Early Antiretroviral Therapy Is Associated with Better Viral Suppression and Less HIV Drug Resistance After Implementation of Universal Treatment in South Africa

All people living with HIV should receive antiretroviral therapy (ART), but those with CD4 counts >500 cells/mm(3) at ART initiation ("early initiators") may be less motivated to adhere to treatment, compared with those with CD4 counts <200 cells/mm(3) ("late initiators"). We performed a cross-sectional analysis among HIV-positive adults who had a viral load taken at 6 months after first-line ART initiation in a South African public clinic. Retrospective HIV drug resistance testing was performed on all samples with a viral load >1,000 copies/mL. We used Poisson regression models with robust variance to evaluate associations between early ART initiation and viral suppression <40 copies/mL. We assessed HIV drug resistance using descriptive statistics. Of 390 participants enrolled between February and August 2017, 60% were women and median age was 32 years [interquartile range (IQR) 27-38]. At ART initiation, median CD4 count was 366 cells/mm(3) (IQR 204-546), and 30% were early initiators with CD4 > 500 cells/mm(3). In multivariable analysis, early initiators were more likely to be virally suppressed compared with late initiators (adjusted risk ratio: 1.29, 95% confidence interval: 1.13-1.46). All 18 participants with viral load >1,000 copies/mL had successful genotyping, which identified drug resistance in 14/18 (77.8%). Among early initiators, drug resistance was detected in only 1/117 (0.9%), compared with 11/93 (11.8%) among late initiators. In conclusion, among people receiving ART in a South African public clinic, early initiators had better viral suppression after 6 months and less drug resistance than late initiators, which further supports universal treatment. Clinical trials registration: NCT03066128.