Rapid antiretroviral therapy in primary HIV-1 infection enhances immune recovery.
Thornhill JP., Fox J., Martin GE., Hall R., Lwanga J., Lewis H., Brown H., Robinson N., Kuldanek K., Kinloch S., Nwokolo N., Whitlock G., Fidler S., Frater J.
Objective:We present findings from a large cohort of individuals treated during Primary HIV Infection (PHI) and examine the impact of time from HIV-1 acquisition to antiretroviral therapy (ART) initiation on clinical outcomes. We also examine the temporal changes in the demographics of individuals presenting with PHI to inform HIV-1 prevention strategies.Methods:Individuals who fulfilled the criteria of PHI and started ART within three months of confirmed HIV-1 diagnosis were enrolled between 2009 and 2020. Baseline demographics of those diagnosed between 2009-2015 (before preexposure prophylaxis (PrEP) and universal ART availability) and 2015-2020 (post-PrEP and universal ART availability) were compared. We examined the factors associated with immune recovery and time to viral suppression.Results:204 individuals enrolled, 144 from 2009-2015 and 90 from 2015-2020; median follow-up was 33 months. At PHI, the median age was 33 years; 4% were women, 39% were UK-born, and 84% were MSM. The proportion of UK-born individuals was 47% in 2009-2015, compared with 29% in 2015-2020. There was an association between earlier ART initiation after PHI diagnosis and increased immune recovery; each day that ART was delayed was associated with a lower likelihood of achieving a CD4>900 cells/mm3 [HR 0.99 (95%CI 0.98, 0.99), P = 0.02) and CD4/CD8>1.0 (HR 0.98 (95%CI 0.97, 0.99).Conclusion:Early initiation of ART at PHI diagnosis is associated with enhanced immune recovery, providing further evidence to support immediate ART in the context of PHI. Non-UK-born MSM accounts for an increasing proportion of those with primary infection; UK HIV-1 prevention strategies should better target this group.