At least if the discussion revolves around HIV testing and accessing treatment; with a study suggesting that initiating antiretroviral therapy (ART) on the same day as HIV testing may actually lead to improved retention and outcomes in people living with HIV.
The current practice in diagnosis and treatment of HIV is to first conduct counseling before a person is tested for HIV; and if a person does test positive, he/she will then be asked to return numerous times for laboratory procedures before ART is even initiated.
In the Philippines, the practice is made more complex – if not tedious – by an antiquated mandate of the Republic Act 8504 (or AIDS Law). Those who want to get tested are (usually) given the rapid test first after a pre-test counseling. If the result is non-reactive, it is recommended that they return some three months after their suspected risk of exposure for a follow-up test; but if their result is reactive, the blood sample taken from them is forwarded to the STD/AIDS Cooperative Central Laboratory (SACCL) of San Lazaro Hospital (in Metro Manila) for a more comprehensive test to be done to confirm the result. This step – the “confirmatory test” – is what ascertains if a person is “positive” or “negative”. This period takes days for those in Metro Manila; though for those outside Metro Manila, it could take weeks or even months before the confirmatory test results are given back to the persons who got tested.
This is the very issue tackled by Serena P. Koenig , Nancy Dorvil, Jessy G. Dévieux, et al in “Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial”, published by PLOS Medicine, with the researchers noting that “multiple visits for counseling, laboratory testing, and other procedures to prepare patients for initiation of antiretroviral therapy (ART) are burdensome and contribute to the high rate of attrition during the period from HIV testing to ART initiation.”
The researchers randomly assigned patients who presented for HIV testing at a clinic in Port-au-Prince, Haiti to standard ART initiation or same-day HIV testing and ART initiation (356 in the standard and 347 in the same-day groups). The standard group had three weekly visits with a social worker and physician and then started ART 21 days after the date of HIV diagnosis; while the same-day ART group initiated ART on the day of HIV diagnosis.
All participants in the same-day ART group and 92% of participants in the standard group initiated ART.
Twelve months after HIV testing, a higher proportion of participants in the same-day ART group were retained in care (80% versus 72%), and a higher proportion were retained in care with viral load <50 copies/ml (53% versus 44%) and viral load <1,000 copies/ml (61% versus 52%).
While the study is limited by being conducted at only one clinic in urban Haiti, the researchers nonetheless stressed that “this study demonstrates that it is feasible to initiate ART on the day of HIV diagnosis for patients with early HIV clinical disease and that same-day treatment leads to increased ART uptake, retention in care, and viral suppression.”
With the World Health Organization (WHO) changing its guidelines to recommend ART for all persons living with HIV (no matter the CD4 count and/or viral load), the researchers hope for further similar studies to be done to ascertain if this strategy will also be effective in other settings.