Clinical Outcomes of the “Test and start” Anti-retroviral Therapy Programme among People Living with HIV in Mombasa, Kilifi and Kwale Counties in Coastal Kenya

Abstract

In 2016, Kenya adopted the universal testing and treatment of people living with HIV in line with WHO recommendations and as a fast track to achieving the UNAIDS 2030 target of 95:95:95. This “Test and start” program has been implemented for six years with little literature on its implementation challenges at the individual level and clinical outcomes, especially comparing to the previous period before “Test and start”. This study compared the survivorship and viral load suppression among PLHIV who started ART in the period before “Test and start” and after “Test and start “and also determined the factors associated with survivorship among PLHIV. A retrospective cohort study design was used to study PLHIV aged more than 15 years and started on ART in the periods of April to August 2016, and April to August 2017, then followed up for 24 months. Primary outcomes were death or loss to follow up. Kaplan–Meier survival methods were used to describe time to primary outcome. Cox proportional regression analysis was used to determine features associated with poor clinical outcomes. In this study, 786 patients (470 pre “Test and start” ”, and 316 in the “Test and start” cohorts) were enrolled. At 24 months after recruitment, retention rates for the pre and after “Test and start” groups were similar at 68% and 64% respectively (absolute difference: -4.0%, 95%CI -11-3.1, P=0.27). In multivariable regression model, the “Test and start” group showed no significant effect on risk of poor outcomes (aHR=1.17, 95% CI=0.89-1.54). Of the 240 with poor outcomes, 102 out of 316 (32%) and 138 out of 470 (29%) occurred among the “Test and start” group and pre “Test and start” patients respectively. Increasing age (aHR=0.98, 95% CI =0.97−0.99), formal employment (aHR=0.42, 95%CI=0.23- 0.76) and not being employed (aHR=0.53, 95% CI=0.34-0.81) were associated with lower risk of poor outcomes. The risk of poor outcomes was higher among males compared to female patients (aHR=1.37, 95%CI=1.03−1.82), and among divorced/separated patients compared to the married (aHR= 1.44, 95%CI= 1.04−1.99). Among 274 patients with a viral load reading at month 6 after starting ART, 15 (9.9%) were unsuppressed (VL≥1000 copies /ml) in the pre “Test and start” group while 12 (9.8%) were unsuppressed in the after “Test and start” group. The proportion of viral load suppression was not significantly different (P=0.95) in the two cohorts with similar findings found at 12 and 24 months. The viral load suppression rates, retention and attrition patterns for the “Test and start” cohort was comparable to those started on ART before “Test and start”. Patients who are males, young, divorced/separated, with poor socio-economic status had higher risks for poor clinical outcomes. Therefore, the “Test and start” program is as effective as the previous policy in clinical outcomes and should be continued as the early ART treatment averts severe morbidity and mortality as outlined in previous studies.