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Benefits and risks of rapid initiation of antiretroviral therapy

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Background:

Recent attention has focused on the question of how quickly antiretroviral therapy (ART) should be started once HIV diagnosis is confirmed. We assessed whether rapid ART initiation improves patient outcomes.
Methods:

We searched five databases from inception up to August 2017. Rapid ART initiation was defined as initiation within 14 days of HIV diagnosis. Data were pooled using random effects meta-analysis.
Results:

Across the randomized trials, ART start on the same day increased viral suppression at 12 months [three trials: relative risk (RR) 1.17, 95% confidence interval (CI) 1.07–1.27], retention in care at 12 months (RR 1.11, 95% CI 0.99–1.26), and the likelihood of starting ART within 90 days (four trials: RR 1.35, 95% CI 1.13–1.62) and 12 months after eligibility was established (three trials: RR 1.17, 95% CI 1.07–1.27). There was a nonsignificant trend toward reduced mortality (three trials: RR 0.53, 95% CI 0.24–1.08), as well as reduced loss to follow-up at 12 months (2 trials: RR 0.66, 95% CI 0.42–1.04). In the observational studies, offering accelerated ART initiation resulted in a greater likelihood of having started ART within 3 months (two studies: RR 1.53, 95% CI 1.11–2.10). There was a trend toward an increased risk of being lost to follow-up at 6 months (three studies: RR 1.85, 95% CI 0.96–3.55).
Conclusion:

Accelerated ART initiation can lead to improved clinical outcomes and is likely to be of particular benefit in those settings where extensive patient preparation prior to starting ART results in long delays. These findings informed a WHO recommendation supporting accelerated ART initiation, including same day ART start.
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Keywords: antiretroviral therapy; rapid initiation; same day start

Document Type: Research Article

Affiliations: 1: Department of HIV, World Health Organization, Geneva, Switzerland, Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa 2: Department of HIV, World Health Organization, Geneva, Switzerland 3: HIV Unit, Division of Infectious Diseases, Geneva University Hospital, Geneva, Switzerland 4: Médecins sans Frontières, Mbabane, Swaziland 5: School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada 6: HIV/AIDS and STIs Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland 7: University of Rwanda, Kigali, Rwanda 8: Department of Medicine, University of Cape Town Health Sciences Faculty, Cape Town, South Africa 9: Department of Infectious Disease Epidemiology, Imperial College London, London, UK.

Publication date: January 2, 2018

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