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Selected Presentations from CROI 2018
Starting ART on Day of Home HIV Test Improves Linkage, Viral Suppression
25th Conference on Retroviruses and Opportunistic Infections (CROI), March 4-7, 2018, Boston

Mark Mascolini

Starting antiretroviral therapy (ART) on the same day a person tests positive for HIV at home significantly improved entry to HIV care, retention in care, and viral suppression in the randomized CASCADE trial in rural Lesotho [1]. CASCADE investigators argued that same-day ART requires few additional resources because health workers are already in the home for the HIV test.

Home-based HIV testing has made inroads in sub-Saharan Africa, the Swiss research team observed, but its effectiveness remains limited because low percentages of people who test positive start care and ART. They conducted the randomized CASCADE trial to see whether offering same-day ART to people testing positive at home improves linkage, retention, and viral suppression. Adults were eligible for the trial if they tested positive in a home-based program and lived or worked in the study area. The trial excluded pregnant or breastfeeding women and people with WHO stage 4 HIV or cryptococcal infection.

From February through July 2016, researchers randomized 278 antiretroviral-naive positive testers to the intervention (immediate 30-day ART supply with spaced follow-up clinic visits) or to Lesotho's standard of care (referral to clinic for 2 or more pre-ART visits). The investigators defined linkage as making a clinic visit within 90 days of testing positive. They defined viral suppression as a viral load below 100 copies 12 months after testing positive. A ClinicalTrials.gov entry details the protocol [2].

The primary analysis included 137 people assigned to same-day ART and 137 assigned to standard care. Three quarters of participants were women, median age stood at 39 years, and median CD4 count measured 380. Half of participants completed primary education, and 23% had a regular job. Median time to get to the clinic was 1 hour, and 49% walked.

A significantly higher proportion in the same-day ART group entered care within 3 months (69% versus 43%, P < 0.001). Ninety days after testing positive, 69% in the same-day group versus 31% of the standard-care group had started ART (P < 0.001). Significantly more same-day participants attained viral suppression within 12 months (50% versus 38%, P < 0.039), and significantly more remained in care 12 months after testing positive (56% versus 43%, P = 0.03).

The CASCADE investigators concluded that in this rural region with high HIV prevalence, offering ART on the same day a person tests positive improves linkage, retention, and viral suppression through 12 months after a supervised home-based HIV test. If studies in other areas confirm these findings, they proposed, home-based same-day ART "could become policy in countries with established home-based HIV testing."

CASCADE results appeared in JAMA on March 6, 2018, the day of this presentation at CROI: https://jamanetwork.com/journals/jama/fullarticle/2674479