 21%), a complier causal risk difference of 70 percentage points (95% CI 42 to 98; p < 0.001). The major limitations of the study are the potential for limited generalizability, the potential for outcome misclassification, and the absence of data on longer-term health outcomes. CONCLUSIONS:Patients who were eligible for immediate ART had dramatically higher retention in HIV care than patients who just missed the CD4-count eligibility cutoff. The clinical and population health benefits of offering immediate ART regardless of CD4 count may be larger than suggested by clinical trials. |
| first_indexed | 2024-12-12T03:02:20Z |
| format | Article |
| id | doaj.art-2568fd8fed8642ddb8b1c6e585efec39 |
| institution | Directory Open Access Journal |
| issn | 1549-1277 1549-1676 |
| language | English |
| last_indexed | 2024-12-12T03:02:20Z |
| publishDate | 2017-11-01 |
| publisher | Public Library of Science (PLoS) |
| record_format | Article |
| series | PLoS Medicine |
| spelling | doaj.art-2568fd8fed8642ddb8b1c6e585efec392022-12-22T00:40:36ZengPublic Library of Science (PLoS)PLoS Medicine1549-12771549-16762017-11-011411e100246310.1371/journal.pmed.1002463Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa.Jacob BorMatthew P FoxSydney RosenAtheendar VenkataramaniFrank TanserDeenan PillayTill BärnighausenBACKGROUND:Loss to follow-up is high among HIV patients not yet receiving antiretroviral therapy (ART). Clinical trials have demonstrated the clinical efficacy of early ART; however, these trials may miss an important real-world consequence of providing ART at diagnosis: its impact on retention in care. METHODS AND FINDINGS:We examined the effect of immediate (versus deferred) ART on retention in care using a regression discontinuity design. The analysis included all patients (N = 11,306) entering clinical HIV care with a first CD4 count between 12 August 2011 and 31 December 2012 in a public-sector HIV care and treatment program in rural South Africa. Patients were assigned to immediate versus deferred ART eligibility, as determined by a CD4 count < 350 cells/μl, per South African national guidelines. Patients referred to pre-ART care were instructed to return every 6 months for CD4 monitoring. Patients initiated on ART were instructed to return at 6 and 12 months post-initiation and annually thereafter for CD4 and viral load monitoring. We assessed retention in HIV care at 12 months, as measured by the presence of a clinic visit, lab test, or ART initiation 6 to 18 months after initial CD4 test. Differences in retention between patients presenting with CD4 counts just above versus just below the 350-cells/μl threshold were estimated using local linear regression models with a data-driven bandwidth and with the algorithm for selecting the bandwidth chosen ex ante. Among patients with CD4 counts close to the 350-cells/μl threshold, having an ART-eligible CD4 count (<350 cells/μl) was associated with higher 12-month retention than not having an ART-eligible CD4 count (50% versus 32%), an intention-to-treat risk difference of 18 percentage points (95% CI 11 to 23; p < 0.001). The decision to start ART was determined by CD4 count for one in four patients (25%) presenting close to the eligibility threshold (95% CI 20% to 31%; p < 0.001). In this subpopulation, having an ART-eligible CD4 count was associated with higher 12-month retention than not having an ART-eligible CD4 count (91% versus 21%), a complier causal risk difference of 70 percentage points (95% CI 42 to 98; p < 0.001). The major limitations of the study are the potential for limited generalizability, the potential for outcome misclassification, and the absence of data on longer-term health outcomes. CONCLUSIONS:Patients who were eligible for immediate ART had dramatically higher retention in HIV care than patients who just missed the CD4-count eligibility cutoff. The clinical and population health benefits of offering immediate ART regardless of CD4 count may be larger than suggested by clinical trials.http://europepmc.org/articles/PMC5705070?pdf=render |
| spellingShingle | Jacob Bor Matthew P Fox Sydney Rosen Atheendar Venkataramani Frank Tanser Deenan Pillay Till Bärnighausen Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. PLoS Medicine |
| title | Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. |
| title_full | Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. |
| title_fullStr | Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. |
| title_full_unstemmed | Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. |
| title_short | Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. |
| title_sort | treatment eligibility and retention in clinical hiv care a regression discontinuity study in south africa |
| url | http://europepmc.org/articles/PMC5705070?pdf=render |
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