Starting antiretroviral treatment early: an update

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Almost four years ago I wrote a blog post titled “Advocating a treatment that may not help the treated?”, which was in response to the news that starting treatment with antiretroviral drugs immediately rather than waiting until the then standard of falling below a CD4+ count of 250 significantly reduced transmission of HIV among HIV-discordant couples. The study also reported effects on the health of the HIV-infected partner and found that the evidence for any beneficial effects for the person being treated were weak at best.

Fast forward to last week, when NIAID released news that another study (Strategic Timing of AntiRetroviral Treatment, or START), which started widely around the same time I wrote the last blog, found that HIV-infected individuals have a lower risk of developing AIDS or other serious illnesses if they start taking antiretroviral drugs sooner. As I usually complain that people don’t update their beliefs easily, it seems like a good idea to disseminate this new evidence here.
 
The study enrolled about 5,000 individuals with a CD4+ count above 500, whose median age was 36. Half of the group was randomly assigned to take drugs immediately while the other group waited until their count fell under 350 cells/mm3. The study was supposed to continue until the end of 2016, but the interim results were strong enough that an independent data and safety monitoring board recommended the release of the results immediately. Approximately after three years of treatment, the group taking the drugs had 41 instances of serious AIDS events, serious non-AIDS events (such as major cardiovascular, renal and liver disease and cancer), and death. This number compared to 86 such events in the comparison group, for a 53% reduction in risk of experiencing these events. While the incidence of these events is small (about 2.5%) in this young population, the results are nonetheless hopeful and can change the advice given to HIV-infected patients with respect to treatment.
 
I still would like to know more about the long-term effects of being on these drugs to be able weigh against these benefits. This New Yorker article from last December suggested that such effects might not be negligible, with the author stating, “In the United States, a year’s worth of HAART costs many thousands of dollars per patient, and the long-term side effects can be debilitating.”

Still, this is obviously good news. And I’m happy to have been blogging long enough for a question I raised years ago to be answered by a long-term study…

Topics

Authors

Berk Ozler

Lead Economist, Development Research Group, World Bank

Join the Conversation

Nelson
June 02, 2015

Very brave to admit that you were wrong--you had company and the collective hesitation and naysaying contributed to significant delays in people accessing treatment with only 50 percent on treatment worldwide. Hopefully people will now realize that test and treat is far superior to test and wait for both individual and community. Hopefully the WB will now support expanding access to treatment as prevention of illness and death and the spread of HIV. Thank you again for your honesty--do not see many bloggers with your degree of integrity. Bravo!