The impact of same-day and rapid ART initiation under the Universal Health Coverage programme on HIV outcomes in Thailand: a retrospective real-life cohort study

IF 4.6 1区医学 Q2 IMMUNOLOGY

Journal of the International AIDS Society Pub Date : 2025-01-02 DOI:10.1002/jia2.26406

Sirinya Teeraananchai, David C. Boettiger, Cheewanan Lertpiriyasuwat, Rattaphon Triamwichanon, Patchara Benjarattanaporn, Nittaya Phanuphak

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Abstract

Introduction

Antiretroviral therapy (ART) initiation, regardless of CD4 count, has been recommended in Thailand since 2014, with same-day initiation recommended since 2021. We assessed HIV treatment outcomes among Thai people living with HIV (PLHIV) by the time from HIV diagnosis to ART initiation under the Universal Health Coverage (UHC) programme and identified factors associated with virological failure (VF).

Methods

PLHIV aged ≥15 years initiating ART between 2014 and 2022 were included from the UHC database. We categorized participants into four groups using the duration from HIV diagnosis to ART initiation: (1) ≤ 7 days (same-day ART); (2) 8 days to <1 month; (3) 1–3 months; and (4) >3 months. Viral load (VL) was measured 6 months after starting ART, and annually thereafter. VF was defined as VL ≥1000 copies/ml. Factors associated with VF were analysed using competing risk models considering death and loss to follow-up (LTFU) as competing events.

Results

Among 252,239 PLHIV who started ART, the median age at initiation was 34 years (interquartile range [IQR]: 26–43 years). The median (IQR) pre-ART CD4 count was 233 (76–420) cells/mm³. ART initiation occurred within 7 days for 25% (17% on the same day, 8% in 2–7 days), 24% in 8 days to <1 month, 23% in 1–3 months and 28% in >3 months. ART initiation within 7 days increased from 20% (2014–2016) to 32% (2021–2022). VF occurred with a rate of 3.11 (95% CI 3.07–3.159) per 100 person-years (PYs). PLHIV initiating ART 8 days to 1 month were at lower risk of VF (aSHR 0.52, 95% CI 0.50–0.54) when compared to ART initiation >3 months. ART initiation within 7 days resulted in the lowest mortality (6%: 1.28 [95% CI 1.24–1.32] per 100 PYs), but the highest rate of LTFU (12%: 2.69 [95% CI 2.63–2.75] per 100 PYs) when compared to other ART initiation groups.

Conclusions

Although ART initiation within 7 days has increased in Thailand, the overall rate of early initiation remains low. ART initiation within 1 month significantly lowered the risk of VF. ART initiation within 7 days significantly reduced mortality. To further optimize health outcomes, innovative strategies are urgently needed to promote earlier ART initiation in Thailand.

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全民健康覆盖规划下的同日快速抗逆转录病毒治疗对泰国艾滋病毒结局的影响：一项回顾性现实队列研究。

简介泰国自 2014 年起开始推荐抗逆转录病毒疗法（ART），无论 CD4 细胞计数如何，并建议自 2021 年起当天开始治疗。我们评估了泰国艾滋病病毒感染者（PLHIV）在全民医保（UHC）计划下从确诊艾滋病病毒到开始抗逆转录病毒疗法的治疗效果，并确定了与病毒学失败（VF）相关的因素：从全民医保数据库中纳入了 2014 年至 2022 年期间开始接受抗逆转录病毒疗法的年龄≥15 岁的艾滋病毒感染者。我们根据从 HIV 诊断到开始抗逆转录病毒疗法的持续时间将参与者分为四组：(1) ≤ 7 天（当日抗逆转录病毒疗法）；(2) 8 天至 3 个月。开始抗逆转录病毒疗法 6 个月后测量病毒载量（VL），此后每年测量一次。VF定义为VL≥1000拷贝/毫升。使用竞争风险模型分析了与 VF 相关的因素，并将死亡和失去随访（LTFU）视为竞争事件：在 252 239 名开始接受抗逆转录病毒疗法的艾滋病毒感染者中，开始接受抗逆转录病毒疗法的中位年龄为 34 岁（四分位距[IQR]：26-43 岁）。开始抗逆转录病毒疗法前的 CD4 细胞计数中位数（IQR）为 233 (76-420) cells/mm3。25%的患者在 7 天内开始接受抗逆转录病毒疗法（17% 的患者在当天开始，8% 的患者在 2-7 天内开始），24% 的患者在 8 天至 3 个月内开始。7 天内开始抗逆转录病毒疗法的比例从 20%（2014-2016 年）增至 32%（2021-2022 年）。VF 发生率为每百人年 3.11 例（95% CI 3.07-3.159）。与开始抗逆转录病毒疗法超过 3 个月的患者相比，开始抗逆转录病毒疗法 8 天至 1 个月的 PLHIV 发生 VF 的风险较低（aSHR 0.52，95% CI 0.50-0.54）。与其他抗逆转录病毒疗法启动组相比，7 天内启动抗逆转录病毒疗法的死亡率最低（6%：1.28 [95% CI 1.24-1.32]/100PYs），但 LTFU 率最高（12%：2.69 [95% CI 2.63-2.75]/100PYs）：结论：尽管泰国在 7 天内开始抗逆转录病毒疗法的人数有所增加，但早期开始抗逆转录病毒疗法的总体比例仍然很低。在 1 个月内开始抗逆转录病毒疗法可显著降低 VF 风险。在 7 天内开始抗逆转录病毒疗法大大降低了死亡率。为了进一步优化健康结果，泰国急需创新战略来促进更早地开始抗逆转录病毒疗法。

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来源期刊

Journal of the International AIDS Society IMMUNOLOGY-INFECTIOUS DISEASES

CiteScore

8.60

自引率

10.00%

发文量

186

审稿时长

>12 weeks

期刊介绍： The Journal of the International AIDS Society (JIAS) is a peer-reviewed and Open Access journal for the generation and dissemination of evidence from a wide range of disciplines: basic and biomedical sciences; behavioural sciences; epidemiology; clinical sciences; health economics and health policy; operations research and implementation sciences; and social sciences and humanities. Submission of HIV research carried out in low- and middle-income countries is strongly encouraged.