Prior to recent shifts in global policy, in Zambia and many other countries in sub-Saharan Africa, people living with HIV were only treated once their disease had progressed to a point where it caused some degree of immunosuppression or they had complications of HIV like tuberculosis. In the past five to seven years, policies to treat all individuals living with HIV regardless of disease status, known as “universal treatment”, have been implemented, changing the landscape of when and to whom treatment is offered. The World Health Organization rolled out its recommendations for universal treatment in 2015: everyone living with HIV should be treated regardless of disease stage. Zambia implemented universal treatment policies in 2017.
In a comprehensive study, one WashU research team, led by Assistant Professor in the Division of Infectious Diseases and Institute for Public Health Faculty Scholar, Aaloke Mody, MD, set out to determine how treatment and outcomes have changed in Zambia once policies to treat all patients—not just some—were implemented. His study is now published in The Lancet HIV.
Mody has worked extensively with the Centre for Infectious Disease Research in Zambia (CIDRZ), a nongovernmental organization based in Lusaka, Zambia, to investigate real-world implementation of public health HIV programs in Zambia and understand how to deliver high-quality and patient-centered HIV care in routine practice in resource-limited settings. This study is one example.
Mody explains the study parameters, “We sought to examine the effect of implementing policies for universal treatment for everyone living with HIV on same-day treatment initiation and retention in care on treatment 12-months later. We used a design called a natural experiment, where we compared people who came to clinic right before policy changes to those who came right after policies were in place.”
What did the study find? Mody says, “Following the policy change allowing treatment for all, we saw that more people started treatment quicker than they had previously done; and that more patients returned for continued treatment compared to before the policy changes. Before, people often had to wait for lab results to see if they were eligible for treatment, now thew were rapidly started on treatment the first day they came to clinic. Ultimately, more people were still in care 12 months later, too.” He adds, “There was likely a behavioral affect, with quicker and easier access to treatment, more people stayed in care versus dropping off.”
Implementation Science also played a critical role in the study. “We used a study design called a “natural experiment”, which provides results that are both rigorous (akin to what you might get from a randomized trial) but also results that are relevant because we are studying an intervention as it is actually implemented in the real world, not in a controlled research setting,” says Mody. “In Implementation Science, it is critical to know what is happening in real-world scenarios and these methods provide a very powerful way to do so.” Mody’s team also found a decrease in disparities across age groups and sex: previously groups such as men and younger individuals ended up starting treatment at relatively lower rates. After policies were put into place, all groups started treatment at nearly the same level. However, differences in who remained in care through 12 months were largely unchanged. “Implementing this universal treatment policy was a major step in reaching high and equitable levels of treatment initiation in Zambia,” Mody concludes. “This helps to address one of the most important steps in the cascade of events needed for successful HIV outcomes—starting treatment—but there are still issues to be addressed earlier, such as HIV testing, and issues further along the cascade, like keeping people engaged in care.”