When Should Antiretroviral Therapy be Initiated in HIV Treatment?

The recommended time to begin antiretroviral therapy (called the ART-start threshold) has changed since ART first arrived in the mid 90s. Now, clinicians are able to prescribe ART more liberally because of its improved adverse event profile and wider array of available drugs. This greatly improved the prognosis for HIV patients.

The electronic resource AIDS Research and Therapy recently published a review article outlining when clinicians should initiate ART. The day of waiting for clinical or immunological signals is gone.

CD4 levels were the previous determinant of when to start ART; clinicians delayed the ART-start due to fear of adverse events.

The current recommendation in international guidelines is to start treating all adults who have HIV regardless of CD4 count. This stems from the findings of 3 major randomized control trials—HPTN 052, Temprano ANRS 12136 and START. The studies enrolled patients with widely varying CD4 counts.

Starting ART early when CD4 counts are high creates benefits such as reducing the individual's viral load and subsequently, the exposure risk for others. It also provides personal benefits such as reducing disease progression and opportunistic infection. In low resource countries where tuberculosis and other bacterial diseases are highly prevalent, the latter benefit is especially important.

This switch—the move to treat everyone regardless of CD4 count—means more people will receive treatment, increasing the financial drain related to medication and testing. This recommendation may challenge low resource areas.

Providers will also need to monitor and encourage patient adherence to prevent resistance. Patients who interrupt treatment at even higher CD4 counts have increased morbidity as demonstrated in the Trivacan and SMART trials.

The researchers report that providers must, “Seek, test, and treat every HIV infected persons, and empower staff and patients to ensure lifelong treatment continuity.”

Reference

Abdool Karim SS. Overcoming impediments to global implementation of early antiretroviral therapy. N Engl J Med. 2015;373(9):875—6.