What are the benefits of and indications for rapid antiretroviral therapy (ART) start (Rapid ART Start) in the management of HIV infection and AIDS?

Updated: Mar 05, 2020
  • Author: Shelley A Gilroy, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

Randomized trials in Lesotho, Haiti, and South Africa showed significant improvements in viral load suppression at 10-12 months of treatment and retention in care with rapid initiation of therapy. [120]

In one study, individuals were randomized to early ART with simplified counseling and point-of-care CD4 cell assays or to standard care. In the intervention group, 80% began ART within 14 days, and 71% started ART the same day of eligibility, compared with 38% and 18%, respectively, in the control group. Virologic suppression at one year was improved in the intervention group (85% vs 75%). San Francisco implemented a citywide rapid ART program in which newly diagnosed persons were linked to care within 5 days of diagnosis and offered treatment on the day of the clinic visit. Of 265 newly diagnosed persons, 97% were linked to care (30% within 5 days) and 81% started ART; time from diagnosis to HIV RNA level below 200 copies/mL decreased by more than 50%, and time from first care visit to ART initiation decreased from 27 days to 1 day. A large HIV clinic in Atlanta implemented rapid access to ART on the day of the initial visit. Median time from initial diagnosis to HIV-1 RNA level below 200 copies/mL decreased from 67 to 41 days; however, the program was not sustainable because of increased patient load and inadequate funding for staffing. [120]

Starting ART on the day of diagnosis requires coordination between testing and treatment setting and access to resources that may limit uptake.

ART initiation, including rapid start, is recommended in all infected ambulatory patients committed to starting ART (unless the patient has symptoms that suggest an opportunistic infection for which immediate ART is contraindicated) and in those with unclear HIV diagnosis (eg, discordant serologic or rapid test results). Treatment with nonucleoside reverse transcriptase inhibitors (NNRTIs) is not recommended for rapid start owing to concerns about transmitted drug resistance (eg, K103N mutation), and abacavir should not be initiated until results of testing for the HLA-B*5701 allele are available. [120]


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