James McMahon

Brings together data from Africa, Thailand and Amsterdam on same day ART initiation and also one presentation on how that impacts the management of TB-HIV co-infection in Mozambique

The presentation from Amsterdam was a model for high-risk MSM referred from primary care/STI clinics for diagnostic testing including HIV RNA, and demonstrated more people diagnosed in acute/early infection. The Thai group have previously reported benefits to care retention and now report same-day ART is more likely without increased mortality if patients were not deemed to need baseline blood tests, and increased acceptability amongst adolescents. Ordering of baseline tests and clinical referral review was performed for higher risk patients with suspected opportunistic infection (OI). In over 8000 TB/HIV co-infected people from Mozambique a concerning increase in mortally from <15% to nearly 30% between 2013-2017 as geneXpert testing and ‘test-and-treat’ were rolled out was correlated with an increased likelihood of ART initiation before tuberculosis was diagnosed. By 2017, 59% of TB-HIV cases would commence ART before anti-TB medications highlighting the importance of adequately ruling out serious OIs before commencing ART

Same-day ART initiation can shorten time to virological suppression and improve care retention in some jurisdictions (e.g Thailand). These benefits are more likely where barriers to ART initiation exist at diagnosis (separate ART clinics, financial and transport barriers) and systems to exclude opportunistic infections (OIs) are robust. The challenge of ruling out OIs and potential for increased mortality with same day ART described. The increased mortality in Mozambique highlights how better strategies to rule out OIs are needed if same-day ART is considered and how programs need to consider clinical and structural factors in their jurisdiction before promoting this practice.