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When to start antiretroviral therapy in people with HIV

UPDATE August 4th 2015:The ASHM Sub-Committee for Guidance on HIV Management Committee recommends that antiretroviral therapy should be initiated in all people with HIV, irrespective of CD4 count, taking into account the following principles:

  1. Antiretroviral therapy (ART) is recommended for all HIV-infected individuals, irrespective of CD4 count, to reduce the risk of disease progression.
  2. The decision to start ART should take into account both personal health benefits and risks, and reduction in transmission risk
  3. Clinicians should regularly discuss the current state of knowledge regarding when to start ART with all individuals with HIV who are not yet on treatment
  4. All decisions to start ART should be made by the individual with HIV, in consultation with their health care providers and on the basis that they are fully informed and supported in their decision making.

This recommendation is consistent with guidance from the US DHHS Panel, which has recently been upgraded to an A1 Recommendation (strong recommendation based on data from randomised controlled trials) due to the publication of the results of the START and TEMPRANO Trials.

Treatment as prevention

Recent data from interim analyses of two cohort studies presented at CROI in 2014 and 2015 reported no transmissions in serodiscordant homosexual male couples with undetectable viral load. This included data from the European PARTNER study (Rodger, 2014) which reported no HIV transmissions in 308 couple years of follow-up when condomless anal intercourse was reported, and the HIV positive partner had undetectable viral load (Rodger, 2014), and data from the Australian-Thai-Brazilian Opposites Attract study, which reported no transmissions when condomless anal intercourse was reported in 89 person years of follow up in couples with viral load less than 200 (Grulich, 2015). Data from these two studies strongly suggest that anti-retrovrial therapy greatly reduces HIV transmission in serodiscrodant homosexiual couples. A very low rate of transmission cannot be ruled out. Follow up continues in both studies and final study results are expected in 2016-17.

References
Rodger A et al. HIV transmission risk through condomless sex if HIV+ partner on suppressive ART: PARTNER Study. 21st CROI, 3-6 March 2014, Boston. Oral late breaker abstract 153LB.

Grulich AE, Bavinton BR, Jin F, Prestage G, Zablotska I, Grinsztejn B, Phanuphak N, Moore R, Koelsch KK on behalf of the Opposites Attract Study Group. HIV Transmission in Male Serodiscordant Couples in Australia, Thailand and Brazil. Presented at CROI, Seattle, 2015

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