In the Journals

Prompt ART improves HIV patient outcomes

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May 20, 2016

A single-visit ART initiation and care program appeared to offer improved rates of viral suppression among African HIV patients, according to a recently published study.

“The [Rapid Initiation of Treatment (RapIT)] intervention showed clinically meaningful improvements in ART uptake and viral suppression, providing proof of principle that a single-visit treatment approach can have benefits,” Sydney Rosen, MPA, research professor in the department of global health at Boston University School of Public Health, said in a press release. “The patients who likely benefited the most from it are those who would not otherwise have initiated treatment at all, or who would have waited until they were sick enough to compromise their prognosis.”

Rosen and colleagues recruited 377 adult non-pregnant HIV patients receiving care at two public sector clinics in Africa to either an accelerated treatment program or a standard clinical regimen. Patients assigned to the rapid arm (n = 187) received point-of-care CD4 count testing, TB testing if symptomatic, blood testing, evaluation, counseling and ART drugs upon their first clinical visit. Controls (n = 190) underwent three to five additional visits over a 2- to 4-week period before receiving ART. The researcher’s primary outcome of interest was incidence of viral suppression, defined as 400 or fewer copies/mL among those retained in care, within 10 months of enrollment. They also measured the proportion of patients in each group who were retained in care or demonstrated other indicators of clinical outcome, and conducted an attrition analysis among patients from either group who received ART within 90 days.

Patient characteristics were similar between study arms; the median age was 35 years, and the median CD4 count was less than 200 cells/mm3. Sixty-four percent of patients in the intervention arm achieved viral suppression, as opposed to 51% in the control arm (RR = 1.26; 95% CI, 1.05-1.5). At 90 days after enrollment, 97% of the intervention arm and 72% of controls had received ART (RR = 1.36; 95% CI, 1.24-1.49).

Using point-of-care testing, the researchers also detected four cases of TB within the intervention arm and initiated appropriate treatment. Among the 318 patients who initiated ART within 90 days, Rosen and colleagues detected no differences in 10-month attrition between the two study arms (HR = 1.06; 95% CI, 0.61-1.84).

These findings demonstrate the patient benefits of rapid ART initiation, the researchers wrote, and provide “proof of principle” that the organization of such programs is feasible within similar settings.

“The RapIT trial has demonstrated that accelerating ART initiation can be effective and feasible,” they wrote. “The next challenge will be adapting [the intervention] to the range of settings and conditions found in clinics throughout Africa.”

Swift care linkage reduces progression, time to viral suppression

Additional data presented at the CDC’s 2015 National HIV Prevention Conference also suggested clinical benefits when HIV patients are quickly brought into care.

Using data from the National HIV Surveillance System, Anna Satcher Johnson, MPH, epidemiologist and supervisor at the HIV Incidence and Case Surveillance branch of the CDC’s Division of HIV/AIDS Prevention, and colleagues examined case information from 26,026 persons from 14 U.S. jurisdictions who received an HIV diagnosis in 2010 and 2011. They categorized patients based on the time between diagnosis and linkage to care (less than 1 month, 2 to 3 months, more than 3 months), and analyzed these groups for an association with the duration of illness before viral suppression. The researchers defined linkage of care as a patient’s first CD4 or viral load test result, and the major outcome was percentage of patients with viral suppression at 12 and 24 months.

Anna Satcher Johnson, MPH

Anna Satcher Johnson

According to Johnson and colleagues, 79% of enrolled patients were linked to care within 3 months, and 81.7% of those patients were linked to care within 1 month. The mean time to viral suppression for all patients diagnosed within 3 months was 15.9 months, with 63.6% and 75.5% achieving viral suppression at 12 months and 24 months, respectively.

Compared with those linked to care within 1 month, a significantly lower proportion of patients linked to care within 2 to 3 months achieved viral suppression at 12 months (64.9% vs. 58.2%) and 24 months (76.1% vs. 72.7%). Outcomes were much worse for those who were not linked to care for more than 3 months, as viral suppression was only achieved by 17% at 12 months and 32.7% at 24 months.

“Raising the bar for prompt linkage to care supports current guidelines to offer treatment to all persons with HIV,” Johnson said during a presentation. “Our results indicate that linkage within 1 month improves outcomes compared to linkage within 2 to 3 months, and may accelerate mitigation of onward HIV transmission.” – by Dave Muoio

Reference:

Hall HI, et al. Abstract 5057. Presented at: National HIV Prevention Conference; Dec. 6-9, 2015; Atlanta.

Disclosure: The researchers report no relevant financial disclosures.

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