Expanded HIV Treatment Eligibility Does Not Crowd Out Sickest.

In September 2015, the World Health Organization revised its antiretroviral therapy (ART) treatment guidelines for HIV. Whereas before ART treatment only began when a patient’s HIV infection had reached a designated threshold, the WHO now recommends everyone diagnosed should begin ART immediately upon HIV diagnosis. As resource-limited countries begin adopting the new guidelines, concerns have arisen about whether health systems can handle a large influx of newly eligible patients, and whether sicker, previously eligible patients would be adversely affected.

Now, a new study led by School of Public Health researchers shows ART eligibility expansion did not crowd out the sickest patients or reduce quality of care.

Published in Tropical Medicine & International Health, the study looked at a large ART eligibility expansion in South Africa in 2011, which increased the ART-eligible population by 51 percent. The researchers found expanding eligibility led to a 32-percent increase in patients starting ART per month. However, all patients started ART faster and there was no decline in ART uptake among sicker patients who had been eligible under earlier guidelines.

“These findings are a positive indication that it is possible to expand HIV treatment access without adverse consequences,” says study co-author Jacob Bor, assistant professor and Peter T. Paul Career Development professor of global health and epidemiology.

ART eligibility guidelines were historically based on the levels of CD4 cells in the blood. Lower CD4 counts indicate worse health, and sicker patients were traditionally prioritized for treatment. South Africa expanded ART eligibility in August 2011 to include anyone with a CD4 count of under 350 cells per microliter of blood, up from the previous threshold of 200 cells.

For the study, the researchers used data on the 13,809 people who presented to the public sector HIV program in Hlabisa sub-district, KwaZulu-Natal, South Africa, from April 2010 to June 2012. They assessed the impact of the eligibility expansion on the number of patients seeking care, the number of patients initiating ART, and the time from HIV diagnosis to ART initiation among patients who had always been eligible (CD4 0-200), were newly eligible (CD4 201-350), and were not yet eligible (CD4 over 350).

The researchers found that expanded eligibility led to an average of 95.5 more patients starting ART per month at the Hlabisa program. Newly eligible patients (CD4 201-350) initiated treatment within a similar timeframe as the always-eligible group had previously.

Rather than seeing a negative effect on patients with CD4 counts at always-eligible levels (CD4 0-200), the researchers found the speed and rate of ART uptake actually improved slightly in this group.

The study was led by Sheryl Kluberg (SPH’17), who was a doctoral student in epidemiology during the study. The other co-authors were: Matthew Fox, professor of epidemiology and global health; Michael LaValley, professor of biostatistics; Deenan Pillay of the Africa Health Research Institute in KwaZulu-Natal and of University College London; and Till Bärnighausen of the Africa Health Research Institute and the University of Heidelberg.

—Michelle Samuels