Rapid ART Start

The International AIDS Society (IAS)-USA recently released its 2018 HIV treatment and prevention recommendations. The document is particularly notable for its discussion of "When to Start ART."

The IAS-USA recommends "rapid" or immediate start of ART upon diagnosis of HIV, stating that treatment "should be initiated as soon as possible after diagnosis, including immediately after diagnosis, unless [the] patient is not ready to commit to starting therapy (evidence rating A1a)." IAS-USA recognizes that structural and other barriers may hinder immediate linkage, patient evaluation, and provision of ART, but recommends that testing sites and treatment sites work to resolve any impediments to same-day initiation of ART.

Clinical Bottom Line

These recommendations follow 2017 World Health Organization recommendations to start ART on the same day as HIV diagnosis (and at least within 7 days of diagnosis of HIV). The WHO guidance in turn is based on randomized clinical trials in resource-limited settings showing that provision of immediate ART improved ART uptake, retention in care, virologic suppression, and, in one study, mortality rates. In the United States, pilot studies in several cities have shown that the offer of immediate ART after diagnosis led to substantially earlier linkage to care, earlier ART initiation, and a shorter time to HIV RNA suppression. And, while the DHHS adult and adolescent ARV guidelines, last updated in 2017, consider immediate ART upon diagnosis to be an "investigational" approach, same-day ART initiation has become the standard of care in a number of clinical settings and jurisdictions, including the city of San Francisco (under the aegis of the San Francisco Getting to Zero initiative). More data on the impact of immediate-start protocols in U.S. settings will be forthcoming within the next year or two.

References

• Saag MS, Benson CA, Gandhi RT, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2018 recommendations of the International Antiviral Society-USA Panel. JAMA. 2018 Jul 24;320(4):379-396.
• World Health Organization. Guidelines for Managing Advanced HIV Disease and Rapid Initiation of Antiretroviral Therapy, July 2017. Geneva: World Health Organization; 2017.
• Pilcher CD, Ospina-Norvell C, Dasgupta A, et al. The effect of same-day observed initiation of antiretroviral therapy on HIV viral load and treatment outcomes in a U.S. public health setting. J Acquir Immune Defic Syndr. 2017 Jan 1;74(1):44-51.
• Bacon O, Chin JC, Hsu L, et al. The Rapid Art Program Initiative for HIV Diagnoses (RAPID in San Francisco. In: Program and abstracts of the 2018 Conference on Retroviruses and Opportunistic Infections; March 4-7, 2018; Boston. Abstract 93.
• Halperin J, Butler I, Conner K, et al. Linkage and antiretroviral therapy within 72 hours at a federally qualified health center in New Orleans. AIDS Patient Care STDS. 2018 Feb 1; 32(2): 39–41.
• Colasanti J, Sumitani J, Mehta CC, et al. Implementation of a rapid entry program decreases time to viral suppression among vulnerable persons with HIV in the southern United States. Open Forum Infect Dis. 2018 Jun 28;5(6).
• Getting to Zero San Francisco website (accessed 10/16/2018).
• San Francisco Department of Public Health. San Francisco Program for RAPID ART Initiation and Linkage to Care Standard Operating Procedures. v2: August 2016 (accessed 10/16/2018).
• HHS Panel on Antiretroviral Guidelines for Adults and Adolescents Panel Members and Consultants. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. October 17, 2017 update (accessed 10/16/2018).