Benefits and risks of rapid initiation of antiretroviral therapy

Abstract

Background:Recent attention has focused on the question of how quickly antiretroviral therapy (ART) should be started once HIV diagnosis is confirmed. We assessed whether rapid ART initiation improves patient outcomes.Methods:We searched five databases from inception up to August 2017. Rapid ART initiation was defined as initiation within 14 days of HIV diagnosis. Data were pooled using random effects meta-analysis.Results:Across the randomized trials, ART start on the same day increased viral suppression at 12 months [three trials: relative risk (RR) 1.17, 95% confidence interval (CI) 1.07–1.27], retention in care at 12 months (RR 1.11, 95% CI 0.99–1.26), and the likelihood of starting ART within 90 days (four trials: RR 1.35, 95% CI 1.13–1.62) and 12 months after eligibility was established (three trials: RR 1.17, 95% CI 1.07–1.27). There was a nonsignificant trend toward reduced mortality (three trials: RR 0.53, 95% CI 0.24–1.08), as well as reduced loss to follow-up at 12 months (2 trials: RR 0.66, 95% CI 0.42–1.04). In the observational studies, offering accelerated ART initiation resulted in a greater likelihood of having started ART within 3 months (two studies: RR 1.53, 95% CI 1.11–2.10). There was a trend toward an increased risk of being lost to follow-up at 6 months (three studies: RR 1.85, 95% CI 0.96–3.55).Conclusion:Accelerated ART initiation can lead to improved clinical outcomes and is likely to be of particular benefit in those settings where extensive patient preparation prior to starting ART results in long delays. These findings informed a WHO recommendation supporting accelerated ART initiation, including same day ART start.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults

“…10 A statistically non-significant trend toward worse viral suppression was observed for those who started ART rapidly in 1 cohort. 10 San Francisco implemented a citywide rapid ART program in which newly diagnosed persons were linked to care within 5 days from diagnosis and offered treatment on the day of their clinic visit. Of 265 newly diagnosed persons, 97% were linked to care (30% within 5 days) and 81% started ART; time from diagnosis to HIV RNA level below 200 copies/mL decreased by more than 50% and time from first care visit to ART decreased from 27 days to 1 day.…”

Rapid initiation of antiretroviral therapy at HIV diagnosis: definition, process, knowledge gaps

“…Ford et al . observed a trend towards loss to follow up at 6 months in his meta‐analysis of those who rapidly initiated ART, but this finding was not statistically significant (RR 1.85, 95% CI 0.96–3.55).…”

“…standard of care . Reproduced with permission . ART, antiretroviral therapy; CI, confidence interval; LTFU, long‐term follow‐up.…”

Providing antiretroviral therapy to all who are HIV positive: the clinical, public health and programmatic benefits of Treat All

“…In considering the potential programmatic benefits of Treat All , particular value was placed on the potential reduce the substantial loss to care among pre‐ART patients who had been diagnosed with HIV infection but were not yet eligible to start ART. A systematic review of retention in care prior to starting ART found that 41% of patients were lost to care in the step between testing HIV positive and being assessed for eligibility for treatment (by CD4 cell count or clinical stage), and 32% of patients were lost between determination of eligibility and starting ART Rapid initiation of ART, including starting ART on the same day that a positive HIV diagnosis is made, is now strongly by WHO as a way to reduce losses to care during this pre‐ART period .…”

“…Clinical and implementation research continue to provide important insights into the effectiveness of treating all persons living with HIV. Data from the START trial have found that immediate ART led to improved quality of life , and the programmatic benefits of early and rapid ART initiation in terms of reducing pre‐ART loss‐to‐care can be substantial .…”