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.

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