Background

Ensuring that individuals who are living with HIV rapidly initiate antiretroviral therapy (ART) is an essential step in meeting the 90-90-90 targets. We evaluated the feasibility and outcomes of rapid ART initiation in the Botswana Combination Prevention Project (BCPP). We aimed to establish whether simplified ART initiation with the offer of same-day treatment could increase uptake and reduce time from clinic linkage to treatment initiation, while maintaining rates of retention in care and viral suppression.

Methods

We did a quasi-experimental before and after study with use of data from the BCPP. The BCPP was a community-randomised HIV-prevention trial done in 30 communities across Botswana from Oct 1, 2013, to June 30, 2018. Participants in the 15 intervention clusters, who were HIV-positive and not already taking ART were offered universal HIV-treatment and same-day ART with a dolutegravir-based regimen at first clinic visit. This rapid ART intervention was implemented mid-way through the trial on June 1, 2016, enabling us to determine the effect of rapid ART guidelines on time to ART initiation and rates of retention in care and viral suppression at 1 year in the BCPP intervention group.

Findings

We assessed 1717 adults linked to study clinics before rapid ART introduction and 800 after rapid ART introduction. During the rapid ART period, 457 (57·1%, 95% CI 53·7–60·6) individuals initiated ART within 1 day of linkage, 589 (73·7%, 70·6–76·7) of 799 within 1 week, 678 (84·9%, 82·4–87·3) of 799 within 1 month, and 744 (93·5%, 91·6–95·1) of 796 within 1 year. Before the introduction of rapid ART, 163 (9·5%, 95% CI 8·2–11·0) individuals initiated ART within 1 day of linkage, 276 (16·1%, 14·4–17·9) within 1 week, 839 (48·9%, 46·5–51·3) within 1 month, and 1532 (89·2%, 87·7–90·6) within 1 year. 1 year after ART initiation, 1472 (90·5%, 87·4–92·8) of 1627 individuals who linked in the standard ART period were in care and had a viral load of less than 400 copies per mL, compared with 578 (91·6%, 88·1–94·1) of 631 in the rapid ART period (risk ratio 1·01, 95% CI 0·92–1·11).

Interpretation

Our findings provide support for the WHO recommendations for rapid ART initiation, and add to the accumulating evidence showing the feasibility, acceptability, and safety of rapid ART initiation in low-income and middle-income country settings.

Funding

US President's Emergency Plan for AIDS Relief.

中文翻译：

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博茨瓦纳联合预防项目启动快速抗逆转录病毒治疗：研究前后的准实验。

 背景

确保艾滋病毒感染者迅速开始抗逆转录病毒治疗 (ART) 是实现 90-90-90 目标的重要一步。我们评估了博茨瓦纳联合预防项目 (BCPP) 中快速启动 ART 的可行性和结果。我们的目的是确定提供当天治疗的简化 ART 启动是否可以增加接受率并减少从临床联系到治疗启动的时间，同时保持护理和病毒抑制的保留率。

 方法

我们使用 BCPP 的数据在研究前后进行了准实验。 BCPP 是一项社区随机艾滋病毒预防试验，于 2013 年 10 月 1 日至 2018 年 6 月 30 日在博茨瓦纳全国 30 个社区进行。15 个干预组中的艾滋病毒呈阳性且尚未接受抗逆转录病毒疗法的参与者获得了普遍的艾滋病毒治疗- 首次就诊时采用基于多替拉韦的方案进行治疗和当天 ART。这种快速 ART 干预于 2016 年 6 月 1 日在试验中实施，使我们能够确定快速 ART 指南对 BCPP 干预组中 ART 启动时间以及 1 年护理保留率和病毒抑制的影响。

 发现

我们评估了快速 ART 引入前与研究诊所相关的 1717 名成年人和快速 ART 引入后的 800 名成年人。在快速 ART 期间，457 名 (57·1%, 95% CI 53·7–60·6) 个人在连接后 1 天内启动了 ART，799 名受试者中有 589 名 (73·7%, 70·6–76·7) 1周内，1个月内799例中有678例（84·9%，82·4–87·3），1年内796例中有744例（93·5%，91·6–95·1）。在引入快速 ART 之前，163 名 (9·5%, 95% CI 8·2–11·0) 人在连接后 1 天内开始了 ART，276 名 (16·1%, 14·4–17·9) 在连接后 1 天内开始了 ART。 1周内，839（48·9％，46·5–51·3）在1个月内，1532（89·2％，87·7–90·6）在1年内。开始 ART 后 1 年，在标准 ART 期间进行关联的 1627 名个体中，有 1472 名（90·5%，87·4–92·8）正在接受护理，并且病毒载量低于每毫升 400 个拷贝，而这一数字为 578 名。 (91·6%, 88·1–94·1) 631 人处于快速 ART 阶段（风险比 1·01，95% CI 0·92–1·11）。

 解释

我们的研究结果为世卫组织关于快速启动 ART 的建议提供了支持，并增加了越来越多的证据，表明在低收入和中等收入国家环境中快速启动 ART 的可行性、可接受性和安全性。

 资金

美国总统艾滋病紧急救援计划。