Population uptake and effectiveness of test-and-treat antiretroviral therapy guidelines for preventing the global spread of HIV: an ecological cross-national analysis

Objectives: Although the benefits of adopting test-and-treat antiretroviral therapy (ART) guidelines that recommend initiation of ART regardless of CD4 cell counts have been demonstrated at the individual level, there is uncertainty about how this translates to the population level. Here, we explored whether adopting ART guidelines recommending earlier treatment initiation improves population ART access and viral suppression and reduces overall disease transmission. Methods: Data on ART initiation guidelines and treatment coverage, viral suppression, and HIV incidence from 37 European and Central Asian countries were collected from the European Centre for Disease Prevention and Control and the Global HIV Policy Watch and HIV 90-90-90 Watch databases. We used multivariate linear regression models to quantify the association of ART initiation guidelines with population ART access, viral suppression, and HIV incidence, adjusting for potential confounding factors. Results: Test-and-treat policies were associated with 15.2 percentage points (pp) [95% confidence interval (CI) 0.8–29.6 pp; P = 0.039] greater treatment coverage (proportion of HIV-positive people on ART) compared with countries with ART initiation at CD4 cell counts ≤ 350 cells/μL. The presence of test-and-treat policies was associated with 15.8 pp (95% CI 2.4–29.1 pp; P = 0.023) higher viral suppression rates (people on ART virally suppressed) compared with countries with treatment initiation at CD4 counts ≤ 350 cells/μL. ART initiation at CD4 counts ≤ 500 cells/μL did not significantly improve ART coverage compared to initiation at CD4 counts ≤ 350 cells/μL but achieved similar degrees of viral suppression as test-and-treat. Conclusions: Test-and-treat was found to be associated with substantial improvements in population-level access to ART and viral suppression, further strengthening evidence that rapid initiation of treatment will help curb the spread of HIV.