Antiretroviral therapy (ART) initiation, regardless of CD4 count, has been recommended in Thailand since 2014, with same-day initiation recommended since 2021. We assessed HIV treatment outcomes among Thai people living with HIV (PLHIV) by the time from HIV diagnosis to ART initiation under the Universal Health Coverage (UHC) programme and identified factors associated with virological failure (VF).
PLHIV aged ≥15 years initiating ART between 2014 and 2022 were included from the UHC database. We categorized participants into four groups using the duration from HIV diagnosis to ART initiation: (1) ≤ 7 days (same-day ART); (2) 8 days to <1 month; (3) 1–3 months; and (4) >3 months. Viral load (VL) was measured 6 months after starting ART, and annually thereafter. VF was defined as VL ≥1000 copies/ml. Factors associated with VF were analysed using competing risk models considering death and loss to follow-up (LTFU) as competing events.
Among 252,239 PLHIV who started ART, the median age at initiation was 34 years (interquartile range [IQR]: 26–43 years). The median (IQR) pre-ART CD4 count was 233 (76–420) cells/mm3. ART initiation occurred within 7 days for 25% (17% on the same day, 8% in 2–7 days), 24% in 8 days to <1 month, 23% in 1–3 months and 28% in >3 months. ART initiation within 7 days increased from 20% (2014–2016) to 32% (2021–2022). VF occurred with a rate of 3.11 (95% CI 3.07–3.159) per 100 person-years (PYs). PLHIV initiating ART 8 days to 1 month were at lower risk of VF (aSHR 0.52, 95% CI 0.50–0.54) when compared to ART initiation >3 months. ART initiation within 7 days resulted in the lowest mortality (6%: 1.28 [95% CI 1.24–1.32] per 100 PYs), but the highest rate of LTFU (12%: 2.69 [95% CI 2.63–2.75] per 100 PYs) when compared to other ART initiation groups.
Although ART initiation within 7 days has increased in Thailand, the overall rate of early initiation remains low. ART initiation within 1 month significantly lowered the risk of VF. ART initiation within 7 days significantly reduced mortality. To further optimize health outcomes, innovative strategies are urgently needed to promote earlier ART initiation in Thailand.
WHO's Integrated Care for Older People (ICOPE) proposes we measure the functional construct of intrinsic capacity (IC) to monitor and identify individuals with age-associated vulnerabilities. Assessments of IC may be useful to address the evolving, non-HV care needs of ageing people with HIV (PWH). However, to date, its utility within the context of HIV has not been assessed.
Participants included 200 PWH attending out-patient care (2021−2023) in Universiti Malaya Medical Centre, Malaysia and 101 community controls aged 35 years and above. The ICOPE framework was adapted to derive aggregate IC scores (ranging 0–6) encompassing the five domains of cognition, sensory (hearing and vision), mobility, mood and vitality. Multivariable analyses were used to explore the association of IC scores in PWH with multiple health outcomes including frailty, difficulties performing instrumental activities of daily living (IADL) and inflammatory markers. Area under the receiver operator characteristic (AUC-ROC) was calculated to predict frailty and IADL deficits in the current cohort and an independent cohort of 275 PWH from Hong Kong (HK).
Median (interquartile range, IQR) age among PWH and controls were 50 (42−56) and 50 (39−59) years, respectively. There were more males among PWH (83% vs. 56%, p<0.001). All PWH received antiretroviral therapy (ART) for a median duration of 11 (8−14) years. Aggregate IC scores were lower in PWH but not significantly different compared to controls, (5.4 vs. 5.6, p = 0.093) and PWH performed significantly worse than controls only in the cognitive domain. Aggregate IC scores in PWH was independently associated with frailty (OR 0.17 95% CI 0.07−0.42, p<0.001), IADL deficits (OR 0.25 95% CI 0.14−0.46, p<0.001) and all other patient-reported outcomes assessed. Aggregate IC scores correlated with IL-6 but not sCD14 and sCD163 levels. IC scores performed well in identifying PWH with frailty (AUC-ROC ≥ 0.80) in the HK and Malaysian cohorts but more modestly (AUC-ROC ≥ 0.64) for IADL deficits.
IC is a good composite measure to monitor non-HIV, age-associated physical and social vulnerabilities in PWH on ART and should complement disease-based monitoring in routine HIV care. Assessments of IC should be validated in larger, longitudinal cohorts of PWH from diverse settings.
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