Assessing HIV Treatment Outcomes for Jamaica Before and After Universal Testing and Treatment: Analysis of the National HIV Treatment Services Information System

Jamaica did not achieve the UNAIDS fast track targets of 90-90-90 by 2020, namely 90% of people living with Human Immunodeficiency Virus (HIV), (PLHIV) are diagnosed, 90% of those diagnosed are receiving anti-retroviral therapy (ART) and 90% of people on ART achieve a suppressed viral load. As of 2020, the achievement was 86-47-68, so while diagnosis was almost achieved, ART retention and viral suppression were lagging. The Ministry of Health and Wellness has recommitted to achieving these targets by the year 2025 and implemented several strategies to do so including Universal Test and Treat (UTT) in 2017. The objective of this dissertation is to assess several factors associated with HIV treatment outcomes in the era of UTT and identify other strategies to reduce current gaps.

The first two studies described the characteristics of PLHIV on ART in Jamaica and assessed changes in HIV treatment outcomes before and after implementation of the UTT strategy in 2017. A secondary analysis of anonymized patient-level data extracted from the National Treatment Service Information System (TSIS2) was conducted. The baseline sample was 8,363 PLHIV, 15 years and older who initiated ART from January 2015 to December 2019 across all 4 regional health authorities. Patients were assessed for three binary outcomes: 1. stage at HIV diagnosis (early or late), 2. ART initiation time (same day or 31+ days) and 3. viral load status achieved at the first viral load test (suppressed or non-suppressed). Categorical independent variables: age, sex, regional health authority and ART initiation year, were investigated using multivariable logistic regression. Adjusted odds ratios and 95% confidence limits were reported.

In Study I, we found that after UTT late HIV diagnoses decreased from 60% to 39% and there was a small increase in viral suppression from 76% to 80%. Males were significantly more likely to be diagnosed late both before and after UTT compared to females. In Study II, we found that same-day ART initiation increased over the five-year period from 37% to 51%. Same day initiation was significantly associated with male sex, viral suppression at the first viral load test and ART initiation years 2018 and 2019 compared to 2017.

The third study assessed time to viral suppression among 4,560 persons who received a first viral load testing both pre and post ART initiation from 2017-2019. We used descriptive statistics and Kaplan-Meier estimates to compare survival curves by ART initiation year (2017, 2018, 2019), sex and types of treatment site used (public and non-governmental organizations (NGOs). Persons were censored if suppression was not achieved in the study period. A mixed effects Cox Regression was used to determine the effect of each covariate on the likelihood of viral suppression. We report adjusted hazard ratios and 95% confidence limits. Pre-ART viral load testing decreased from 36% in 2017 to 30% in 2019. The median time to viral suppression decreased by 3 months overall, that is from 7.4 months in 2017 to 4 months in 2019. The likelihood of suppression was almost 2 times greater in 2018 and 3 times greater in 2019 compared to 2017. NGO treatment sites had a greater likelihood of suppression than public sites and there was significant variability between types of treatment site after adjusting for clustering. Sex was not significantly associated with the likelihood of suppression.

The three studies show UTT has been an effective strategy to improve Jamaica’s HIV treatment outcomes but was insufficient to ensure the global targets were achieved in time. The proportion of PLHIV diagnosed early, initiated on ART and virally suppressed has increased while late diagnosis, median ART initiation time and time to achieve viral suppression have decreased. The goal of same-day initiation is increasingly being met but remains too low and early diagnosis was associated with viral suppression after UTT. However, there is need to increase the number of persons retained on ART and scale up interventions targeting men and aging PLHIV to address late diagnosis. Our findings support the World Health Organization’s recommendations to tailor service delivery through differentiated care and highlight the need to further investigate both demand and supply-side contextual factors that impact ART uptake and viral suppression.