Three antiretroviral therapy (ART) models, tested in different hospitals in Thailand, are feasible and safe if administered on the same day as diagnosis, researchers report. These models have been implemented in Thailand since 2017, following a World Health Organization recommendation that all individuals diagnosed as HIV-positive should receive ART on the same day as their diagnosis.
Thai researchers reported that patients in the "Same-Day Antiretroviral Therapy" program at a Thai Red Cross clinic in Bangkok were 2.2 times more likely to achieve viral suppression than other patients. Based on these results, the team wanted to investigate whether this program could be replicated in other settings in Thailand.
Therefore, they carried out an evaluation study, the first results of which were presented by Dr. Pich Seekaew, from the Thai Red Cross AIDS Research Centre, at the recent 10th International AIDS Society Conference on HIV Science (IAS 2019) in Mexico City.
The data came from an observational cohort of 5733 HIV-positive individuals who attended nine health centers in five Thai provinces with a high HIV burden between 2017 and 2019.
All three models aligned with Thailand's national guidelines on HIV treatment and prevention, recommending a list of baseline tests at the time of HIV diagnosis, such as creatinine, CD4 count, kidney function test, syphilis test, and chest x-ray. They also include a medical history review, physical examination, and a physician's determination of ART eligibility.
The difference between the models was whether people had to wait until their baseline lab test results were available before starting ART. Each health center adopted its own model, based on local hospital guidelines and physician preferences.
The facilities were classified by requirements based on the results of laboratory tests, prior to the start of the TAR:
Model A: no laboratory results required.
Model B: CD4 count only.
Model C: Additional safety lab results are required to detect kidney disease, cryptococcal meningitis, or other problems, but no CD4 count is needed.
Seekaew described the overall performance of all models. 4349 patients in the cohort (76%) were available for analysis. Among them, 3812 (88%) agreed to immediate ART, and of these, 3385 (89%) were assessed by physicians and deemed eligible for ART initiation.
A large majority of this latter group of 3385 people had started ART within a short period of time – 88% within 7 days:
72.2% on the same day as HIV diagnosis.
7.1% within 2-3 days.
8.4% within 4-7 days.
5.7% within 8-14 days.
2.3% within 15-21 days.
3.8% for 21 days.
After three months, 91.2% remained in care, while 5.1% were discontinued. After six months, 84.4% were retained and 7.1% were discontinued. A major concern, highlighted by Seekaew, was that only 65.6% of people on ART for at least six months had undergone viral load testing. Among them, only 84.7% had suppressed viremia.
Pich Seekaew concluded that not using baseline laboratory results had facilitated faster initiation of ART, without an increase in serious adverse events or deaths. Requiring a CD4 count before starting treatment had resulted in a longer delay in initiating HIV therapy, increasing the risk of opportunistic infections. However, some leading physicians still based their practice on anecdotal case reports and experience, and had conservative requirements before prescribing ART to patients.
He also said that Thailand's next steps were to develop standardized clinical guidelines on ART to be given on the same day as diagnosis, viral load training programs for people with HIV, and an immediate ART initiation network in provinces with a high HIV burden.
By: Alain Volny-Anne