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Starting ART Within 7 Days of Diagnosis Cuts Mortality in Thailand
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IAS 2023, July 23-26, 2023. Brisbane
Mark Mascolini
Starting antiretroviral therapy (ART) within 7 days of HIV diagnosis significantly cut mortality in a 252,000-person analysis of Thailand’s Universal Health Coverage program [1]. But in the last 3 years of that program, fewer than one third of people diagnosed with HIV started ART that quickly.
The Universal Health Coverage program in Thailand offers free HIV testing and treatment to all. Since 2014 guidelines have recommended starting ART regardless of CD4 count, and since 2021 Thailand recommended same-day ART initiation.
Researchers from Bangkok’s Kasetsart University aimed to assess HIV outcomes according to time from HIV diagnosis to starting ART from January 2014 through December 2022. They grouped people with HIV into four clusters: (1) same-day ART or within 7 days of diagnosis, (2) ART started between 7 days and 1 month of diagnosis, (3) ART started between 1 and 3 months of diagnosis, and (4) ART started more than 3 months after diagnosis.
The investigators defined virologic failure as a viral load at or above 1000 copies after ART began, while loss to follow-up meant no active care within 12 months, regardless of whether a person later returned to care. They confirmed death after ART began through the National Death Registry.
The study population consisted of 252,239 people, 25% same-day or 2-7 days, 24% 7 days-1 month, 23% 1-3 months, and 28% over 3 months. Same-day or 2-7 days starting became more frequent in Thailand over the years: 29% in 2014-2016, 32% in 2017-2019, and 38% in 2020-2022. Yet in the latest 3-year period, fewer than one-third of HIV-diagnosed people (23,944 of 74,265) started ART within 7 days of diagnosis.
Two thirds of each group were male, and overall median age stood at 34 years. About 9 in 10 people started ART with a nonnucleoside, with little difference between the four time-to-start groups. Median pre-ART CD4 count was substantially higher in the same-day group than in the other three groups: (1) 319, (2) 202, (3) 145, and (4) 260.
Through a median follow-up of 3.76 years, crude virologic failure rate per 100 person-years was lower in the same-day group and the 7 days-1 month group than in the other two groups: (1) 2.76, (2) 2.33, (3) 3.35, and (4) 3.78. At 5 years cumulative incidence of virological failure followed the same pattern: (1) 11.9%, (2) 10.3%, (3) 13.5%, and (4) 15.4%.
Mortality per 100 person-years was significantly lower in the same-day contingent than in the other three groups: (1) 1.28, 95% confidence interval (CI) 1.24 to 1.32, (2) 2.04, 95% CI 1.99 to 2.10, (3) 2.49, 95% CI 2.44 to 2.55, and (4) 2.49, 95% CI 2.44 to 2.54. But loss to follow-up per 100 person-years was highest in the same-day contingent: (1) 2.69, (2) 2.47, (3) 1.51, and (4) 1.60. But this analysis did not adjust for confounding factors, such as initial CD4 count.
A multivariate model adjusted for HIV stage, current year, and region determined that, compared with starting ART more than 3 months after diagnosis, starting in any of the three faster groups lowered risk of virologic failure (P < 0.001) by the following adjusted hazard ratios (and 95% confidence intervals):
-- Same-day or 2-7 days: aHR 0.87 (0.84 to 0.90)
-- 7 days-1 month: aHR 0.62 (0.60-0.64)
-- 1-3 months: aHR 0.79 (0.77 to 0.82)
This analysis independently linked four other factors to a higher risk of virologic failure: female gender (aHR 1.04, 1.01 to 1.07); age younger than 50 years, first ART with a protease inhibitor versus dolutegravir (aHR 1.27, 1.12 to 1.43), and pre-ART CD4 count below 500 (P < 0.001 for all comparisons).
The Kasetsart team concluded that starting ART within 7 days of HIV diagnosis significantly lowered overall mortality in these people, and starting within 1 month significantly cut risk of virologic failure.
A similar antiretroviral program, RAPID, began in San Francisco General Hospital in 2013, aiming to start ART on the day of HIV diagnosis or the next day [2]. In this urban population with high rates of mental illness, substance use, and unstable housing, 96% of 216 people had a viral load below 200 copies at least once in the year after treatment began, and 92% had a sub-200-copy load at their most recent measure.
References
1. Teeaananchai S, Boettiger DC, Lertpiriyasuwat C, et al. The impact of same-day and rapid ART initiation under the Universal Health Coverage program on HIV outcomes in Thailand. IAS 2023, July 23-26, 2023. Brisbane.
2. Coffey S, Bacchetti P, Sachdev D, et al. RAPID antiretroviral therapy: high virologic suppression rates with immediate antiretroviral therapy initiation in a vulnerable urban clinic population. AIDS. 2019;33:825-832. doi: 10.1097/QAD.0000000000002124.
https://journals.lww.com/aidsonline/pages/articleviewer.aspx?year=2019&issue=04010&article=00007&type=Fulltext
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