Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection

Jens D Lundgren; Abdel G Babiker; Fred Gordin; Sean Emery; Birgit Grund; Shweta Sharma; Anchalee Avihingsanon; David A Cooper; Gerd Fätkenheuer; Josep M Llibre; Jean-Michel Molina; Paula Munderi; Mauro Schechter; Robin Wood; Karin L Klingman; Simon Collins; H Clifford Lane; Andrew N Phillips; James D Neaton; INSIGHT START Study Group

doi:10.1056/nejmoa1506816

Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection

Jens D Lundgren, Abdel G Babiker, Fred Gordin, Sean Emery, Birgit Grund, Shweta Sharma, Anchalee Avihingsanon, David A Cooper, Gerd Fätkenheuer, Josep M Llibre, Jean-Michel Molina, Paula Munderi, Mauro Schechter, Robin Wood, Karin L Klingman, Simon Collins, H Clifford Lane, Andrew N Phillips, James D Neaton, INSIGHT START Study Group

Department of Clinical Medicine

1548 Citations (Scopus)

Abstract

Background Data from randomized trials are lacking on the benefits and risks of initiating antiretroviral therapy in patients with asymptomatic human immunodeficiency virus (HIV) infection who have a CD4+ count of more than 350 cells per cubic millimeter. Methods We randomly assigned HIV-positive adults who had a CD4+ count of more than 500 cells per cubic millimeter to start antiretroviral therapy immediately (immediate-initiation group) or to defer it until the CD4+ count decreased to 350 cells per cubic millimeter or until the development of the acquired immunodeficiency syndrome (AIDS) or another condition that dictated the use of antiretroviral therapy (deferred-initiation group). The primary composite end point was any serious AIDS-related event, serious non-AIDS-related event, or death from any cause. Results A total of 4685 patients were followed for a mean of 3.0 years. At study entry, the median HIV viral load was 12,759 copies per milliliter, and the median CD4+ count was 651 cells per cubic millimeter. On May 15, 2015, on the basis of an interim analysis, the data and safety monitoring board determined that the study question had been answered and recommended that patients in the deferred-initiation group be offered antiretroviral therapy. The primary end point occurred in 42 patients in the immediate-initiation group (1.8%; 0.60 events per 100 personyears), as compared with 96 patients in the deferred-initiation group (4.1%; 1.38 events per 100 person-years), for a hazard ratio of 0.43 (95% confidence interval [CI], 0.30 to 0.62; P<0.001). Hazard ratios for serious AIDS-related and serious non-AIDS-related events were 0.28 (95% CI, 0.15 to 0.50; P<0.001) and 0.61 (95% CI, 0.38 to 0.97; P = 0.04), respectively. More than two thirds of the primary end points (68%) occurred in patients with a CD4+ count of more than 500 cells per cubic millimeter. The risks of a grade 4 event were similar in the two groups, as were the risks of unscheduled hospital admissions. Conclusions The initiation of antiretroviral therapy in HIV-positive adults with a CD4+ count of more than 500 cells per cubic millimeter provided net benefits over starting such therapy in patients after the CD4+ count had declined to 350 cells per cubic millimeter.

Original language	English
Journal	New England Journal of Medicine
Volume	373
Issue number	9
Pages (from-to)	795-807
Number of pages	13
ISSN	0028-4793
DOIs	https://doi.org/10.1056/nejmoa1506816
Publication status	Published - 27 Aug 2015

Keywords

Adult
Anti-Retroviral Agents
Asymptomatic Diseases
CD4 Lymphocyte Count
Female
Follow-Up Studies
HIV
HIV Seropositivity
Humans
Kaplan-Meier Estimate
Male
RNA, Viral
Time-to-Treatment
Viral Load

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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https://www.arca.fiocruz.br/bitstream/icict/29591/2/Initiation%20of%20Antiretroviral%20Therapy%20in%20Early%20Asymptomatic%20HIV%20Infection_Beatriz_Grinsztejn_etal_INI_Lapclin-AIDS_2015.pdf

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Lundgren, J. D., Babiker, A. G., Gordin, F., Emery, S., Grund, B., Sharma, S., Avihingsanon, A., Cooper, D. A., Fätkenheuer, G., Llibre, J. M., Molina, J-M., Munderi, P., Schechter, M., Wood, R., Klingman, K. L., Collins, S., Lane, H. C., Phillips, A. N., Neaton, J. D., & INSIGHT START Study Group (2015). Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. New England Journal of Medicine, 373(9), 795-807. https://doi.org/10.1056/nejmoa1506816

