Oldenburg, CE;
Bor, J;
Harling, G;
Tanser, F;
Mutevedzi, T;
Shahmanesh, M;
Seage, GR;
... Bärnighausen, T; + view all
(2018)
Impact of early antiretroviral therapy eligibility on HIV acquisition: household-level evidence from rural South Africa.
AIDS
, 32
(5)
pp. 635-643.
10.1097/QAD.0000000000001737.
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Abstract
OBJECTIVES: We investigate the effect of immediate ART eligibility on HIV incidence among HIV-uninfected household members. DESIGN: Regression discontinuity study arising from a population-based cohort. METHODS: Household members of patients seeking care at the Hlabisa HIV Treatment and Care Programme in rural KwaZulu-Natal South Africa between January 2007 and August 2011 with CD4^{+} counts up to 350 cells/μl were eligible for inclusion if they had at least two HIV tests and were HIV-uninfected at the time the index patient linked to care (N = 4,115). A regression discontinuity design was used to assess the intention-to-treat effect of immediate versus delayed ART eligibility on HIV incidence among household members. Exploiting the CD4^{+} count-based threshold rule for ART initiation (CD4^{+} < 200 cells/μl until August 2011), we used Cox proportional hazards models to compare outcomes for household members of patients who presented for care with CD4^{+} cell counts just above versus just below the ART initiation threshold. RESULTS: Characteristics of household members of index patients initiating HIV care were balanced between those with an index patient immediately eligible for ART (N = 2,489) versus delayed for ART (N = 1,626). There were 337 incident HIV infections among household members, corresponding to an HIV incidence of 2.4 infections per 100 person-years (95% CI 2.5 to 3.1). Immediate eligibility for treatment reduced HIV incidence in households by 47% in our optimal estimate (HR = 0.53, 95% CI 0.30 to 0.96), and by 32-60% in alternate specifications of the model. CONCLUSIONS: Immediate eligibility of ART led to substantial reductions in household-level HIV incidence.
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