Abstract
We investigated the effect of early antiretroviral treatment (ART) initiation on HIV status disclosure and social support in a cluster-randomized, treatment-as-prevention (TasP) trial in rural South Africa. Individuals identified HIV-positive after home-based testing were referred to trial clinics where they were invited to initiate ART immediately irrespective of CD4 count (intervention arm) or following national guidelines (control arm). We used Poisson mixed effects models to assess the independent effects of (a) time since baseline clinical visit, (b) trial arm, and (c) ART initiation on HIV disclosure (n = 182) and social support (n = 152) among participants with a CD4 count > 500 cells/mm3 at baseline. Disclosure and social support significantly improved over follow-up in both arms. Disclosure was higher (incidence rate ratio [95% confidence interval]: 1.24 [1.04; 1.48]), and social support increased faster (1.22 [1.02; 1.46]) in the intervention arm than in the control arm. ART initiation improved both disclosure and social support (1.50 [1.28; 1.75] and 1.34 [1.12; 1.61], respectively), a stronger effect being seen in the intervention arm for social support (1.50 [1.12; 2.01]). Besides clinical benefits, early ART initiation may also improve psychosocial outcomes. This should further encourage countries to implement universal test-and-treat strategies.
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Acknowledgements
Our sincere thanks to the PLHIV and workers who participated into the TasP trial. This study was funded by the ANRS (France Recherche Nord & Sud Sida-HIV Hépatites; ANRS 12324). We also thank Jude Sweeney for revising and editing the English version of the manuscript.
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Appendices
Appendix 1: Baseline Characteristics Regarding HIV Disclosure for the Study Population on (n = 182) and for Participants Excluded Because Only One Measure of this Outcome was Available for the Whole Study Period (n = 290), ANRS 12,249 TasP trial
Covariates | Study population (n = 182) | Excluded participants (n = 290) | Total (n = 472) | P valuea |
|---|---|---|---|---|
Sociodemographic and economic characteristics | ||||
Female gender, n (%) | 152(84%) | 240 (83%) | 392 (83%) | 0.831 |
Age (in years), median [IQR]* | 32 [25–48] | 30 [24–44] | 31 [25–45] | 0.155 |
Having a regular partner, n (%) | ||||
Yes | 144 (79%) | 235 (81%) | 379 (80%) | 0.611 |
HIV prevalence in the geographical cluster of residence, n (%) | ||||
≥ 30% | 150 (82%) | 211 (73%) | 361 (77%) | 0.016 |
Educational level#, n (%) | 0.162 | |||
Primary or less | 84 (46%) | 117 (41%) | 201 (43%) | |
Some secondary | 58 (32%) | 116 (41%) | 174 (37%) | |
At least completed secondary | 40 (22%) | 53 (19%) | 93 (20%) | |
Employment status§, n (%) | 0.788 | |||
Employed | 21 (12%) | 38 (13%) | 59 (13%) | |
Student | 14 (8%) | 19 (7%) | 33 (7%) | |
Inactive | 146 (81%) | 224 (80%) | 370 (80%) | |
Clinical characteristics | ||||
Having received HIV care in government clinics (currently or previously), n (%) | ||||
Yes | 94 (52%) | 105 (35%) | 199 (42%) | 0.001 |
Newly diagnosed, n (%) | ||||
Yes | 14 (8%) | 56 (19%) | 70 (15%) | 0.001 |
CD4 cell count/mm3, median [IQR] | 660 [568–816] | 665 [569–801] | 662 [569–807] | 0.566 |
Time to linkage to a trial clinic after referral, n (%) | 0 | |||
0–1 month | 111 (61%) | 143 (49%) | 254 (54%) | |
1–6 months | 47 (26%) | 51 (18%) | 98 (21%) | |
More than 6 months | 24 (13%) | 96 (33%) | 120 (25%) | |
HIV disclosure score, median [IQR] | 0.915 |
Appendix 2: Baseline Characteristics Regarding Social Support for the Study Population (n = 152) and of for Participants Excluded Because Only One Measure for This Outcome was Available for the Whole Study Period (n = 320), ANRS 12,249 TasP trial
Study population (n = 152) | Excluded participants (n = 320) | Total (n = 472) | P-valuea | |
|---|---|---|---|---|
Sociodemographic and economic characteristics | ||||
Female gender, n (%) | 128 (84%) | 264 (83%) | 392 (83%) | 0.643 |
Age (in years), median [IQR]* | 32 [25–48] | 30 [24–44] | 31 [25–45] | 0.34 |
