Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection: results from the phase 3 HPTN 052 randomised controlled trial

详细信息    查看全文

• 作者：Beatriz Grinsztejn ; MD^j ; Mina C Hosseinipour ; MD^d ; ^m ; Heather J Ribaudo ; PhD^f ; Susan Swindells ; MBBS^w ; Joseph Eron ; MD^d ; Ying Q Chen ; PhD^a ; Lei Wang ; PhD^a ; San-San Ou ; MS^a ; Maija Anderson ; MN^a ; Marybeth McCauley ; MPH^r ; Theresa Gamble ; PhD^g ; Nagalingeshwaran Kumarasamy ; MBⁿ ; James G Hakim ; MD^k ; Johnstone Kumwenda ; FRCP^o ; Jose H S Pilotto ; MD^v ; Sheela V Godbole ; MD^h ; Suwat Chariyalertsak ; MD^c ; Marineide Gonç ; alves de Melo ; MDⁱ ; Kenneth H Mayer ; MD^q ; Susan H Eshleman ; MD^e ; Estelle Piwowar-Manning ; MT^e ; Joseph Makhema ; FRCP^p ; Lisa A Mills ; MD^s ; Ravindre Panchia ; MBBCh^u ; Ian Sanne ; MBBCh^u ; Joel Gallant ; MD^e ; Irving Hoffman ; PA^d ; Taha E Taha ; MBBS^b ; Karin Nielsen-Saines ; MD^t ; David Celentano ; ScD^b ; Max Essex ; DVM^f ; Diane Havlir ; MD^l ; Dr Myron S Cohen ; MD^d ; ^{mscohen@med.unc.edu" class="auth_mail} ; the HPTN 052-ACTG Study Team &dagger
• 刊名：The Lancet Infectious Diseases
• 出版年：April, 2014
• 年：2014
• 卷：14
• 期：4
• 页码：281-290
• 全文大小：507 K

文摘

| Figures/TablesFigures/Tables | ReferencesReferences

Summary

Background

Use of antiretroviral treatment for HIV-1 infection has decreased AIDS-related morbidity and mortality and prevents sexual transmission of HIV-1. However, the best time to initiate antiretroviral treatment to reduce progression of HIV-1 infection or non-AIDS clinical events is unknown. We reported previously that early antiretroviral treatment reduced HIV-1 transmission by 96%. We aimed to compare the effects of early and delayed initiation of antiretroviral treatment on clinical outcomes.

Methods

The HPTN 052 trial is a randomised controlled trial done at 13 sites in nine countries. We enrolled HIV-1-serodiscordant couples to the study and randomly allocated them to either early or delayed antiretroviral treatment by use of permuted block randomisation, stratified by site. Random assignment was unblinded. The HIV-1-infected member of every couple initiated antiretroviral treatment either on entry into the study (early treatment group) or after a decline in CD4 count or with onset of an AIDS-related illness (delayed treatment group). Primary events were AIDS clinical events (WHO stage 4 HIV-1 disease, tuberculosis, and severe bacterial infections) and the following serious medical conditions unrelated to AIDS: serious cardiovascular or vascular disease, serious liver disease, end-stage renal disease, new-onset diabetes mellitus, and non-AIDS malignant disease. Analysis was by intention-to-treat. This trial is registered with , number .

Findings

1763 people with HIV-1 infection and a serodiscordant partner were enrolled in the study; 886 were assigned early antiretroviral treatment and 877 to the delayed treatment group (two individuals were excluded from this group after randomisation). Median CD4 counts at randomisation were 442 (IQR 373-522) cells per 渭L in patients assigned to the early treatment group and 428 (357-522) cells per 渭L in those allocated delayed antiretroviral treatment. In the delayed group, antiretroviral treatment was initiated at a median CD4 count of 230 (IQR 197-249) cells per 渭L. Primary clinical events were reported in 57 individuals assigned to early treatment initiation versus 77 people allocated to delayed antiretroviral treatment (hazard ratio 0路73, 95% CI 0路52-1路03; p=0路074). New-onset AIDS events were recorded in 40 participants assigned to early antiretroviral treatment versus 61 allocated delayed initiation (0路64, 0路43-0路96; p=0路031), tuberculosis developed in 17 versus 34 patients, respectively (0路49, 0路28-0路89, p=0路018), and primary non-AIDS events were rare (12 in the early group vs nine with delayed treatment). In total, 498 primary and secondary outcomes occurred in the early treatment group (incidence 24路9 per 100 person-years, 95% CI 22路5-27路5) versus 585 in the delayed treatment group (29路2 per 100 person-years, 26路5-32路1; p=0路025). 26 people died, 11 who were allocated to early antiretroviral treatment and 15 who were assigned to the delayed treatment group.

Interpretation

Early initiation of antiretroviral treatment delayed the time to AIDS events and decreased the incidence of primary and secondary outcomes. The clinical benefits recorded, combined with the striking reduction in HIV-1 transmission risk previously reported, provides strong support for earlier initiation of antiretroviral treatment.

Funding

US National Institute of Allergy and Infectious Diseases.