Initiating antiretroviral therapy (ART) on the same day as HIV testing is feasible and leads to improved retention and health outcomes, according to a trial published in PLOS Medicine.
Standard care for patients who test positive for HIV in most settings involves multiple visits for counseling and laboratory procedures to prepare patients for ART initiation and determine eligibility, but this process typically takes weeks and can be a barrier to starting treatment. To determine if accelerating this process can improve retention and health outcomes, Serena Koenig of Brigham and Women's Hospital, USA, Jean William Pape of Weill Medical College of Cornell University, USA, and their colleagues conducted a randomized trial of same-day ART initiation at the GHESKIO Centers in Port-au-Prince, Haiti.
Adults testing positive for HIV with early stage disease were randomized to either standard care (3 weekly visits with a social worker and physician before starting ART), or same-day ART (starting treatment on the day of HIV diagnosis). They found that 12 months after HIV testing, retention in care was improved (80% of participants in the same-day ART group versus 72% of the standard care group), as was evidence that ART was working (53% versus 44% with viral load <50 copies/ml; 61% versus 52% with viral load <1,000 copies/ml).
The authors note that further study is necessary to determine if this strategy will be effective in settings other than a large urban clinic, and that despite the improvements shown here, both retention and suppression rates will need to improve further to hit UNAIDS 90-90-90 targets and maximize long-term outcomes. Nevertheless, they note that "These results are important given recent WHO 2016 guidelines stating the lack of evidence in support of same-day ART initiation."
In a linked perspective, Elvin Geng of the University of California, San Francisco, USA, notes that this study is "a critical step toward addressing the knowledge gap about how fast to start ART", and discusses the need to develop approaches to support same-day ART start and improve retention and adherence on a larger scale.
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Koenig SP, Dorvil N, Dévieux JG, Hedt-Gauthier BL, Riviere C, Faustin M, et al. (2017) Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial. PLoS Med 14(7): e1002357. doi.org/10.1371/journal.pmed.1002357