Start HIV antiretroviral therapy as soon as possible, experts urge

WASHINGTON — Early initiation of antiretroviral therapy (ART) in patients with HIV may lead to better outcomes, particularly for people aged 35 and younger, a follow-up analysis of the BEGINNING test showed.

For patients who have delayed ART until their CD4 count is below 350 cells/mm3there was a 21% risk of death or serious health consequences related to AIDS or not during the 5-year period following the start of treatment compared to patients who started ART immediately (P=0.09), reported Abdel G. Babiker, PhD, of University College London, in his presentation at IDWeek.

Even for patients who had a CD4 count greater than 500 cells/mm3 at the time of diagnosis, “it’s better not to delay treatment,” Babiker said MedPage today. “It’s a gradient; the earlier you start, the better. »

Of the patients who had previously delayed ART, 27 progressed to AIDS and 57 died compared to 15 and 47 in the immediate group. Serious health problems unrelated to AIDS, including cardiovascular disease, end-stage renal disease, decompensated liver disease, and non-AIDS-defining cancer, occurred in 88 patients in the delayed group versus 76 in the immediate group.

“These are critically important findings; we need to diagnose people earlier,” said Carlos del Rio, MD, of Emory University School of Medicine in Atlanta. MedPage today.

“Every time you do a blood test on someone who is at risk, you should do an HIV test,” he urged. “People don’t realize they have it until it’s too late.”

While the risk was worse for those who deferred therapy, Babiker noted the risk was there for everyone. “The risk of AIDS was not zero in patients receiving antiretroviral therapy, even among those who had complete viral suppression while receiving antiretroviral drugs. This finding indicates that damage to the immune system can occur early in life. HIV infection.”

However, one finding surprised the researchers: the disastrous results of delayed treatment were even more magnified in patients aged 35 and under.

In this younger age group, 44 patients in the delayed group had events related to the primary endpoint compared to 19 in the immediate group (HR 0.42, 95% CI 0.24-0.71) , whereas these figures were 69 and 70 in patients over 35 (HR 1.04, 95% CI 0.75-1.45; P=0.004).

“The risk seemed to be completely eliminated” in the older age group, Babiker said. His team did not understand why. “Uptake of antiviral therapy and suppression of viral load were very similar; these did not vary by age – we will still do further research on this age difference.”

The START trial was first initiated in 2009, enrolling 4,684 HIV-positive patients (median age 36 years, 27% female), who had CD4 counts ≥ 500 cells/mm3 (median 651 cells/mm3 ) at least 2 weeks apart within 60 days prior to registration. Of these patients, 2325 were randomized to start ART immediately and 2359 were randomized to delay treatment until their CD4 count was ≤ 350 cells/mm3.

In 2015, the results were published in the New England Journal of Medicine, showing that early treatment reduced the risk of serious AIDS-related events, serious non-AIDS-related health problems and death by 57%.

At that time, participants who had been on delayed ART had significantly lower CD4 counts (median 460 cells/mm3range 345-601) compared to participants who started ART immediately (median 648 cells/mm3range 580-764).

Subsequently, all START participants were treated with ART.

The current analysis included 4,436 patients and spanned from January 2016 to December 2021.

  • Ingrid Hein is a writer for MedPage Today covering infectious diseases. She has been a medical journalist for over a decade. Follow

Disclosures

The START trial was supported by the National Institute of Allergy and Infectious Diseases; national research institutes in Australia, Denmark, France, Germany, the United Kingdom and the United States; the University of Minnesota; and AbbVie, Bristol Myers Squibb, Gilead Sciences, GSK/ViiV Healthcare, Janssen Scientific Affairs and Merck.

The study authors reported no disclosures.

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