HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study

Introduction:&nbsp;The World Health Organisation recommends to&nbsp;Treat All&nbsp;people with HIV, irrespective of CD4 count. However, people with CD4 counts &gt;500&nbsp;cells/&micro;L may be asymptomatic and therefore less motivated to adhere to antiretroviral therapy (ART). We aimed to assess whether people initiated with CD4 counts &gt;500&nbsp;cells/&micro;L had worse treatment outcomes compared to those initiated at lower CD4 counts. Methods:&nbsp;We performed a retrospective cohort study among non‐pregnant adults initiating ART at eight public clinics in South Africa between September 2016, when&nbsp;Treat All&nbsp;was implemented, and August 2017. We assessed whether initiation CD4 count &gt;500&nbsp;cells/&micro;L was associated with the outcomes of attrition (death, lost to follow‐up or treatment interruption &gt;180&nbsp;days), and viraemia &gt;1000&nbsp;copies/mL, by twelve months using Cox proportional hazards and Poisson regression models. Results and discussion:&nbsp;Among 4952 patients initiating ART, the median age was 32.4&nbsp;years (interquartile range (IQR) 27.2 to 39.7), 58.9% were women and 30.3% had an initiation CD4 count &gt;500&nbsp;cells/&micro;L. After twelve months, 3382 (68.3%) were retained in care, 303 (6.1%) had transferred to another clinic, 1010 (20.4%) were lost to follow‐up, 232 (4.7%) had a treatment interruption &gt;180&nbsp;days and 25 (0.5%) were known to have died. Overall, 1267 experienced attrition at a median time of 91&nbsp;days (IQR 23 to 213), with 302 of these (23.8%) experiencing attrition immediately after their ART initiation visit. Among those in care at twelve months with viral load results, 4.6% had viraemia. In multivariable analysis, the hazard of attrition was similar between patients newly eligible for ART with CD4 counts &gt;500&nbsp;cells/&micro;L compared to those with CD4 &le;500&nbsp;cells/&micro;L (adjusted hazard ratio 1.03, 95% confidence interval (CI) 0.90 to 1.17). The risk of viraemia was lower among patients with CD4 counts &gt;500&nbsp;cells/&micro;L compared to those with CD4 &le;500&nbsp;cells/&micro;L (adjusted risk ratio 0.58, 95% CI 0.37 to 0.92). Conclusions:&nbsp;After implementation of&nbsp;Treat All&nbsp;in South African public clinics, we found that patients newly eligible for ART with initiation CD4 counts &gt;500&nbsp;cells/&micro;L had comparable or better outcomes compared to those with lower CD4 counts. These finding support ongoing implementation of&nbsp;Treat All&nbsp;in our setting.</p