Botswana Ministry of Health and Wellness, Gaborone, Botswana.
Centers for Disease Control and Prevention, Division of Global HIV/AIDS and TB, Atlanta, GA, USA.
Lancet HIV. 2020 Aug;7(8):e545-e553. doi: 10.1016/S2352-3018(20)30187-9.
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.
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.
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).
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.
US President's Emergency Plan for AIDS Relief.
确保感染艾滋病毒的个体迅速开始接受抗逆转录病毒治疗（ART）是实现 90-90-90 目标的重要步骤。我们评估了在博茨瓦纳组合预防项目（BCPP）中快速开始 ART 的可行性和结果。我们旨在确定通过提供当日治疗的简化 ART 起始是否可以增加接受程度并减少从诊所联系到开始治疗的时间，同时保持护理和病毒抑制的保留率。
我们使用来自 BCPP 的数据进行了一项准实验性的前后研究。BCPP 是一项在 2013 年 10 月 1 日至 2018 年 6 月 30 日期间在博茨瓦纳 30 个社区进行的社区随机艾滋病毒预防试验。参加者是 HIV 阳性且未接受 ART 的 15 个干预组，他们在第一次就诊时被提供普遍的 HIV 治疗和以度鲁特韦为基础的方案的当日 ART。这项快速 ART 干预在 2016 年 6 月 1 日试验进行到一半时实施，使我们能够确定快速 ART 指南对 BCPP 干预组的 ART 起始时间和 1 年时护理保留率和病毒抑制率的影响。
我们评估了在快速 ART 引入前的 1717 名与研究诊所联系的成年人和引入后 800 名成年人。在快速 ART 期间，457 人（57.1%，95%CI 53.7-60.6）在联系后的 1 天内开始接受 ART，589 人（73.7%，70.6-76.7）在 1 周内，678 人（84.9%，82.4-87.3）在 1 个月内，744 人（93.5%，91.6-95.1）在 1 年内。在快速 ART 引入之前，163 人（9.5%，95%CI 8.2-11.0）在联系后的 1 天内开始接受 ART，276 人（16.1%，14.4-17.9）在 1 周内，839 人（48.9%，46.5-51.3）在 1 个月内，1532 人（89.2%，87.7-90.6）在 1 年内。在 ART 开始后的 1 年内，与标准 ART 期联系的 1627 人中，有 1472 人（90.5%，87.4-92.8）在接受护理，且病毒载量低于每毫升 400 拷贝，而在快速 ART 期有 578 人（91.6%，88.1-94.1）（风险比 1.01，95%CI 0.92-1.11）。
我们的发现为快速开始 ART 的世卫组织建议提供了支持，并为在低收入和中等收入国家环境中快速开始 ART 的可行性、可接受性和安全性提供了更多的证据。
美国总统艾滋病紧急救援计划。
