Delayed initiation of antiretroviral therapy among people living with HIV in stable partnerships

Delay of antiretroviral therapy initiation is common in east African HIV-infected individuals in serodiscordant partnerships.

Mujugira A, Celum C, Thomas KK, Farquhar C, Mugo N, Katabira E, Bukusi EA, Tumwesigye E, Baeten JM, Partners PrEP Study Team. J Acquir Immune Defic Syndr. 2014 Aug 1;66(4):436-42. doi: 10.1097/QAI.0000000000000192.

Objective: WHO guidance recommends antiretroviral therapy (ART) initiation for all persons with a known HIV-uninfected partner, as a strategy to prevent HIV transmission. Uptake of ART among HIV-infected partners in serodiscordant partnerships is not known, which we evaluated in African HIV serodiscordant couples.

Design: Prospective cohort study.

Methods: Among HIV-infected persons from Kenya and Uganda who had a known heterosexual HIV-uninfected partner, we assessed ART initiation in those who became ART eligible under national guidelines during follow-up. Participants received quarterly clinical and semi-annual CD4 monitoring, and active referral for ART upon becoming eligible.

Results: Of 1 958 HIV-infected ART-eligible partners, 58% were women, and the median age was 34 years. At the first visit when determined to be ART eligible, the median CD4 count was 273 cells per microliter (interquartile range, 221-330), 77% had WHO stage 1 or 2 HIV disease, and 96% were receiving trimethoprim-sulfamethoxazole prophylaxis. The cumulative probabilities of initiating ART at 6, 12, and 24 months after eligibility were 49.9%, 70.0%, and 87.6%, respectively. Younger age [<25 years; adjusted hazard ratio (AHR), 1.39; P = 0.001], higher CD4 count (AHR, 1.95; P < 0.001 for >350 compared with <200 cells/µL), higher education (AHR, 1.25; P < 0.001), and lack of income (AHR, 1.15; P = 0.02) were independent predictors for delay in ART initiation.

Conclusions: In the context of close CD4 monitoring, ART counseling, and active linkage to HIV care, a substantial proportion of HIV-infected persons with a known HIV-uninfected partner delayed ART initiation. Strategies to motivate ART initiation are needed, particularly for younger persons with higher CD4 counts.

 Abstract access  [1]

Editor’s notes: WHO guidance recommends immediate antiretroviral therapy (ART) initiation, at any CD4 count, for people living with HIV in HIV serodiscordant partnerships. This is included in national HIV strategies in many countries. However, we do not yet know whether individuals will be willing to start ART at a time when they are still asymptomatic, knowing they will have to take the drugs for the rest of their lives. In this study of stable HIV-serodiscordant couples in the Partners PrEP trial, about three-quarters of participants initiated ART during follow-up.  Reasons for non-initiation included higher CD4 count, younger age, and lack of income. The implications of this study for initiating treatment at higher CD4 counts, especially in economically challenged contexts, are important. A better understanding of individuals’ reasons for delaying treatment initiation is needed, including strategies for support. With the move towards higher initiation CD4 thresholds, the success of programming treatment activities may rely heavily on thoroughly understanding the desires and motivations of people who are responsible for taking up treatment. 

Africa [8]
Kenya [9], Uganda [10]
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