Early initiation of antiretroviral therapy significantly improves HIV survival [Classics Series]

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1. The relative risk of death was significantly higher in patients who deferred antiretroviral therapy compared to those who initiated treatment early on

2. This finding remained significant after adjustment for independent risk factors of age, history of injection drug use and HCV infection

Original Date of Publication: April 30, 2009

Study Rundown: All-cause mortality was significantly higher in patients who deferred antiretroviral therapy until CD4+ counts fell below two thresholds of 350 and 500 cells per cubic millimetre. This effect remained significant after adjustment for independent risk factors of age, history of injection drug use and HCV infection. The improvement in survival associated with early treatment initiation may be the result of earlier control of viral replication or protection of immune function. Strengths of the study include the large sample size and measurement of survival as a primary outcome. Limitations of the study include those inherent to an observational study design. Many unknown risk factors can only be controlled for using a randomized design. It remains unclear at what point an asymptomatic HIV-infected patient should initiate antiretroviral therapy to balance the benefit of treatment with toxicity, but this study contributes to the body of evidence supporting earlier treatment. In sum, early initiation of antiretroviral therapy may improve survival in HIV-infected individuals.

Click to read study in NEJM

Relevant Reading:

1. Antiretroviral therapy for HIV infection in adults and adolescents
2. Antiretroviral treatment of adult HIV infection: 2012 Recommendations of the International Antiviral Society – USA Panel

In-Depth [prospective cohort study]: Published in NEJM in 2009, this study analysed data collected by the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Two analyses were conducted on separate patients groups. The first analysis included 8,362 patients who had a baseline CD4+ count of 351 to 500 cells per cubic millimetre. The rate of death from any cause was compared in those who initiated antiretroviral therapy within 6 months of this count (early-therapy group) with those who deferred treatment until CD4+ count fell below this range (deferred-therapy group). The second analysis included 9,155 patients who had a CD4+ count higher than 500 cells per cubic millimetre and made the same comparison between those who initiated therapy early with those who deferred treatment. The relative risk of death was markedly higher in the deferred-therapy group in both analyses.

By Adrienne Cheung, Andrew Cheung, M.D.

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