Same-Day Initiation of HIV Treatment Recommended by WHO.
Despite great progress in making treatment available globally, HIV continues to take a devastating toll on health, with 37 million people infected and 1.2 million deaths worldwide in 2015.
Now, a team of researchers from the School of Public Health is on the forefront of a policy change that could save more lives by demonstrating that immediate initiation of antiretroviral therapy (ART), on the day of HIV diagnosis, results in better health outcomes.
“With so many more people eligible for ART under WHO’s 2015 guidelines, which recommended that all people with HIV be on treatment, regardless of disease stage, finding ways to get them started on medications quickly, without long waits or multiple clinic visits, is essential,” said Sydney Rosen, a research professor of global health whose study in South Africa influenced the July 2017 WHO recommendation for same-day initiation.
In releasing the recommendations this summer for rapid initiation of HIV treatment, WHO cited the study led by SPH, dubbed “RapIT” for Rapid Initiation of Treatment, as one of the main sources of evidence in favor of immediate initiation of ART.
Rosen said new guidelines are “recommendations from WHO to national HIV programs as to the best way to manage HIV patients. Each country will adapt the guidelines to its own health system, or choose not to follow the recommendations.”
For those that do adopt them, she said, effective procedures to incorporate the recommendations into practice have to be developed. Rosen’s team is at work on that now.
“For ART initiation, the recommendation is to offer same-day treatment to patients who are clinically eligible and ready, but it does not explain how exactly to do that,” she said. “Operational research is needed to define eligibility and develop the best process for implementing the guidelines.” The team is midway through a follow-on study, called “SLATE” for Simplified Algorithm for Treatment Eligibility, that is testing a simple procedure for starting treatment in a single clinic visit in South Africa and Kenya.
Until 2015, the WHO’s treatment guidelines were based on earlier research that said patients did not have to start treatment until the disease had progressed to a certain point. But new studies have found that starting ART immediately upon diagnosis prevents some serious HIV-related illnesses and, more importantly, reduces HIV transmission to others. This “treat all” strategy is central to global efforts to control the HIV epidemic.
Clinical trials have confirmed that early use of ART keeps people living with HIV alive longer and healthier, and reduces the risk of them passing on the virus. Studies also have projected that test-and-treat approaches could reduce HIV transmission and alter the course of the epidemic.
In September 2016, South Africa followed the WHO’s guidelines to “treat all”— removing the CD4-count thresholds that dictated who could receive ART. However, based on experiences of patients in rural South Africa, researchers have predicted that fewer than one in four newly eligible patients will initiate ART within six months of testing positive.
Merely eliminating CD4 count treatment thresholds for all HIV patients without expanding HIV testing and care, however, is unlikely to lead to a critical mass of people with HIV starting ART, according to a recent analysis in South Africa. SPH researchers have recommended additional interventions and improvements to initiation strategies.
SPH researchers on the HIV studies include: Matthew Fox, professor of epidemiology; Lawrence Long, research assistant professor of global health; Bruce Larson, research professor of global health; and Alana Brennan, an instructor in global health.
The treat all strategy has been widely accepted in Nigeria since it’s inclusion in the 2016 national guidelines. Of course there are varied programmatic limitations but one is very salient and especially amplified with the same day initiation which is retention in treatment. Our studies show that the earlier patients start lifelong therapy the less likely they are to adhere and remain on treatment due to the short processing time for acceptance of disease and preparation for therapy.
It may be worthwhile looking for ways to ameliorate this while we push for a same day initiation.