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/mm3 at ART initiation ("early initiators") may be less motivated to adhere to treatment, compared with those with CD4 counts 1,000 copies/mL. We used Poisson regression models with robust variance to evaluate associations between early ART initiation and viral suppression  500 cells/mm3. 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.