Study authors urge physicians to begin antiretroviral treatment even earlier for HIV patients

Immediate antiretroviral treatment (ART) for people diagnosed with HIV more than doubles their prospects of staying healthy and surviving, according to a major study presented at the International AIDS Society (IAS) 2015 Conference in Vancouver, Canada.

Another study presented at IAS 2015 showed that starting ART early also reduces the risk of transmitting HIV between uninfected heterosexual partners.

“IAS 2015 will be remembered as the definitive moment when the world agreed earlier initiation of treatment is the best way to preserve the health of people living with HIV, and one of the best tools we have to slow HIV transmission to others,” said Julio Montaner, MD, IAS 2015 local co-chair and director of the British Columbia Centre for Excellence in HIV/AIDS. “The new data presented today will inform HIV treatment guidelines worldwide, and inspire governments, funders, and health systems to act to save millions more lives.”

• START study. Study co-chair Jens Lundgren, MD, of the University of Copenhagen, presented full results of the Strategic Timing of Antiretroviral Treatment (START) study, which was halted in May 2015 after preliminary data showed significant health benefits with earlier initiation of HIV treatment regardless of the state of an individual’s immune health. START was conducted in 215 clinics in 35 countries and is the first large-scale randomized clinical trial to establish that all individuals with HIV have a considerably lower risk of developing AIDS or other serious illnesses when they begin treatment right away after diagnosis. The results of the START study were published simultaneously in the New England Journal of Medicine.
• HPTN 052. Study chair Myron Cohen, MD, of the University of North Carolina at Chapel Hill, presented the final results of the landmark HPTN 052 study, which showed that the risk of sexual transmission of HIV was dramatically reduced—by 95%—for the duration of the 10-year study among individuals whose infections were well suppressed by therapy. This trial included 1,171 HIV-serodiscordant, heterosexual couples in Malawi, Zimbabwe, South Africa, Botswana, Kenya, Thailand, Brazil and the United States. An interim data review in May 2015 found that of the total 28 cases of HIV infection among the previously uninfected partners, only 1 case occurred among those couples where the HIV-infected partner began immediate antiretroviral therapy. The new data confirms the significant “treatment as prevention” benefit to early ART for HIV prevention.

Both studies reflect the evolution antiretroviral therapy in HIV research. In 2006, the recommended CD4+ count threshold for starting ART in asymptomatic HIV-infected adults in countries with lower health care resources was 200 cells per cubic millimeter. That was increased in 2013 to 500 cells per cubic millimeter. Now, the SMART study found significant benefit of immediate initiation of ART therapy in HIV-positive patients regardless of cell count.

The next step—implementation of these findings—is much more difficult. Researchers at the IAS 2015 conference banded together to release The Vancouver Consensus, which called upon governments and society as a whole to improve access for diagnosis and treatment of HIV.

The Consensus states: “The world must act rapidly to drive down HIV incidence, death, and long term costs. Yet we are gravely concerned that the global AIDS response is under-resourced and that treatment rationing is too common. Only 10 countries have formally adopted the option for people diagnosed with HIV to start treatment immediately. Many have not fully implemented WHO guidelines to start at CD4 500, years after that recommendation. Further delays threaten not only millions of lives but threaten a resurgence of this pandemic.”

The principal signatories invite physicians to read and sign the consensus atVancouverconsensus.org. 

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