Abstract
BackgroundViral suppression is a critical indicator of HIV treatment success. In the era of test-and-start, little is known about treatment outcomes and time to undetectable viral loads. This study compares treatment outcomes, median times to achieve undetectable viral loads and its predictors under different antiretroviral (ART) treatment initiation schedules (i.e. within seven days of enrolment or later).MethodsA retrospective cohort of 367 patients <18 years who enrolled in care between January 2010 and December 2015 with a baseline viral load of >5000 copies/ml were followed up for 60 months. Undetectable viral load measurements were based on both Roche (<20copies/ml) and Abbot (<75copies/ml). Clinical treatment outcomes were compared using chi-squared test. Survival experiences between the two cohorts were assessed through incidence rates and Kaplan Meier curves. A cox model with competing risks was used to assess predictors for time to undetectable viral load.ResultsOf the 367 patients, 180 (49.1%) initiated ART within seven days from enrolment, 192 (52.3%) attained undetectable viral load of which 133 (69.3%) were children below six years and 101 (52.6%) were females. Among those who initiated ART within seven days 15 (8.3%) died and 6 (3.3%) were lost to follow-up compared to 27 (14.4%) and 16 (8.6%) respectively in the later initiators. The median time to undetectable viral load was 24.9 months (95% CI: 19.7, 28.5) among early ART initiators and 38.5 months (95% CI: 31.1, 44.5) among those initiating beyond seven days. There was a significant difference in failure estimates between those initiating within seven and those that deferred (log rank, p = 0.001). Significant predictors for time to undetectable viral load were; starting ART within seven days (SHR = 2.02, 95% CI: 1.24, 3.28), baseline WHO stage I or II (SHR = 1.59, 95% CI: 1.06, 2.28), inconsistent adherence on three consecutive clinic visits (SHR = 0.44, 95% CI: 0.28, 0.67), and baseline weight (SRH = 1.04, 95% CI: 1.01, 1.07).ConclusionPrompt initiation of ART within the first week of enrolment is associated with better treatment outcomes. Early timing, baseline WHO clinical stage and adherence rates should be major considerations while managing HIV among children.
Highlights
Viral suppression is a critical indicator of Human immunodeficiency virus (HIV) treatment success
Our results show that ART initiation within the first seven days of enrolment, consistently high adherence rates >95%, lower baseline World Health Organization (WHO) clinical stage, and weight are significantly associated with achieving undetectable viral load among HIV-1 clients starting treatment for the first time
Evidence elsewhere has shown that same-day initiation of ART after HIV diagnosis is feasible in resource-limited settings [12] and early ART initiation may yield better treatment outcomes including reduced mortality, low occurrences of opportunistic infections and early immunological recovery [6, 26]
Summary
Viral suppression is a critical indicator of HIV treatment success. In the era of test-and-start, little is known about treatment outcomes and time to undetectable viral loads. Amidst the evidence on the feasibility of starting ART on the first day of HIV diagnosis [12] and the critical role on treatment outcomes, the current guidelines do not provide clear direction in terms of the actual timing of treatment initiation. It may take a few days for treatment initiation to be effected since many HIV testing facilities may not have capabilities to initiate treatment and newly diagnosed HIV infected individuals have to be referred elsewhere for ART. It is not known if treatment outcomes of those who start within a few days (e.g. as early as seven days of diagnosis) are better than those that defer treatment
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