Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention.
BACKGROUND
Multistage stepwise HIV testing and treatment initiation procedures can result in lost opportunities to provide timely antiretroviral therapy (ART). Incomplete patient engagement along the continuum of HIV care translates into high levels of preventable mortality. We aimed to evaluate the ability of a simplified test and treat structural intervention to reduce mortality.


RESULTS
In the "pre-intervention 2010" (from January 2010 to December 2010) and "pre-intervention 2011" (from January 2011 to December 2011) phases, patients who screened HIV-positive at health care facilities in Zhongshan and Pubei counties in Guangxi, China, followed the standard-of-care process. In the "post-intervention 2012" (from July 2012 to June 2013) and "post-intervention 2013" (from July 2013 to June 2014) phases, patients who screened HIV-positive at the same facilities were offered a simplified test and treat intervention, i.e., concurrent HIV confirmatory and CD4 testing and immediate initiation of ART, irrespective of CD4 count. Participants were followed for 6-18 mo until the end of their study phase period. Mortality rates in the pre-intervention and post-intervention phases were compared for all HIV cases and for treatment-eligible HIV cases. A total of 1,034 HIV-positive participants (281 and 339 in the two pre-intervention phases respectively, and 215 and 199 in the two post-intervention phases respectively) were enrolled. Following the structural intervention, receipt of baseline CD4 testing within 30 d of HIV confirmation increased from 67%/61% (pre-intervention 2010/pre-intervention 2011) to 98%/97% (post-intervention 2012/post-intervention 2013) (all p < 0.001 [i.e., for all comparisons between a pre- and post-intervention phase]), and the time from HIV confirmation to ART initiation decreased from 53 d (interquartile range [IQR] 27-141)/43 d (IQR 15-113) to 5 d (IQR 2-12)/5 d (IQR 2-13) (all p < 0.001). Initiation of ART increased from 27%/49% to 91%/89% among all cases (all p < 0.001) and from 39%/62% to 94%/90% among individuals with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). Mortality decreased from 27%/27% to 10%/10% for all cases (all p < 0.001) and from 40%/35% to 13%/13% for cases with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). The simplified test and treat intervention was significantly associated with decreased mortality rates compared to pre-intervention 2011 (adjusted hazard ratio [aHR] 0.385 [95% CI 0.239-0.620] and 0.380 [95% CI 0.233-0.618] for the two post-intervention phases, respectively, for all newly diagnosed HIV cases [both p < 0.001], and aHR 0.369 [95% CI 0.226-0.603] and 0.361 [95% CI 0.221-0.590] for newly diagnosed treatment-eligible HIV cases [both p < 0.001]). The unit cost of an additional patient receiving ART attributable to the intervention was US$83.80. The unit cost of a death prevented because of the intervention was US$234.52.


CONCLUSIONS
Our results demonstrate that the simplified HIV test and treat intervention promoted successful engagement in care and was associated with a 62% reduction in mortality. Our findings support the implementation of integrated HIV testing and immediate access to ART irrespective of CD4 count, in order to optimize the impact of ART.
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Zunyou
Z
Wu
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Yan
Y
Zhao
Guangxi Bureau of HIV/AIDS, Guangxi Health Department, Nanning, China.
Xianmin
X
Ge
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Yurong
Y
Mao
Guangxi Center for Disease Control and Prevention, Nanning, China.
Zhenzhu
Z
Tang
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Cynthia X
CX
Shi
Guangxi Bureau of HIV/AIDS, Guangxi Health Department, Nanning, China.
Chi
C
Chen
Guangxi Antiretroviral Treatment Center, Liuzhou, China.
Yong
Y
Li
Zhongshan County Health Bureau, Zhongshan, China.
Xuejun
X
Qiu
Zhongshan County Center for Disease Control and Prevention, Zhongshan, China.
Guide
G
Nong
Zhongshan County General Hospital, Zhongshan, China.
Shanhui
S
Huang
Pubei County Health Bureau, Pubei, China.
Shen
S
Luo
Pubei County Center for Disease Control and Prevention, Pubei, China.
Shaohui
S
Wu
Pubei County General Hospital, Pubei, China.
Wenzhen
W
He
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Mingjie
M
Zhang
Guangxi Center for Disease Control and Prevention, Nanning, China.
Zhiyong
Z
Shen
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Xia
X
Jin
National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
Jian
J
Li
Department of Biostatistics, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, California, United States of America.
Ron
R
Brookmeyer
Department of Epidemiology, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, California, United States of America.
Roger
R
Detels
BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, British Columbia, Canada.
Julio
J
Montaner
Chinese Center for Disease Control and Prevention, Beijing, China.
Yu
Y
Wang
D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D002681:China / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality*; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D016896:Treatment Outcome