BACKGROUND: Antiretroviral therapy (ART) initiation regardless of CD4 count has been recommended since 2014 in Thailand, with same-day ART initiation recommended in 2021. We assessed HIV outcomes among Thai people living with HIV (PLHIV) by time from HIV diagnosis to starting ART under the Universal Health Coverage (UHC) program and determined factors associated with virological failure (VF).
METHODS: PLHIV aged =15 years initiating ART between 2014 to August 2022 were included and categorized into 4 groups based on duration from HIV diagnosis (or registration) to ART initiation: 1) same-day or 2-7 days, 2) <1 month, 3) 1-3 months, and 4) >3 months. VF was defined as viral load (VL) =1000 copies/mL after at least 6 months of ART. Factors associated with VF were analysed using a competing risk model considering death and loss to follow-up (LTFU) as competing events. Vital status was confirmed with Death Registry.
RESULTS: Of 229,171 PLHIV who started ART, 65% had date of HIV diagnosis recorded. Median (IQR) age was 34 (26-43) years and pre-ART CD4 count was 232 (77-419) cells/mm3. ART initiation happened same-day in 17%, 2-7 days in 6%, <1 month in 23%, 1-3 months in 25% and >3 months in 30%. ART initiation within 7 days significantly increased from 19% during 2014-2016 to 30% during 2020-2022. ART initiation within 7 days resulted in the lowest mortality [10%: 1.31 (95%CI 1.27-1.36) per 100 person-years (PY)], but the highest rate of LTFU [8%: 2.29 (95%CI 2.22-2.36) per 100 PY] when compared with others initiating ART groups. VF occurred with a rate of 3.44 (95%CI 3.40-3.489) per 100 PY. PLHIV initiating ART within 1 month were at lower risk of VF (aSHR 0.79, 95%CI 0.75-0.81) when compared to ART initiation >3 month after diagnosis/registration.
CONCLUSIONS: ART initiation within 7 days became more common in Thailand over time although this occurred in less than one-third of PLHIV in the last 3 years of the UHC program. ART initiation within 7 days significantly reduced mortality. ART initiation within 1 month significantly lowered risk of VF. To further optimize health outcomes, innovative strategies are urgently needed to implement earlier ART initiation in Thailand.