The role of HIV asymptomatic status when starting ART on adherence and treatment outcomes and implications for test and treat: the Swiss HIV Cohort Study. Clinical Infectious Disease
Glass et al. aimed to assess trends in starting antiretroviral therapy (ART) over time and the potential impact of symptom status at ART initiation on adherence and treatment outcomes.
People living with human immunodeficiency virus (PLHIV) registered in the Swiss HIV Cohort Study (SHCS) between 2003 and 2018 were included. The authors defined asymptomatic as Centers for Disease Control and Prevention stage A within 30 days of starting ART, non-adherence as any self-reported missed doses and viral failure as two consecutive viral load>50 copies/mL after >24 weeks on ART.
Of 7’131 PLHIV, 76% started ART when asymptomatic and 1’478 (22%) experienced viral failure after a median of 1.9 years (interquartile range, 1.1–4.2). In multivariable models, asymptomatic PLHIV were more likely to be younger, men who have sex with men, better educated, have unprotected sex, have a HIV-positive partner, have a lower viral load, and have started ART more recently. Asymptomatic status was not associated with nonadherence (odds ratio, 1.03 [95% confidence interval {CI}, .93–1.15]). Asymptomatic PLHIV were at a decreased risk of viral failure (adjusted hazard ratio, 0.87 [95% CI, .76–1.00]) and less likely to develop resistance (14% vs 27%, P < .001) than symptomatic PLHIV.
In conclusion, this is the first study to report comprehensive clinical picture of asymptomatic PLHIV starting ART in a high-income setting. After adjusting for a comprehensive list of confounders, asymptomatic PLHIV did not report more nonadherence and remained less likely to experience viral failure at the threshold of RNA < 50 copies/mL. These results are particularly encouraging considering the already low rates of virologic failure and emergence of drug resistance in the cohort. With additional cost and resources required to treat PLHIV earlier, differentiated care models will be important for monitoring newly diagnosed PLHIV starting ART and providing targeted support for vulnerable groups—younger, less educated, and lacking social support.
Additional comment Dominique Braun and Huldrych Günthard
After a longer break due to the Corona crisis, we are back now and will continue to share interesting results from the SHCS on a weekly base. We hope that you and your families are doing well and we are looking forward to meeting you soon in person.