Immediate Treatment of Acute HIV in a Tertiary Healthcare Center

Bridging Gaps in Communication Using Smartphones

S Perez-Patrigeon; A Camiro-Zúñiga; MR Jaramillo-Jante; PF Belaunzarán-Zamudio; B Crabtree-Ramírez; LE Soto-Ramírez; JJ Calva; C Hernández-León; JL Mosqueda-Gómez; S Navarro-Alvarez; JG Sierra-Madero

Disclosures

HIV Medicine. 2019;20(5):308-316. 

In This Article

Discussion

We describe our experience implementing an immediate ART initiation strategy in adults with acute HIV infection based on a multidisciplinary approach supported by instant communications tools for smart phones. The inclusion of medical, laboratory and administrative staff in an instant communications group improved the coordination and execution of actions needed to confirm the diagnosis of patients with acute HIV infection and ensure rapid provision of ART. The median time to ART initiation was significantly reduced in these patients compared with the standard of care for patients enrolled in our centre during the study period, from 21 to 2 days. Patients with acute HIV infection enrolled through this approach had similar rates of engagement in care, ART initiation and complete viral suppression when compared with those with chronic HIV infection. The lack of significant observed differences in these parameters between both intervention and comparison groups and immediate and nonimmediate groups shows that the intervention does not have a negative impact on the cascade of care of HIV-infected patients in our centre. There were no other statistically significant differences in treatment acceptability, mortality and loss to follow-up between the two groups in their first year of follow-up after enrolment (data not shown).

Our study has several similarities with other early ART initiation studies. The different appointments and clinical and laboratory examinations are all compressed into 1 day, we initiate ART in most patients with INSTIs, and we enrol the patient in care on the same day on which we initiate treatment.[3–5] As opposed to other same-day ART studies, we exclusively included acutely HIV-infected patients. As in other studies that implemented immediate ART initiation in settings with a high rate of engagement in care, our study showed no modification of engagement rates.[2,3] The absence of an observable difference in the time to achieve viral suppression could be attributed to the lack of earlier and more frequent viral load measurements, like those carried out in those studies.[2,3]

There are important limitations to our study. Most importantly, the lack of randomization of the intervention diminished control of confounding factors, and, although most sociodemographic characteristics did not differ significantly between the two groups, the chronically HIV-infected group had a lower median socioeconomic status. This in part reflects the fact that patients in Mexico tend to be linked to care late,[13] and shows that patients who seek care in the acute phase of HIV infection tend to have a higher socioeconomic status. Finally, our treatment strategy requires more time and effort from all the involved personnel, as well as a controlled deviation from standard ART protocol, which might not be a possibility in some settings. However, the study demonstrates that implementation of a same-day treatment initiation strategy is feasible in our setting, and our findings may also be applicable to other settings with similar highly regulated ART programmes and complicated administrative processes that pose important challenges for implementation of early ART.

An important aspect of our study is the coordinated approach to identify acutely HIV-infected patients in a tertiary care centre. Most of the efforts towards timely detection of new infections in Mexico are targeted at the first level of care, with up to 86.4% of HIV tests performed in nonspecialized centres in 2016.[16] We have shown that specialized care centres represent areas of opportunity for HIV diagnosis[17] that also happen to possess the necessary tools for the identification of acute HIV infection and immediate ART initiation.[18] Moreover, multidisciplinary task forces and specialized instant action algorithms have been created and successfully used for the detection of other medical conditions in these settings, such as cerebrovascular disease.[19,20] Our results demonstrate that an optimized utilization of these resources could have a positive impact on the care of adults with HIV infection in similar settings, allowing personnel at tertiary care hospitals and primary HIV care centres to identify HIV infections in their very early stages and make significant progress towards the national goals in HIV care.

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