Treat All in India: Bringing People With HIV Onto Treatment, 2017–2018

Summary

• The World Health Organization's Treat All policy recommends antiretroviral therapy (ART) for everyone with HIV as soon as they are diagnosed.
• To put it into practice, 46 ART centers in two Indian states, supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), tried to reach 25,007 people enrolled in HIV care but not on ART. Over 14 months, 9,898 (40%) started ART — 6,315 of them after being contacted, including 1,635 who had dropped out of care.
• Tracing people with HIV who aren't on treatment, and explaining the benefits of early treatment, can help make Treat All work.

Background

Since September 2015, WHO has recommended ART for everyone with HIV regardless of disease stage or CD4 count. Starting early, rather than waiting for the CD4 count to fall (for example, below 500 cells/mm³ under earlier guidelines), reduces illness, death and transmission — and about half of people in "pre-ART" care (monitoring without treatment) were lost before they ever became eligible.

India, with the world's third-largest number of people with HIV (2.1 million), adopted Treat All on April 28, 2017. Of those 2.1 million in 2017, 1.7 million (81%) had been diagnosed and 1.2 million received free ART. CDC and its partners, through PEPFAR, support HIV care in three districts each of Maharashtra (32 ART centers) and Andhra Pradesh (14), the two states with the highest HIV prevalence.

What the centers did

From May 1, 2017, health authorities, CDC and partners:

• forecast drug needs, assuming half of those not on ART would start within 6 months;
• used lab registers and databases to find everyone at the 46 centers who'd had a CD4 count or visit in January 2014–April 2017 but wasn't on ART, then checked paper records to remove duplicates and confirm status and contact details;
• classed them as in active care (seen every 6 months) or lost to follow-up (not seen for 12 months or more);
• had counselors make three phone attempts per person with standard materials on the benefits of early ART, and home visits for those not reached, who declined, or who agreed but didn't come;
• phoned people who missed appointments within about 7 days (before starting ART) or 2 days (after), and tracked starts and retention in spreadsheets.

Results

• People who had been in active care were far likelier to come in (73.7%) than those lost to follow-up (45.9%); nearly all who came (97.0%) started ART.
• Median time from agreeing to visiting: 18 days; from visiting to starting ART: 3 days.
• Median CD4 count was 571 overall and 645 among those who visited — high, suggesting most felt well.
• Another 3,583 were found to have started ART after May 1 on their own (1,950 through outreach, 1,633 from center records), for 9,898 (39.6%) in all.
• Retention: 85.1% of those who started after outreach were still in care at 6 months, and 84.3% at 12 months — 13 points above India's national average of 71%.
• Before Treat All, the centers started a median of 1,847 people a month on ART. Starts peaked at 3,797 in July 2017, when people from pre-ART care were about half (52%); that share later fell to about 2%. Center staff needed less and less help from partners as time went on.

New ART starts by month at the 46 centers. Figure from the CDC report.

What it means

This is the first report of a national program's push to start pre-ART patients on treatment right after adopting Treat All. At its peak, monthly ART starts doubled, and about two-thirds of those who started did so after active follow-up. The effort built centers' skills in counseling, tracing and data management, and India's National AIDS Control Organization scaled it up nationwide.

• Only half could be reached, so contact details must be kept current.
• Most who were reached agreed to come, but fewer than two-thirds did. Their high CD4 counts suggest many felt healthy and still believed, from earlier guidance, that they didn't qualify — so education about Treat All is needed.
• With half still unreached and new starts falling back toward earlier levels, ongoing outreach is needed to understand and remove barriers to treatment. The full benefit of Treat All depends on early diagnosis, fast linkage and ART start, and support to stay on treatment; India is adopting patient-centered service models to get there.

Limits: center records may contain errors; people who started ART elsewhere may have been missed; trends in districts without PEPFAR support couldn't be compared; and the activities can't be shown to have caused the rise in ART starts.

Sources

Based on Kiren Mitruka, Manish Bamrotiya, Reshu Agarwal and others, "Implementation of the Treat All Policy Among Persons with HIV Infection Enrolled in Care But Not on Antiretroviral Therapy — India, May 2017–June 2018," MMWR, Centers for Disease Control and Prevention; a work of the United States government in the public domain.