Rapid treatment start doesn't benefit all

People who started HIV treatment in the first few weeks after being diagnosed with HIV were significantly less likely to be retained in care a year later, a large French study has reported.

French researchers associated with the Dat’AIDS study group, reporting their analysis in the journal PLOS ONE, say that measures to speed up treatment initiation are not benefitting all people.

Treatment initiation as soon as possible after HIV diagnosis is recommended in most national treatment guidelines and in some settings, such as San Francisco, protocols for rapid treatment initiation have been implemented.

Glossary

retention in care

A patient’s regular and ongoing engagement with medical care at a health care facility. 

hazard

Expresses the risk that, during one very short moment in time, a person will experience an event, given that they have not already done so.

hazard ratio

Comparing one group with another, expresses differences in the risk of something happening. A hazard ratio above 1 means the risk is higher in the group of interest; a hazard ratio below 1 means the risk is lower. Similar to ‘relative risk’.

multivariate analysis

An extension of multivariable analysis that is used to model two or more outcomes at the same time.

stigma

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

French researchers wanted to find out how quickly people started treatment in France and what impact rapid treatment initiation has had on retention in care, looking at the Dat’AIDS cohort, which covers 23 HIV treatment centres in France and overseas territories.

They looked at people diagnosed with HIV between January 2010 and December 2015, a total of 7245 people. The study population was 72% male, 46% men who have sex with men, 45% men who acquired HIV through sex with women and 1.2% people who inject drugs. Just under 11% had been diagnosed during acute HIV infection and the median CD4 cell count at diagnosis was 362 cells/mm3.

The median time from diagnosis to first encounter or appointment with an HIV physician was 13 days and the median time from first appointment to antiretroviral drug prescription was 27 days.

The interval between first appointment with a physician and antiretroviral prescription fell significantly between 2010 and 2015, from 42 days to 18 days.

However, the interval between first appointment and prescription was much greater in people diagnosed with higher CD4 cell counts. Whereas people with CD4 counts below 200 – in urgent need of treatment – received a prescription a median of 14 days after their first appointment, people with CD4 counts above 500 received a prescription a median of 80 days after their first appointment.

One reason why rapid treatment initiation has been endorsed in treatment guidelines is because of its potential to reduce the amount of time during which people might be able to pass on HIV. The study found that in the Dat’AIDS cohort, the time from diagnosis to a viral load suppressed below 50 copies/ml (non-infectious) fell from 378 days in 2010 to 169 days in 2015.

After people started treatment, they were more likely to be retained in care one year later if they had experienced a longer interval between their first appointment with an HIV physician and starting treatment.

Whereas 80% of those who took nine days or less to go from first appointment to HIV treatment prescription were still in care a year later, 85% of those who took more than 90 days were still in care a year later (p < 0.0001).

Multivariate analysis found that older age at HIV diagnosis and a longer time between first appointment and prescription were each associated with better retention in care one year after starting treatment.

"An early start to ART should not be a hasty start to ART"

Compared with people under the age of 28, people aged 47 years and over were 78% more likely to be in care after one year on treatment (adjusted hazard ratio 1.78, 95% CI 1.48-2.14, p < 0.0001). People aged 28 to 36 years were 44% more likely to be in care, and people aged 37 to 46 years were 67% more likely to be in care than those aged under 28.

People who took more than 90 days to go from a first appointment to a prescription were 48% more likely to remain in care a year after starting treatment (adjusted hazard ratio 1.48, 95% CI 1.24-1.76). The likelihood of remaining in care was similar for people who received their first prescription 28 to 90 days after a first appointment (1.52, 95% CI 1.28-1.82).

One group of people were less likely to remain in care. Men who acquired HIV through sex with women were 28% less likely to be in care, after controlling for all other factors, than women (adjusted hazard ration 0.72, 95% CI 0.61-0.86, p = 0.0001).

The investigators say that more research is needed to determine why men who have sex with women were less likely to remain in care during a period when the interval between diagnosis and treatment was shrinking. They speculate that this group may be less aware of the benefits of antiretroviral treatment and so are less motivated to stay on treatment once they begin.

But they also acknowledge that factors such as migration, stigma and difficulties in adjusting to an HIV diagnosis may have a greater impact on retention in HIV care among men who have sex with women.

“Going faster than already fast did not bring any advantage regarding retention in care. Indeed, if patients are not prepared, educated and motivated on HIV treatment […] starting ART [antiretroviral therapy] too early may be counterproductive.

“We consider, based on our study, that an early start to ART should not be a hasty start to ART."