The initiation of antiretroviral therapy in 4,685 HIV-positive adult study participants with a CD4+ count of more than 500 cells per cubic millimeter provided net benefits over beginning the same therapy in patients after the CD4+ count had declined to 350 cells per cubic millimeter.
The patients were followed for a mean of 3 years and at study entry the median HIV viral load was 12,759 copies per milliliter, with the median CD4+ count of 651 cells per cubic millimeter. Primary composite end point was any serious AIDS-related events, serious non-AIDS-related events, or death from any cause. Among the finds that resulted in recommendation that patients in the deferred-initiation group be offered antiretroviral therapy were:
• Primary end point occurred in 42 patients in the immediate-initiation group compared with 96 patients in the deferred-initiation group (HR 0.43).
• Hazard ratios for serious AIDS-related and serious non-AIDS-related events were 0.28, respectively.
• 68% of the primary end points occurred in patients with a CD4+ count of more than 500 cells per cubic millimeter.
Citation: Lundgren JD, Babiker AG, Gordin F, et al. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. [Published online ahead of print July 20, 2015]. doi: 10.1056/NEJMoa1506816.
Commentary: Standard therapy recommendations have suggested waiting until the CD4+ count has decreased below a defined threshold, with the threshold being different in different guideline recommendations and having changed over time. This study provides strong evidence that initiation of therapy in HIV-positive adults with a CD4+ count of greater than 500 leads to improved outcomes compared to waiting until a CD4+ count of less than 350. Early initiation of therapy led to a decreased rate of serious AIDS and non-AIDS related events. This information, along with evidence that treatment decreases transmission of disease, suggests important benefit to early initiation of therapy. —Neil Skolnik, MD
This Week's Must Reads
Intensive BP Control & Risk of Dementia, JAMA; ePub 2019 Jan 28; SPRINT MIND Investigators
Outpatient Care for Adults With Primary Care, JAMA Intern Med; ePub 2019 Jan 28; Levine, et al
Antibiotic Therapy in Patients with Asthma, JAMA Intern Med; ePub 2019 Jan 28; Stefan, et al
Outpatient Benzodiazepine Prescribing in US, JAMA Netw Open; 2019 Jan 25; Agarwal, et al
Reduction of Readmissions Through Primary Care, JAMA Netw Open; 2019 Jan 25; Wiest, et al
Must Reads in HIV
Preexposure Prophylaxis to Prevent HIV Acquisition, Can new intervention reduce HIV infections?
Pre-exposure prophylaxis to prevent HIV-1 infection, Just how effective is PrEP?
Initiation of Antiretroviral Therapy for HIV, A look at the benefits and risk