Daniel Reeders

Same-day initiation of antiretroviral therapy for people who test positive for HIV is cost effective and leads to high rates of retention in care and viral suppression. Meanwhile, innovative pilots and implementation studies are exploring the feasibility, acceptability and efficacy of event-based pre-exposure prophylaxis (PrEP).

Sita Lujintanon (Thailand) describes an implementation study of key-population-led same-day antiretroviral-therapy initiation hubs in Bangkok which demonstrates timely initiation of treatment (97.9%) with good retention in care (84.6%) and viral suppression outcomes (94.3%). Innovations include point-of-care testing for labs and physician supervision via telemedicine. Meanwhile, Starley Shade (USA) reports a study of Rapid Start same-day treatment initiation and finds the approach cost-effective. Nevertheless, costs are higher in smaller clinics, especially those targeting multiply-marginalised clients, yet costs per person decline over time. Next, John Danvic Rosadiño (Philippines) describes a remarkable pilot of ‘e-PrEPPY’ — an all-virtual, community-led, de-medicalised service offering PrEP access to men who have sex with men. Privacy and urban density mean logistics are crucial. The pilot uses a nation-wide parcel delivery network, and in Manila, it trains its own motorcycle couriers to reach clients who could not have medication mailed to their homes. Finally, Precious Moyo (Zimbabwe) reports event-based PrEP is feasible and acceptable for MSM recruited through city clinics in Harare (n=196; 79% practice sex work). Users value the way in which pill burden tracks variation in their sexual frequency, yet daily PrEP is seen as important where sex is frequent and unplanned.

Same-day initiation of therapy is a practical response to the problem of loss to follow-up among people with HIV. However, it does not in itself address the mechanisms causing this problem and more work is needed to improve downstream experiences of HIV treatment and long-term retention in care. Data from treatment initiatives demonstrate the enormous promise of key-population-led care services. We need studies of policy enablers — best practices for persuading skeptical or even hostile clinical professionals and governments — to help us overcome resistance and even crackdowns, as seen with PrEP delivery initiatives in Thailand.