Lundgren, JD, Babiker, AG, Gordin, F, Emery, S, Grund, B, Sharma, S, Avihingsanon, A, Cooper, DA, Fätkenheuer, G, Llibre, JM, Molina, J-M, Munderi, P, Schechter, M, Wood, R, Klingman, KL, Collins, S, Lane, HC, Phillips, AN, Neaton, JD & INSIGHT START Study Group 2015, 'Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection', New England Journal of Medicine, vol. 373, no. 9, pp. 795-807. https://doi.org/10.1056/nejmoa1506816

@article{a9f179b2437e42cbb63aec037b1c1a2e,

title = "Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection",

abstract = "Background Data from randomized trials are lacking on the benefits and risks of initiating antiretroviral therapy in patients with asymptomatic human immunodeficiency virus (HIV) infection who have a CD4+ count of more than 350 cells per cubic millimeter. Methods We randomly assigned HIV-positive adults who had a CD4+ count of more than 500 cells per cubic millimeter to start antiretroviral therapy immediately (immediate-initiation group) or to defer it until the CD4+ count decreased to 350 cells per cubic millimeter or until the development of the acquired immunodeficiency syndrome (AIDS) or another condition that dictated the use of antiretroviral therapy (deferred-initiation group). The primary composite end point was any serious AIDS-related event, serious non-AIDS-related event, or death from any cause. Results A total of 4685 patients were followed for a mean of 3.0 years. At study entry, the median HIV viral load was 12,759 copies per milliliter, and the median CD4+ count was 651 cells per cubic millimeter. On May 15, 2015, on the basis of an interim analysis, the data and safety monitoring board determined that the study question had been answered and recommended that patients in the deferred-initiation group be offered antiretroviral therapy. The primary end point occurred in 42 patients in the immediate-initiation group (1.8%; 0.60 events per 100 personyears), as compared with 96 patients in the deferred-initiation group (4.1%; 1.38 events per 100 person-years), for a hazard ratio of 0.43 (95% confidence interval [CI], 0.30 to 0.62; P<0.001). Hazard ratios for serious AIDS-related and serious non-AIDS-related events were 0.28 (95% CI, 0.15 to 0.50; P<0.001) and 0.61 (95% CI, 0.38 to 0.97; P = 0.04), respectively. More than two thirds of the primary end points (68%) occurred in patients with a CD4+ count of more than 500 cells per cubic millimeter. The risks of a grade 4 event were similar in the two groups, as were the risks of unscheduled hospital admissions. Conclusions The initiation of antiretroviral therapy in HIV-positive adults with a CD4+ count of more than 500 cells per cubic millimeter provided net benefits over starting such therapy in patients after the CD4+ count had declined to 350 cells per cubic millimeter.",

keywords = "Adult, Anti-Retroviral Agents, Asymptomatic Diseases, CD4 Lymphocyte Count, Female, Follow-Up Studies, HIV, HIV Seropositivity, Humans, Kaplan-Meier Estimate, Male, RNA, Viral, Time-to-Treatment, Viral Load",

author = "Lundgren, {Jens D} and Babiker, {Abdel G} and Fred Gordin and Sean Emery and Birgit Grund and Shweta Sharma and Anchalee Avihingsanon and Cooper, {David A} and Gerd F{\"a}tkenheuer and Llibre, {Josep M} and Jean-Michel Molina and Paula Munderi and Mauro Schechter and Robin Wood and Klingman, {Karin L} and Simon Collins and Lane, {H Clifford} and Phillips, {Andrew N} and Neaton, {James D} and {INSIGHT START Study Group}",

