Benefits of early ART initiation on mortality among people with HIV

Abstract

Initiating antiretroviral therapy (ART) early and immediately is important for reducing the risk of mortality and improving quality of life among people with HIV. In The Lancet HIV, Fangfang Chen and colleagues1Chen F Cai C Wang S et al.Trends in suicide mortality among people with HIV after diagnosis during 2012–18: a retrospective, national cohort study in China.Lancet HIV. 2022; 9: e102-e111Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar reported that suicide mortality in people with HIV was particularly high in the first year after diagnosis (standardised mortality ratio 9·2, 95% CI 8·5–9·8), especially in the first 3 months (98·1, 93·1–103·4). Early ART initiation might allow people with HIV to receive greater social support and enhance resilience. People diagnosed late or who are never on ART usually have advanced stage disease with low survival rates2Trickey A May MT Vehreschild J-J et al.Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies.Lancet HIV. 2017; 4: e349-e356Summary Full Text Full Text PDF PubMed Scopus (544) Google Scholar and the limited treatment options might increase the risk of suicide. Thus, there should be focus on suicide prevention programmes for people with HIV, especially considering the effect of the COVID-19 pandemic on public mental health. Previous studies in China have shown that early initiation of ART can reduce the risks of virological failure, loss to care (attrition), and mortality.3Zhu J Yousuf MA Yang W et al.Mortality and attrition rates within the first year of antiretroviral therapy initiation among people living with HIV in Guangxi, China: an observational cohort study.BioMed Res Int. 2021; 20216657112 Crossref Scopus (3) Google Scholar, 4Zhou C Zhang W Lu RR et al.Benefits of early and immediate initiation of antiretroviral therapy among HIV patients in Chongqing, China.Biomed Environ Sci. 2020; 33: 282-285PubMed Google Scholar, 5Kang R Li J Chen H et al.Using longitudinal genetic-network study to understand HIV treatment-as-prevention.AIDS. 2021; 35: 947-955Crossref PubMed Scopus (7) Google Scholar Early ART initiation (with CD4 counts of 500 cells per μL) had a lower virological failure rate (6·6%) than initiation at pre-ART CD4 counts of less than 350 cells per μL (9·0%).4Zhou C Zhang W Lu RR et al.Benefits of early and immediate initiation of antiretroviral therapy among HIV patients in Chongqing, China.Biomed Environ Sci. 2020; 33: 282-285PubMed Google Scholar Delayed ART increased the attrition rate when compared with immediate ART: adjusted hazard ratio 1·3 (95% CI 1·2–1·5) for 31–90 days delayed, 1·9 (1·7–2·1) for 91–365 days delayed, and 2·2 (2·0–2·5) for 1 year or longer delayed.4Zhou C Zhang W Lu RR et al.Benefits of early and immediate initiation of antiretroviral therapy among HIV patients in Chongqing, China.Biomed Environ Sci. 2020; 33: 282-285PubMed Google Scholar Moreover, early and immediate initiation of ART can further prevent HIV secondary transmission at the population and community level. A study in a real-world setting showed a 53·6% (95% CI 42·1–65·1) reduction in HIV transmission for treatment-as-prevention at the population level.5Kang R Li J Chen H et al.Using longitudinal genetic-network study to understand HIV treatment-as-prevention.AIDS. 2021; 35: 947-955Crossref PubMed Scopus (7) Google Scholar The preventive efficacy for HIV transmission among patients on treatment with viral load less than 50 copies per mL was 61·1% (95% CI 51·0–71·1).5Kang R Li J Chen H et al.Using longitudinal genetic-network study to understand HIV treatment-as-prevention.AIDS. 2021; 35: 947-955Crossref PubMed Scopus (7) Google Scholar In summary, benefits of early and immediate initiation of ART had been observed in China, including reduced HIV-related death (by reducing suicides, attrition, and virological failure) and the prevention of secondary transmission. Because the rate of late diagnosis in China did not decrease from 2012 to 2018 and initiating ART in a timely manner is still challenging,1Chen F Cai C Wang S et al.Trends in suicide mortality among people with HIV after diagnosis during 2012–18: a retrospective, national cohort study in China.Lancet HIV. 2022; 9: e102-e111Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar early diagnosis and the immediate initiation of ART, regardless of CD4 counts, should be emphasised in comprehensive programmes of HIV prevention and control. We declare no competing interests. This work was supported by National Natural Science Foundation of China (82160636, 11971479), Guangxi Key Laboratory of AIDS Prevention Control and Translation (ZZH2020010), Guangxi Bagui Honor Scholarship, and Chinese State Key Laboratory of Infectious Disease Prevention and Control. Trends in suicide mortality among people with HIV after diagnosis during 2012–18: a retrospective, national cohort study in ChinaSuicide mortality decreased during the study period, which coincided with improvement in access to care and treatment coverage. This study suggests the importance of targeted suicide prevention for people with HIV throughout the course of diagnosis and that the focus of efforts should be concentrated on the first 3 months after diagnosis. Our findings highlight the urgent need to integrate suicide screening and prevention in HIV care. Full-Text PDF