Antiretroviral Therapy Initiation for Treatment and Prevention in East Africa
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In serodiscordant couples, provision of antiretroviral therapy (ART) to the HIV-infected partner significantly decreases risk of sexual HIV transmission of HIV. The World Health Organization has recently issued guidelines recommending ART initiation, regardless of CD4 count, for HIV-infected members of serodiscordant couples to prevent HIV transmission to the uninfected partner. We conducted a prospective cohort study among 1998 HIV-infected individuals with known HIV-uninfected partners who were enrolled in the Partners PrEP Study, an HIV prevention clinical trial in Kenya and Uganda. The primary objective was to assess ART initiation in those who became ART-eligible during study follow-up. The cumulative probabilities of initiating ART at 6, 12, and 24 months after referral were 60.8%, 78.8% and 91.5%, respectively. Approximately 40% of HIV-infected partners had not initiated ART six months after initial referrals. Higher CD4 (p<0.001), asymptomatic HIV disease (p=0.04), and alcohol use (p=0.001) were significant predictors of ART initiation. To evaluate whether HIV-infected persons would be interested in earlier ART (CD4 >350 cells/μL) for HIV prevention, as recommended by the WHO, we conducted a cross-sectional study among an additional 571 East African HIV-infected individuals in serodiscordant partnerships. The objective of the study was to determine whether fertility intentions were correlated with a greater likelihood to initiate early ART for prevention. We found that HIV-infected partners with fertility intentions were nearly twice as likely to express interest in early ART for HIV prevention (adjusted odds ratio [AHR] 1.83, p=0.02) than those without fertility intentions. Younger age (p<0.001), male sex (p=0.05), lack of children in the partnership (p=0.002), and unprotected sex in the prior month (p=0.05) were associated with fertility intentions among HIV-infected partners. Our results show that delay in ART initiation was common among East African HIV-infected individuals in serodiscordant partnerships initiating ART for their own health, despite regular clinical and immunological monitoring, ART counseling, and active linkage into care. Positively, they emphasize some HIV-infected partners with higher CD4 counts may be interested in early ART for HIV prevention, particularly if they wish to conceive.
- Epidemiology