year = "2015",

month = aug,

day = "27",

doi = "10.1056/nejmoa1506816",

language = "English",

volume = "373",

pages = "795--807",

journal = "New England Journal of Medicine",

issn = "0028-4793",

publisher = "Massachusetts Medical Society",

number = "9",

}

TY - JOUR

T1 - Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection

AU - Lundgren, Jens D

AU - Babiker, Abdel G

AU - Gordin, Fred

AU - Emery, Sean

AU - Grund, Birgit

AU - Sharma, Shweta

AU - Avihingsanon, Anchalee

AU - Cooper, David A

AU - Fätkenheuer, Gerd

AU - Llibre, Josep M

AU - Molina, Jean-Michel

AU - Munderi, Paula

AU - Schechter, Mauro

AU - Wood, Robin

AU - Klingman, Karin L

AU - Collins, Simon

AU - Lane, H Clifford

AU - Phillips, Andrew N

AU - Neaton, James D

AU - INSIGHT START Study Group

PY - 2015/8/27

Y1 - 2015/8/27

N2 - Background Data from randomized trials are lacking on the benefits and risks of initiating antiretroviral therapy in patients with asymptomatic human immunodeficiency virus (HIV) infection who have a CD4+ count of more than 350 cells per cubic millimeter. Methods We randomly assigned HIV-positive adults who had a CD4+ count of more than 500 cells per cubic millimeter to start antiretroviral therapy immediately (immediate-initiation group) or to defer it until the CD4+ count decreased to 350 cells per cubic millimeter or until the development of the acquired immunodeficiency syndrome (AIDS) or another condition that dictated the use of antiretroviral therapy (deferred-initiation group). The primary composite end point was any serious AIDS-related event, serious non-AIDS-related event, or death from any cause. Results A total of 4685 patients were followed for a mean of 3.0 years. At study entry, the median HIV viral load was 12,759 copies per milliliter, and the median CD4+ count was 651 cells per cubic millimeter. On May 15, 2015, on the basis of an interim analysis, the data and safety monitoring board determined that the study question had been answered and recommended that patients in the deferred-initiation group be offered antiretroviral therapy. The primary end point occurred in 42 patients in the immediate-initiation group (1.8%; 0.60 events per 100 personyears), as compared with 96 patients in the deferred-initiation group (4.1%; 1.38 events per 100 person-years), for a hazard ratio of 0.43 (95% confidence interval [CI], 0.30 to 0.62; P<0.001). Hazard ratios for serious AIDS-related and serious non-AIDS-related events were 0.28 (95% CI, 0.15 to 0.50; P<0.001) and 0.61 (95% CI, 0.38 to 0.97; P = 0.04), respectively. More than two thirds of the primary end points (68%) occurred in patients with a CD4+ count of more than 500 cells per cubic millimeter. The risks of a grade 4 event were similar in the two groups, as were the risks of unscheduled hospital admissions. Conclusions The initiation of antiretroviral therapy in HIV-positive adults with a CD4+ count of more than 500 cells per cubic millimeter provided net benefits over starting such therapy in patients after the CD4+ count had declined to 350 cells per cubic millimeter.

AB - Background Data from randomized trials are lacking on the benefits and risks of initiating antiretroviral therapy in patients with asymptomatic human immunodeficiency virus (HIV) infection who have a CD4+ count of more than 350 cells per cubic millimeter. Methods We randomly assigned HIV-positive adults who had a CD4+ count of more than 500 cells per cubic millimeter to start antiretroviral therapy immediately (immediate-initiation group) or to defer it until the CD4+ count decreased to 350 cells per cubic millimeter or until the development of the acquired immunodeficiency syndrome (AIDS) or another condition that dictated the use of antiretroviral therapy (deferred-initiation group). The primary composite end point was any serious AIDS-related event, serious non-AIDS-related event, or death from any cause. Results A total of 4685 patients were followed for a mean of 3.0 years. At study entry, the median HIV viral load was 12,759 copies per milliliter, and the median CD4+ count was 651 cells per cubic millimeter. On May 15, 2015, on the basis of an interim analysis, the data and safety monitoring board determined that the study question had been answered and recommended that patients in the deferred-initiation group be offered antiretroviral therapy. The primary end point occurred in 42 patients in the immediate-initiation group (1.8%; 0.60 events per 100 personyears), as compared with 96 patients in the deferred-initiation group (4.1%; 1.38 events per 100 person-years), for a hazard ratio of 0.43 (95% confidence interval [CI], 0.30 to 0.62; P<0.001). Hazard ratios for serious AIDS-related and serious non-AIDS-related events were 0.28 (95% CI, 0.15 to 0.50; P<0.001) and 0.61 (95% CI, 0.38 to 0.97; P = 0.04), respectively. More than two thirds of the primary end points (68%) occurred in patients with a CD4+ count of more than 500 cells per cubic millimeter. The risks of a grade 4 event were similar in the two groups, as were the risks of unscheduled hospital admissions. Conclusions The initiation of antiretroviral therapy in HIV-positive adults with a CD4+ count of more than 500 cells per cubic millimeter provided net benefits over starting such therapy in patients after the CD4+ count had declined to 350 cells per cubic millimeter.

KW - Adult

KW - Anti-Retroviral Agents

KW - Asymptomatic Diseases

KW - CD4 Lymphocyte Count

KW - Female

KW - Follow-Up Studies

KW - HIV

KW - HIV Seropositivity

KW - Humans

KW - Kaplan-Meier Estimate

KW - Male

KW - RNA, Viral

KW - Time-to-Treatment

KW - Viral Load

U2 - 10.1056/nejmoa1506816

DO - 10.1056/nejmoa1506816

M3 - Journal article

C2 - 26192873

SN - 0028-4793

VL - 373

SP - 795

EP - 807

JO - New England Journal of Medicine

JF - New England Journal of Medicine

IS - 9

ER -

Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection

Abstract

Keywords

UN SDGs

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