Identifying Patients With HIV Who May Benefit Most From Immediate ART Initiation

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A new study assessed whether patients at higher absolute risk would benefit more from early initiation of antiretroviral therapy because of the increased magnitude of risk reductions.

The patients who benefit most from immediate initiation of antiretroviral therapy (ART) are asymptomatic, ART-naive older adults with CD4 counts higher than 500 cells/μL and have low CD4 to CD8 ratios or high plasma HIV RNA viral loads, according to results published in the Lancet HIV.

In situations where resources are limited, these patients could potentially be prioritized for treatment.

This post hoc subgroup analysis looked at participants of the START trial ( identifier: NCT00867048), a randomized controlled trial in asymptomatic, HIV-positive adults who were previously untreated with ART. Participants with CD4 counts >500 cells/μL were randomly assigned to receive immediate ART (n=2325) or to defer ART until CD4 counts were <350 cells/μL (n=2359). The primary end point was serious AIDS-defining illnesses, death from AIDS, serious non-AIDS illnesses, or non-AIDS-related death.

For this study, the researchers estimated event rates and absolute risk reduction for participants who had immediate vs delayed ART.

Among participants who received immediate ART, the primary end point occurred 42 times (0.58 events per 100 person-years) compared with 100 times in the deferred ART group (1.37 events per 100 person-years).

The absolute risk reduction was 0.80 (95% CI, 0.48-1.13) per 100 person-years with immediate ART. To prevent 1 event, 126 participants would need to be treated with ART immediately. The highest absolute risk reductions and the lowest numbers needed to treat were found in participants aged 50 years or older, those with CD4 to CD8 ratios of <0.5, and those with plasma HIV RNA viral loads of 50,000 copies/mL or higher.

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“We identified subgroups of people with HIV who will benefit most from immediate initiation of ART,” the researchers wrote. “These people should be prioritised for immediate treatment by policy makers and health-care workers, particularly in low-resource settings.”


Molina JM, Grund B, Gordin F, et al. Which HIV-infected adults with high CD4 T-cell counts benefit most from immediate initiation of antiretroviral therapy? A post-hoc subgroup analysis of the START trial. [published online January 15, 2018]. Lancet HIV. doi: 10.1016/ S2352-3018(18)30003-1