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Immediate ART for All Still a Long Way Off in France--and Elsewhere
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Conference on Retroviruses and Opportunistic Infections (CROI), February 22-25, 2016, Boston
Mark Mascolini
Starting antiretroviral therapy (ART) in the first year of HIV infection has become a global goal to prevent HIV transmission from people with a detectable viral load. But analysis of more than 6000 people who entered HIV care in 2008-2010 indicates that France--a country with highly accessible HIV care--remains a long way from getting people with HIV into care and making their viral load undetectable.
To address these issues, French ANRS investigators mined two data sources--the national HIV surveillance system and the French Hospital Database on HIV. To estimate times from (1) HIV infection to diagnosis, (2) HIV diagnosis to care entry, (3) care entry to starting ART, and (4) starting ART to reaching an undetectable viral load, they used survival methods with data from 6268 HIV-infected people who started care from 2008 through 2010.
Overall median time from HIV infection to starting ART measured a hefty 64.6 months, or 5.4 years. By far the longest segment of that span came during the 40.6 months (3.4 years) from HIV infection to diagnosis. Only 0.6 month elapsed between diagnosis and entering care, but 5.9 months unspooled between entering care and starting ART.
Men who have sex with men (MSM) and heterosexual women made the quickest leap from infection to starting ART, ranging from 55.7 to 60.1 months (4.6 to 5 years), while it took injection drug users (IDUs) a median of 101.9 months (8.5 years) to start ART after getting infected (P < 0.001 versus MSM and women). MSM spent 32.6 months (2.7 years) carrying HIV before getting diagnosed--the shortest span--while heterosexual men took the longest time to get diagnosed, 54.7 months (4.6 years).
Getting into care after being diagnosed took less than 1 month (median) for all HIV transmission groups except IDUs, who took almost 1 year to start care once they tested positive. Median time from entering care to starting ART proved longest for MSM--10 months--compared with 6.3 months or less for all other groups. This longer time among MSM did not indicate foot dragging, the ANRS team noted, but rather the higher fraction of MSM who got diagnosed and linked to care before being eligible for ART because they had a CD4 count above 350. Once people started ART, median time to reaching an undetectable viral load stood around 6 months for all groups.
Only 9% of people analyzed started ART within the first year of infection. That proportion reached 10% for French-national women and MSM but was lower for French-national heterosexual men and non-French national women (8%), non-French national heterosexual men (6%), and IDUs (5%).
The researchers concluded that time lost starting ART mainly reflected the gap between HIV infection and testing. For IDUs, time lost starting ART reflected both this gap and delayed entry to care once diagnosed.
The ANRS investigators believe their study "shows that even in a country like France, where the health care system offers one of the best environments for HIV care, we are far from early ART for all." Other countries with a similar healthcare system probably have similar gaps, and countries with bigger economic woes and frailer infrastructures will probably have wider gaps.
But this picture is probably already improving in France, the researchers suggested, because the CD4 threshold for starting ART rose to 500 in 2010 and got eliminated entirely in 2013.
Reference
1. Supervie V, Lacombe JM, Dray-Spira R, Costagliola D, for the FHDH-ANRS CO4 Study Group. How far are we from early cART for all? A nationwide population-based study in France. Conference on Retroviruses and Opportunistic Infections (CROI), February 22-25, 2016, Boston. Abstract 1043.
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