# Effect of COVID-19 pandemic on ART access and timely initiation in people living with HIV in 31 countries: a regression discontinuity design study

## TL;DR

The study found that the COVID-19 pandemic had mixed effects on HIV treatment access, with some countries maintaining stable ART initiations while others saw declines.

## Contribution

This study uses a regression discontinuity design to assess the impact of the pandemic on ART access and timely initiation across 31 countries.

## Key findings

- ART initiation numbers remained stable in 25 out of 31 countries during the pandemic.
- Six countries experienced significant decreases in ART initiations, including South Africa and Malawi.
- The proportion of timely ART initiations increased in Kenya and Mozambique during the pandemic.

## Abstract

The COVID-19 pandemic threatened global HIV Test and Treat Efforts. We assessed whether it affected (1) the number of antiretroviral therapy (ART) initiations and (2) the proportion of timely ART initiations in people living with HIV (PLWH) globally.

Quasi-experimental, regression discontinuity design using routinely collected data from HIV clinics.

360 HIV care clinics across primary and secondary levels of care, participating in the International epidemiology Databases to Evaluate AIDS consortium, in 31 countries in Asia, Africa and the Americas.

177 391 PLWH (≥18 years old) who initiated ART 2 years before and 1 year after the onset of the COVID-19 pandemic in their country.

The primary outcome was the number of ART initiations per week; the secondary outcome was the proportion of timely ART initiations (ie, ART initiated within 7 days of enrolment). We assessed changes in these outcomes in the 52 weeks after compared to the 104 weeks before the pandemic onset, defined using each country’s peak Oxford Stringency Index score between January and June 2020.

Among 177 391 newly enrolled PLWH, 129 743 initiated during the pre-pandemic and 47 648 post-pandemic onset. 72.5% of ART initiations were timely pre-pandemic whereas 82.3% were during the pandemic. Absolute number of ART initiations remained stable during the pandemic period in 25 of 31 countries but decreased significantly in six countries: India (−5.0 p, 95% CI −9.2 to −0.7), Rwanda (−10.0 p, −18.6 to −1.4), Malawi (−33.4 p, −54.1 to −12.3), South Africa (−130.8 p, −188.6 to −73.1), Zimbabwe (−12.9 p, −20.0 to −5.8) and Togo (−19.6 p, −39.1 to −0.1). The proportion of timely initiations was stable in all countries except in Kenya (+4.2 pp, 95% CI +0.3 to +8.1) and in Mozambique (+2.7 pp, +0.5 to +4.9), where it increased significantly.

A deeper understanding of the factors that contributed to sustaining ART initiations, particularly in settings with stringent public health and social measures, is needed. These insights should inform preparedness strategies, resource allocation and policy development to ensure continuity of HIV services during future health emergencies, in line with World Health Organisation recommendations.