Abstract Tenofovir is less toxic than other nucleoside reverse transcriptase inhibitors used in antiretroviral therapy (ART) and may improve retention of HIV-infected patients on ART. We assessed the impact of national guideline changes in South Africa (2010) and Zambia (2007) recommending tenofovir in first-line ART. We applied regression discontinuity in a prospective cohort of 52,294 HIV-infected adults initiating first-line ART within ±12-months of each guideline change. We compared outcomes in patients presenting just before/after the guideline changes using local linear regression and estimated intention-to-treat effects on initiation of tenofovir, retention in care, and other treatment outcomes at 24-months. We assessed complier causal effects among patients starting tenofovir. The new guidelines increased the percentage of patients initiating tenofovir in South Africa (risk difference (RD): 81%; 95% confidence interval (CI): 73, 89) and Zambia (RD: 42%; 95% CI: 38, 45). With the guideline change, single-drug substitutions decreased substantially in South Africa (RD: −15%; 95% CI:−18, −12). Starting tenofovir also reduced attrition in Zambia (intent-to-treat RD: −1.8%; 95% CI: −3.5, −0.1, complier relative risk = 0.74) but not in South Africa (RD: −0.9%; 95% CI: −5.9, 4.1, Complier Relative Risk = 0.94). These results highlight the importance of reducing side effects for increasing retention in care, as well as the differences in population impact of policies with heterogeneous treatment effects implemented in different contexts. antiretroviral therapy, human immunodeficiency virus, low- and middle-income countries, regression discontinuity, Southern Africa, stavudine, tenofovir, treatment outcomes, Zambia © The Author(s) 2018. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
American Journal of Epidemiology – Oxford University Press
Published: May 15, 2018
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