Evidence for same-day antiretroviral therapy (ART)?

[Jim Allen]

Found this an interesting read.

Aidsmap.com article in full: https://www.aidsmap.com/news/aug-2023/immediate-art-associated-fewer-deaths-thailand-starting-week-or-two-later-may-lead

In Short:

The evidence for same-day antiretroviral therapy (ART) in terms of viral suppression, mortality, and the proportion who drop out of care is ambiguous. For instance, a study from Lesotho published in 2018 found higher rates of retention in care and viral suppression in people who started ART immediately, while a 2021 study from nearby Eswatini found lower rates of retention and viral suppression.

These studies featured 441 and 1899 people respectively. A much larger study from Thailand was presented at last month’s 12th International AIDS Society Conference on HIV Science (IAS 2023) in Brisbane. It featured all Thai adults – over a quarter of a million people – who started ART between the start of 2014, when treatment for all with HIV regardless of CD4 count was recommended, to the end of 2022. Same-day ART was recommended in national guidelines from January 2021.

The lowest mortality rate was seen in people who started ART within seven days (1.28%), compared to 2.04% in people who started more than a week but less than a month later, and just under 2.5% in people who started more than a month later.

The rate of outright viral failure – defined a having a viral load over 1000 more than six months after starting ART – was also lower in early starters, but was actually lowest in people who started one week to one month after diagnosis. Starting 1-7 days after diagnosis was associated with an annual virological failure rate 0f 2.76%; starting 8 days to a month later with a rate of 2.33%; 1-3 month later with a rate of 3.35%; and more than three months later with a rate of 3.78%.

This pattern persisted: three years after starting ART, the proportion who had had viral failure during that time was 6.9% in people who started from a week to a month after diagnosis, but 8.2% in the earliest starters, and over 10% in later starters.

In multivariate analysis, the advantage of starting early, but not too early, becomes clearer. When the findings were controlled for CD4 count at presentation and year starting, the risk of virological failure was 21% lower in people starting at months 1-3 after diagnosis compared with people who started therapy more than three months after diagnosis, 38% lower in people starting a week to a month after diagnosis, but only 13% lower in the early starters.

The proportion of people who dropped out of care was highest in early starters too. Thailand tends to have excellent retention rates and monitoring. Nonetheless the proportion of early starters who dropped out of care was 2.69% in early starters, 2.47% in one-week-to-one-month starters, but only 1.51% in people who started later.

References
Teeraananchai S et al. The impact of same-day and rapid ART initiation under the Universal Health Coverage program on HIV outcomes in Thailand. 12th IAS Conference, Brisbane. Abstract OAC0105. 2023.

[leatherman]

Nonetheless the proportion of early starters who dropped out of care was 2.69% in early starters, 2.47% in one-week-to-one-month starters, but only 1.51% in people who started later.

I could imagine these percentages have something to do with having that "touch of AIDS". Coming to grips with your own mortality usually has the consequence of making you a lot more amenable to taking care to not die - and that means adhering to daily ARVs. While not having that "come to Jesus" moment leaves people ignorant of the importance and need of adherence.

Looking at the situation from my side of the coin as a late starter (of course, I had to start late. there weren't any meds back then. oof), I can hardly understand someone diagnosed early, started on meds immediately (not having to wait until cd4s <=250, much less a week to get a prescription filled), who would intentionally drop out of care and willfully risk AIDS or death. But I do realize that factors like youth, not being used to taking daily meds, self-stigma, access to health care and medications, substance abuse, and homelessness are just some of the factors that can lead people to stopping treatment.

While the Ryan White program has used measurements like retention in care, medical visit frequency and medical visit gap to catch and hopefully stop those falling out of care, it's still sad people drop out of care and seems like more peer support, along with providing for those other disparities, could increase the retention in care rate.

Needless to say the upshot of this study seems to again confirm what we've known for a while now  - people who are diagnosed sooner and treated sooner live longer with fewer negative consequences.