Assessing the Impact of Universal Test and Treat Implementation Strategy on Retention to Antiretroviral Therapy in HIV Care: A Retrospective Cohort Review

Abstract

Namibia has an adult HIV prevalence of 12.6% according to the Namibia population-based HIV impact assessment survey of 2017 making it one of the highest in the world. Early initiation of antiretroviral therapy (ART) has excellent outcomes for both morbidity and mortality. The National Strategic Framework for HIV and the Namibia Ministry of Health and Social Services (MoHSS) rolled out the WHO 2015 UTTS guidelines making Namibia one of the first African countries to implement UTTS. With UTTS guidelines, rolled out in October 2016, clients who test HIV positive are initiated on ART immediately preferably the same day or within seven days regardless of their HIV clinical stage or CD4 count. Retention in care is required for optimal clinical outcomes in patients with HIV infection. However, after two years of adopting the strategy, it is not well understood whether UTTS affects the retention to care. We therefore sought to establish any emerging differences in retention of ART care after the implementation of UTTS. We used a retrospective cohort review study design that employed both quantitative and qualitative methods. 879 client records were reviewed, 678 clients were initiated on treatment two years prior to the UTTS and 201 were initiated after January 2017 when the UTTS was fully rolled out and had been on treatment for at least 12 months. Data analysis was done using Excel and Statistical Package for Social Sciences (SPSS) version 23.0 software. The overall retention after 12 months of follow-up was (822/879) 93.5% (95% CI: 91.3% to 95.7%). The retention rate at 12 months among clients in the UTTS cohort was 95.5% (95% CI: 93.5% to 97.5%) and somewhat higher than that in the pre-UTTS cohort 92.9% (95% CI: 90.6% to 95.2%). At the end of the review period, attrition was higher in the pre-UTTS cohort 251/678 (37.0%; 95% CI 34.8 to 39.2) versus 42/201 (21.0%; 95% CI 19.0 to 23) during UTTS. Retention on ART was nearly 5% higher after UTTS implementation but young adults and men between 31 and 40 years of age had higher chances of attrition at the time of ART initiation. We recommend that all facilities in Namibia and other parts of sub-Saharan Africa should embrace the UTTS strategy to benefit their clients. Keywords: Antiretroviral therapy, Retention, Retrospective cohort review, Universal test & treat.