Dr. Yun He
Editor’s Note:
The concept of rapid initiation of antiretroviral therapy (ART) has been proposed for nearly 10 years, and many studies have confirmed the long-term benefits of rapid ART initiation. At the 12th International AIDS Society HIV Science Conference (IAS 2023), Thai scholar Sirinya Teeraananchai reported a study on the impact of rapid ART initiation on the health outcomes of People Living with HIV (PLWH). Dr.Yun He from the Third People’s Hospital of Shenzhen, China, was specially invited to comment on the study as follows.
01
Research Overview
Effect of Rapid ART Initiation on HIV Outcomes Under Thailand’s Universal Health Coverage Program (Abstract No: OAC0105)
Background:
Since 2014, Thailand has recommended initiating antiretroviral therapy (ART) without considering CD4 count and recommended starting ART on the day of diagnosis in 2021. We assessed the time from HIV diagnosis to ART initiation for PLWH under the Universal Health Coverage (UHC) program in Thailand and identified factors associated with virological failure (VF).
Method:
Included PLWH aged 15 and above who received ART between 2014 and August 2022. Based on the time from diagnosis (or registration) to ART initiation, patients were divided into 4 groups: (1) start on the same day or within 2-7 days, (2) <1 month initiation, (3) 1-3 months initiation, (4) >3 months initiation. VF is defined as a viral load (VL) ≥1000 copies/mL after at least 6 months of receiving ART. Competing risk models were used to analyze factors related to VF, with death and lost to follow-up (LTFU) viewed as competing events.
Results:
Among the 229,171 PLWH who received ART, 65% had records of the HIV diagnosis date and other information on the same day. The median age was 34 years, with a pre-ART CD4 cell count of 232 cells/mm^3. The proportion of patients initiating ART on the same day, within 2-7 days, <1 month, 1-3 months, and >3 months were 17%, 6%, 23%, 25%, and 30% respectively. The proportion of patients starting ART within 7 days increased significantly from 19% during 2014-2016 to 30% during 2020-2022. Compared to other groups, patients who started ART within 7 days had the lowest mortality rate (10%: 1.31 per 100 person-years) but the highest LTFU rate (8%: 2.29 per 100 person-years). The incidence of VF was 3.44 per 100 person-years. Patients who started ART within a month had a lower risk of VF than those who started after 3 months from diagnosis/registration (aSHR 0.79).
Conclusion:
Over time, initiating ART within 7 days has become more common in Thailand. Initiating ART within 7 days significantly reduces mortality, and initiating within a month significantly reduces the risk of virological failure. To further optimize health outcomes, there is an urgent need to implement innovative early ART strategies in Thailand.
02
Expert Review
We know that the initial threshold for starting HIV treatment was a CD4 cell count of <200 cells/mm^3, which was later expanded to 350 cells/mm^3. After the START study was reported in 2014, the World Health Organization (WHO) and the international community began to advocate for “rapid ART initiation” or “test and treat,” recommending ART initiation regardless of the CD4 cell count at diagnosis. In China, the promotion of the “test and treat” concept began in 2016.
The IDWeek conference last year reported nearly ten years of follow-up data from the START study, showing the long-term benefits of rapid ART initiation. The current study from the IAS conference on Thailand compared the outcomes of patients initiating ART at different times. This study included nearly 230,000 PLWH who received ART over an 8-year period (2014-2022) and divided patients into four groups based on when they started ART.
Looking at the baseline, the median age of the patients was 34, roughly similar to our domestic situation. However, a surprising 30% of patients only started ART after >3 months. On the other hand, the proportion of patients initiating ART within 7 days (in line with the WHO’s rapid initiation definition) has significantly increased from 19% during 2014-2016 to 30% during 2020-2022. Unfortunately, the LTFU rate was highest among patients who started ART within 7 days (8%).
Nevertheless, we see that patients starting ART within 7 days had the lowest mortality rate (10%; 1.31 per 100 person-years); those starting within a month had a lower risk of VF (aSHR 0.79), confirming the clear survival benefits of rapid ART initiation compared to delayed initiation.
This was a rapid ART initiation under Thailand’s UHC program. Our country has also been promoting this concept, striving to allow HIV-infected patients to receive ART within 14 days of diagnosis. Currently, 85% of domestic cases achieve this, and we hope to further increase this to over 90%. In implementing this strategy, there are two main challenges: ensuring an adequate drug reserve for rapid ART initiation and improving patient treatment adherence.
