Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African countries

Elizabeth Zaniewski; Ellen Brazier; Cam Ha Dao Ostinelli; Robin Wood; Meg Osler; Karl-Günter Technau; Joep J van Oosterhout; Nicola Maxwell; Janneke van Dijk; Hans Prozesky; Matthew P Fox; Jacob Bor; Denis Nash; Matthias Egger

doi:10.1016/j.jclinepi.2021.09.001

Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African countries

Elizabeth Zaniewski
, Ellen Brazier
, Cam Ha Dao Ostinelli
, Robin Wood
, Meg Osler
, Karl-Günter Technau
, Joep J van Oosterhout
, Nicola Maxwell
, Janneke van Dijk
, Hans Prozesky
, Matthew P Fox
, Jacob Bor
, Denis Nash
, Matthias Egger

Bristol Medical School (PHS)

Research output: Contribution to journal › Article (Academic Journal) › peer-review

10 Citations (Scopus)

113 Downloads (Pure)

Abstract

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 2016-2017. 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% 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.

Original language	English
Pages (from-to)	101-110
Number of pages	10
Journal	Journal of Clinical Epidemiology
Volume	140
Early online date	3 Sept 2021
DOIs	https://doi.org/10.1016/j.jclinepi.2021.09.001
Publication status	Published - 1 Dec 2021

Bibliographical note

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

Keywords

CD4 lymphocyte count
Viral load
Antiretroviral therapy
Southern Africa
HIV infection
Regression discontinuity design

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Zaniewski, E., Brazier, E., Ostinelli, C. H. D., Wood, R., Osler, M., Technau, K.-G., van Oosterhout, J. J., Maxwell, N., van Dijk, J., Prozesky, H., Fox, M. P., Bor, J., Nash, D., & Egger, M. (2021). Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African countries. Journal of Clinical Epidemiology, 140, 101-110. https://doi.org/10.1016/j.jclinepi.2021.09.001

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abstract = "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 2016-2017. This study included more than 230,000 ART-na{\"i}ve 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\% 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.",

keywords = "CD4 lymphocyte count, Viral load, Antiretroviral therapy, Southern Africa, HIV infection, Regression discontinuity design",

author = "Elizabeth Zaniewski and Ellen Brazier and Ostinelli, \{Cam Ha Dao\} and Robin Wood and Meg Osler and Karl-G{\"u}nter Technau and \{van Oosterhout\}, \{Joep J\} and Nicola Maxwell and \{van Dijk\}, Janneke and Hans Prozesky and Fox, \{Matthew P\} and Jacob Bor and Denis Nash and Matthias Egger",

note = "Copyright {\textcopyright} 2021. Published by Elsevier Inc.",

year = "2021",

month = dec,

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doi = "10.1016/j.jclinepi.2021.09.001",

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Zaniewski, E, Brazier, E, Ostinelli, CHD, Wood, R, Osler, M, Technau, K-G, van Oosterhout, JJ, Maxwell, N, van Dijk, J, Prozesky, H, Fox, MP, Bor, J, Nash, D & Egger, M 2021, 'Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African countries', Journal of Clinical Epidemiology, vol. 140, pp. 101-110. https://doi.org/10.1016/j.jclinepi.2021.09.001

TY - JOUR

T1 - Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African countries

AU - Zaniewski, Elizabeth

AU - Brazier, Ellen

AU - Ostinelli, Cam Ha Dao

AU - Wood, Robin

AU - Osler, Meg

AU - Technau, Karl-Günter

AU - van Oosterhout, Joep J

AU - Maxwell, Nicola

AU - van Dijk, Janneke

AU - Prozesky, Hans

AU - Fox, Matthew P

AU - Bor, Jacob

AU - Nash, Denis

AU - Egger, Matthias

PY - 2021/12/1

Y1 - 2021/12/1

N2 - 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 2016-2017. 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% 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.

AB - 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 2016-2017. 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% 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.

KW - CD4 lymphocyte count

KW - Viral load

KW - Antiretroviral therapy

KW - Southern Africa

KW - HIV infection

KW - Regression discontinuity design

U2 - 10.1016/j.jclinepi.2021.09.001

DO - 10.1016/j.jclinepi.2021.09.001

M3 - Article (Academic Journal)

C2 - 34487837

SN - 0895-4356

VL - 140

SP - 101

EP - 110

JO - Journal of Clinical Epidemiology

JF - Journal of Clinical Epidemiology

ER -

Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African countries

Abstract

Bibliographical note

UN SDGs

Keywords

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