Having a regular partner, n (%) | ||||
Yes | 120 (79%) | 259 (81%) | 379 (80%) | 0.612 |
HIV prevalence in the geographical cluster of residence, n (%) | ||||
≥ 30% | 124 (82%) | 237 (74%) | 362 (77%) | 0.072 |
Educational level#, n (%) | 0.211 | |||
Primary or less | 70 (46%) | 131 (41%) | 201 (43%) | |
Some secondary | 48 (32%) | 126 (40%) | 174 (37%) | |
At least completed secondary | 34 (22%) | 59 (19%) | 93 (20%) | |
Employment status$, n (%) | 0.343 | |||
Employed | 15 (10%) | 44 (14%) | 59 (13%) | |
Student | 13 (9%) | 20 (6%) | 33 (7%) | |
Inactive | 123 (81%) | 247 (80%) | 371 (80%) | |
Clinical characteristics | ||||
Having received HIV care in government clinics (currently or previously), n (%) | ||||
Yes | 74 (49%) | 125 (39%) | 199 (42%) | 0.048 |
Newly diagnosed at referral, n (%) | ||||
Yes | 14 (9%) | 56 (18%) | 70 (15%) | 0.018 |
CD4 cell count/mm3, median [IQR] | 661 [572–824] | 663 [569–796] | 662 [569–807] | 0.938 |
Time to linkage to a trial clinic after referral, n (%) | 0 | |||
0–1 month | 94 (62%) | 160 (50%) | 254 (54%) | |
1–6 months | 38 (25%) | 60 (19%) | 98 (21%) | |
More than 6 months | 20 (13%) | 100 (31%) | 120 (25%) | |
Social support score, median [IQR] | 1 [1–2.5] | 1 [0–2] | 1 [1–2] | 0.265 |
Appendix 3: Characteristics of the Study Population Regarding the Outcome Social Support (n = 152), ANRS 12,249 TasP trial
Control (n = 75) | Intervention (n = 77) | Total (n = 152) | P-valuea | |
|---|---|---|---|---|
Sociodemographic and economic characteristics at baseline (i.e. first clinic visit) | ||||
Female gender, n (%) | 63 (84%) | 65 (84%) | 128 (84%) | 0.944 |
Age (in years), median [IQR] | 32 [24–48] | 32 [25–47] | 32 [25–48] | 0.535 |
Having a regular partner, n (%) | ||||
Yes | 56 (75%) | 64 (83%) | 120 (79%) | 0.201 |
HIV prevalence in the geographical cluster of residence, n (%) | 0.004 | |||
≥ 30% | 68 (91%) | 56 (73%) | 124 (82%) | |
Educational level, n (%) | 0.556 | |||
Primary or less | 36 (48%) | 34 (44%) | 70 (46%) | |
Some secondary | 25 (33%) | 23 (30%) | 48 (32%) | |
At least completed secondary | 14 (19%) | 20 (26%) | 34 (22%) | |
Employment status$, n (%) | 0.379 | |||
Employed | 8 (11%) | 7 (9%) | 15 (10%) | |
Student | 4 (5%) | 9 (12%) | 13 (9%) | |
Inactive | 62 (84%) | 61 (79%) | 123 (81%) | |
Clinical characteristics | ||||
Having received HIV care in government clinics (currently or previously), n (%) | ||||
Yes | 41 (55%) | 33 (43%) | 74 (49%) | 0.145 |
Newly diagnosed at referral, n(%) | 7 (9%) | 7 (9%) | 14 (9%) | 0.959 |
Yes | ||||
CD4 cell count/mm3at baseline, median [IQR] | 687 [581–840] | 655 [551–815] | 661 [572–824] | 0.49 |
Time to linkage to a trial clinic after referral, n (%) | 0.851 | |||
0–1 month | 46 (61%) | 48 (62%) | 94 (62%) | |
1–6 months | 20 (27%) | 18 (23%) | 38 (25%) | |
More than 6 months | 9 (12%) | 11 (14%) | 20 (13%) | |
Time since baseline (in years), median [IQR] | 13.9 [7.3–19.8] | 15.1 [8.3–19.8] | 14.1 [7.8–19.8] | 0.804 |
Followed for at least 6 months, n(%) | 75 (100%) | 77 (100%) | 152 (100%) | |
Followed for at least 12 months, n(%) | 49 (65%) | 50 (65%) | 99 (65%) | 0.959 |
Followed for at least 18 months, n(%) | 27 (36%) | 32 (42%) | 59 (39%) | 0.482 |
Followed for at least 24 months, n(%) | 11 (15%) | 9 (12%) | 20 (13%) | 0.587 |
Having initiated ART in a trial clinic after baseline, n (%) | ||||
At the 6 month-visit | 9 (20%) | 62 (98%) | 71 (66%) | 0 |
At the 12 month-visit | 12 (31%) | 40 (98%) | 52 (65%) | 0 |
At the 18 month-visit | 13 (59%) | 31 (97%) | 44 (81%) | 0.001 |
At the 24 month-visit | 9 (82%) | 9 (100%) | 18 (90%) | 0.479 |
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Fiorentino, M., Nishimwe, M., Protopopescu, C. et al. Early ART Initiation Improves HIV Status Disclosure and Social Support in People Living with HIV, Linked to Care Within a Universal Test and Treat Program in Rural South Africa (ANRS 12249 TasP Trial). AIDS Behav 25, 1306–1322 (2021). https://doi.org/10.1007/s10461-020-03101-y
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DOI: https://doi.org/10.1007/s10461-020-03101-y