The Importance of Starting ART Early in HIV

In HIV treatment, national and global guidelines recommend initiating antiretroviral therapy (ART) in all patients, regardless of CD4 count. However, several factors can delay ART initiation, including patient acceptance and socioeconomic barriers like health insurance, housing, and substance-abuse.
Now, a study published in the January 2017 issue of the Journal of Acquired Immune Deficiency Syndromes indicates that initiating ART on the same day as HIV diagnosis is feasible without compromising acceptability or safety.
Researchers treated a subset of newly diagnosed patients with HIV according to the Rapid ART Program for Individuals with an HIV Diagnosis (RAPID) protocol, in which they evaluated, assessed, and observed first-dose ART in a same-day appointment. They then compared outcomes with both contemporaneous patients who were not managed according to RAPID protocol and a historic cohort.
Treatment was well-accepted, with 37 of the 39 patients eligible for the RAPID protocol beginning ART within 24-hours. Two of these patients experienced minor toxicity, compared with none in the nonintervention group.
Both groups demonstrated similar rates of loss to follow-up.
Time to virologic suppression was significantly faster in participants who received same-day ART initiation compared to the nonintervention group.
Despite these successes, the intensive appointments required more time from all members of the multidisciplinary care team. For example, issues concerning insurance needed to be immediately addressed to initiate ART that day. This increased both urgency and immediate workload, and also detracted from time typically dedicated to patients’ psychological and social stabilization after diagnosis.
The study demonstrates that HIV treatment can be started successfully on the day of diagnosis while still maintaining similar safety and acceptability as the traditional treatment timeline. Further, the RAPID protocol may shorten time to virologic suppression.
Same-day observed initiation required more time and intensified the process. However, the benefits observed prompt further examination of optimal implementation, impact, and cost-effectiveness of such a program.
 Pilcher C, Ospina-Norvell C, Dasgupta A et al. The Effect of Same-Day Observed Initiation of Antiretroviral Therapy on HIV Viral Load and Treatment Outcomes in a US Public Health Setting. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2017;74(1):44-51. doi:10.1097/qai.0000000000001134.

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