Starting ART on the same day as an HIV diagnosis in British Columbia
It is likely that immediate HIV treatment will become the standard of care in high-income countries when this viral infection is diagnosed in the future. It is therefore important to assess programs that offer immediate HIV treatment in order to determine their effectiveness and the attitudes toward them by newly diagnosed people.
Before we delve into the main part of this report, we first provide some background information about acute or very early HIV infection.
About acute HIV infection
After HIV has invaded the ano-genital tract, it infects cells of the immune system that are present in that location. These infected cells produce many more copies of HIV and the cycle of infection continues as new cells are converted into mini-virus factories. Within days of entering the body, HIV-infected cells spread first to nearby lymph nodes and lymphatic tissues, and shortly after to many organ-systems, including the brain. During the period when the virus is spreading from the ano-genital tract and reaching other parts of the body, the immune system is overwhelmed—both by the scale of infection and the chemical signals released by HIV-infected cells that hamper its ability to control the virus.
It takes the immune system some time to reduce the amount of HIV that is being produced during acute infection. As a result, it may take a few weeks after initial exposure and infection before anti-HIV antibodies are detectable in the blood. To assess blood samples for the presence of HIV very early in acute infection, laboratories can use tests called NAATs (nucleic acid amplification tests) that can detect the genetic material of HIV in blood.
In British Columbia
Two clinics that screen for sexually transmitted infections (STIs) in Vancouver used NAATs to help identify people undergoing acute HIV infection. As mentioned earlier in this issue of TreatmentUpdate, offering immediate treatment for HIV infection has many benefits. Researchers in B.C. therefore decided to assess their program that offered immediate ART upon HIV diagnosis.
Researchers with the BC Centre for Disease Control (BCCDC) and the BC Centre for Excellence in HIV/AIDS in Vancouver assessed a program in which participants were offered two choices after an HIV diagnosis:
- counselling and referral to care (as has traditionally been the case)
- counselling and referral to rapid, same-day connection to an HIV specialist and, if needed, additional resources such as peer navigators, primary care doctors and social workers
The research team reviewed health-related information collected between January 2013 and October 2014 from two STI clinics in Vancouver. As part of this study, participants were also briefly interviewed.
For comparison, in 2013, before the implementation of the rapid referral program for care and treatment, there was an average of 21 days before patients saw a doctor after a diagnosis of HIV was made.
In 2014, 19 people were diagnosed with acute HIV infection and 16 (84%) of them chose the rapid referral program. On average, these participants were linked to care within one day after an HIV diagnosis.
Also in 2014, 14 cases of chronic HIV infection were uncovered. These participants took an average of 14 days to connect with care and treatment.
Satisfaction and interest
According to the B.C. team, “the majority of [participants with acute HIV] expressed a high degree of satisfaction with immediate linkage to care and chose to initiate ART on the same day.”
Doctors and nurses reported that patients had “strong” interest in immediate treatment of HIV. However, these clinicians were somewhat concerned that patients who immediately initiated ART might somehow not be able to sustain their ability to take ART every day, exactly as directed, over the long-term.
Room for expansion
Based on the promising results obtained so far, the BCCDC researchers have found additional issues related to the immediate initiation of ART that could be expanded, including the following:
- informing partners and sexual contacts that they may have recently been exposed to HIV and that testing would be a good idea for their health
- offering HIV post-exposure prophylaxis (PEP) to the sexual partners and contacts of people who have tested positive
The present analysis is based on a relatively small number of participants. However, it is an important and vital first step in assessing the impact of immediate initiation of ART. Other steps would include assessing adherence over the long-term.
Some readers may be surprised that the majority of newly diagnosed participants chose same-day initiation of ART. This will likely be the way that HIV will be treated in the years ahead, particularly since the release of the results of the START study.
—Sean R. Hosein
- Haase AT. Perils at mucosal front lines for HIV and SIV and their hosts. Nature Reviews Immunology. 2005 Oct;5(10):783-92.
- Haase AT. Early events in sexual transmission of HIV and SIV and opportunities for interventions. Annual Review of Medicine. 2011;62:127-39.
- Thumath M, Sandstra I, Forrest J, et al. Implementation of a rapid referral pathway to HIV treatment for gay men and MSM diagnosed with acute HIV-infection in sexual health clinics in British Columbia. In: Program and abstracts of the 8th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 19-22 July 2015. Abstract TUPED782.