HIV: immediate antiretroviral therapy lowers the risk for liver fibrosis

  • Dharan NJ & al.
  • Hepatology
  • 8 Oct 2018

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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  • Significant liver fibrosis was rare in antiretroviral therapy (ART)-naïve HIV-positive persons with high CD4 counts.
  • Immediate ART was associated with lower risk for liver fibrosis vs deferred treatment.

Why this matters

  • The findings support current guidance to initiate ART in all patients with HIV irrespective of the CD4 count, particularly considering that modern ART regimens have a lower risk for hepatotoxicity.

Study design

  • START study: 4580 ART-naïve HIV-positive persons with high CD4 counts (>500 cells/μL) received immediate ART (2273) or deferred treatment when their CD4 count was
  • Outcomes: fibrosis (AST to platelet ratio index [APRI]>0.5 or fibrosis-4 index [FIB-4]>1.45), significant fibrosis (APRI>1.5 or FIB-4>3.25), hepatic flare and resolution of elevated APRI and FIB-4 scores.
  • Funding: National Institute of Allergy and Infectious Diseases; National Institutes of Health Clinical Center; National Cancer Institute, National Heart, Lung, and Blood Institute; others.

Key results

  • At baseline, confirmed significant fibrosis (APRI>1.5 and FIB-4>3.25) was reported in 1.1% of the patients by either APRI or FIB-4 and 0.3% of patients by both APRI and FIB-4.
  • Median CD4 count was 651 cells/mm3.
  • Immediate ART group participants were at lower risk of developing increased fibrosis scores than deferred group participants (HR, 0.66; P<.001>
  • By both APRI and FIB-4, liver fibrosis markers normalised faster among those in the immediate ART group vs the deferred therapy ART group (HR, 1.58; P
  • Among participants with APRI>0.5, normalisation occurred at a higher rate in the immediate vs deferred group (56.6 vs 40.9 per 100 person-years; HR, 1.63; P<.001>
  • Among participants with FIB-4>1.45, normalisation rates were higher in the immediate vs deferred group (40.6 vs 27.1 per 100 person-years; HR 1.62; P<.001>


  • Findings cannot be generalised to persons with lower CD4 counts or viral hepatitis coinfection.

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