Impact of rapid initiation of antiretroviral therapy in people living with HIV

  • Mateo-Urdiales A & al.
  • Cochrane Database Syst Rev
  • 17 Jun 2019

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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Takeaway

  • In people living with HIV (PLWH), rapid initiation of antiretroviral therapy (ART) improves outcomes within 1 week of diagnosis across the HIV treatment cascade in low- and middle-income settings.
  • Co-interventions and health system modifications should be considered along with rapid ART to facilitate rapid delivery of ART and ensure efficacy.

Why this matters

  • With universal ART being adopted worldwide, interventions such as rapid ART are increasingly applicable.
  • Despite the evidence that rapid ART improves linkage and short-term retention in HIV care, their long-term effects remain uncertain, particularly for those who initiate ART on the same day of diagnosis.

Study design

  • Cochrane review of 7 randomised controlled trials (RCTs; n=18,011) that compared rapid ART vs standard care in PLWH.
  • Primary outcome: mortality and virological suppression at 12 months.
  • Secondary outcome: retention in HIV care at 12 months.
  • Funding: Liverpool School of Tropical Medicine and Department for International Development, UK.

Key results

  • At 12 months, rapid ART vs standard care was associated with:
    • greater viral suppression (risk ratio [RR], 1.18; 95% CI, 1.10-1.27; moderate-certainty evidence),
    • better ART uptake (RR, 1.09; 95% CI, 1.06-1.12; moderate-certainty evidence), and
    • improved retention in HIV care (RR, 1.22; 95% CI, 1.11-1.35; low-certainty evidence).
  • At 90 days, rapid ART was associated with better ART uptake vs standard care (RR, 1.31; 95% CI, 1.18-1.45; low-certainty evidence).
  • Very low-certainty evidence showed that rapid ART was associated with lower mortality; however, the 95% CIs included no effect compared with standard care (RR, 0.72; 95% CI, 0.51-1.01).
  • Patients who received rapid ART were more likely to experience treatment modification vs those received standard care (RR, 7.89; 95% CI, 0.76-81.74; very low-certainty evidence).

Limitations

  • Risk of bias.
  • High levels of attrition across studies may have affected mortality outcomes.

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