Rapid antiretroviral initiation among Thai youth living with HIV in the National AIDS programme in the era of treatment at any CD4 cell count: a national registry database study

Abstract

Introduction The process indicators of ending the HIV epidemic include 90% of people living with HIV receiving antiretroviral therapy (ART). The population of youth, however, has less access to healthcare. We assessed ART initiation and attrition outcomes of the HIV continuum from HIV diagnosis to ART initiation in youth living with HIV (YLHIV) and factors associated with ART initiation. Methods We studied YLHIV aged 15 to 24 years who were registered on the National AIDS Program (NAP) from January 2008 to May 2019. The study period was divided into 2008 to 2013 (initiated ART by CD4‐guided criteria) and 2014 to 2018 (initiate ART at any CD4). Date of registration was used as a surrogate for the diagnosis date and defined as the baseline. The database included ART prescription and laboratory results, and the vital status was linked daily with the National Death Registry. Competing risk methods were used to assess factors associated with accessing ART, with loss to follow‐up (LTFU) and death considered as competing events. Logistic regression was used to assess factors associated with rapid ART initiation, defined as initiation ≤1 month after registration. Results Overall, 51,607 youth registered on the NAP (42% between 2008 and 2013). Median age was 21 (IQR 20 to 23) years; 64% were male. Overall ART initiation was 80% in the first period and 83% in the second. The ART initiation rate was higher among YLHIV aged 15 to 19 years (86%) than 20 to 24 years (82%) (p < 0.001) in the second period. The proportion of youth starting rapid ART increased significantly from 27% to 52% between the two periods (p < 0.001). Factors associated with ART initiation were age 15 to 19 years (aSHR 1.09, 95% CI 1.06 to 1.11), female (aSHR 1.26, 95% CI 1.23 to 1.29) and registration year 2014 to 2018 (aSHR 1.73, 95% CI 1.69 to 1.76). The cumulative incidence of LTFU/death prior to ART initiation at 12 months was 3.8% (95% CI 3.6% to 4.1%) in the first period and 1.9% (95% CI 1.8% to 2.1%) in the second period. Conclusions In the era of universal treatment of all at any CD4 level, 83% of YLHIV registered on the Thai National AIDS Program initiated ART. The majority initiated within one month of registration.

Long‐term outcomes of rapid antiretroviral NNRTI‐based initiation among Thai youth living with HIV: a national registry database study

“…Policy changes regarding rapid ART initiation led to decreased mortality rates and increased retention in care, similar to those in our study [29, 30]. YLHIV starting rapid ART had the lowest mortality rates, consistent with results from randomized control trials and cohort studies [27, 31]. Rapid ART initiation also accelerated viral suppression rates.…”

A province-wide HIV initiative to accelerate initiation of treatment-as-prevention and virologic suppression in British Columbia, Canada: a population-based cohort study

“…Observational studies from the Netherlands, South Korea, Thailand and New York City also reported a significant decrease in time from HIV diagnosis to treatment initiation in the 2012 to 2015 period, [38][39][40][41] when international guidelines began to recommend rapid ART initiation independent of CD4 count. [42][43][44][45][46] By 2015, however, 75% of people living with HIV in BC initiated ART within 2 months of their diagnosis, compared with 6 months, as noted in the other observational studies.…”

“…[42][43][44][45][46] By 2015, however, 75% of people living with HIV in BC initiated ART within 2 months of their diagnosis, compared with 6 months, as noted in the other observational studies. [38][39][40][41] Although the independent impact of STOP in accelerating time from HIV diagnosis to treatment in BC was evident, the full public benefit of early ART to reduce transmission risk requires a decline in another, more complex, time component, namely time from infection to diagnosis. Delayed HIV diagnosis has previously been observed in 1 in 7 people living with HIV in BC, particularly those who were older, were heterosexual, had ever injected drugs and resided in the Northern health authority.…”

Same‐dayand rapid initiation of antiretroviral therapy in people living withHIVin Asia. How far have we come?

“…The proportion of rapid ART initiation (within 1 month of HIV diagnosis) increased significantly in the second time period compared with the first (52% vs 27%, p <0.001). The cumulative incidence of loss to follow‐up or death prior to ART initiation was also reduced between the two periods (3.8% [95% CI 3.6–4.1] vs 1.9% [95% CI 1.8–2.1]) [25]. A study from an HIV/sexually transmitted infection (STI) testing centre in Bangkok, Thailand, found high numbers of people living with HIV who were eligible and high rates of acceptability of same‐day ART initiation and that it was feasible and safe without immune reconstitution inflammatory syndrome.…”

“…Many countries in the Asia-Pacific region have already implemented or are moving towards implementation of rapid or same-day ART initiation [24,25]. Table 1 outlines key recommendations for rapid ART initiation from guidelines from the USA, Europe, and countries in the Asia-Pacific region (Table 1).…”