TY - JOUR
T1 - Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection
T2 - Results from the phase 3 HPTN 052 randomised controlled trial
AU - Grinsztejn, Beatriz
AU - Hosseinipour, Mina C.
AU - Ribaudo, Heather J.
AU - Swindells, Susan
AU - Eron, Joseph
AU - Chen, Ying Q.
AU - Wang, Lei
AU - Ou, San San
AU - Anderson, Maija
AU - McCauley, Marybeth
AU - Gamble, Theresa
AU - Kumarasamy, Nagalingeshwaran
AU - Hakim, James G.
AU - Kumwenda, Johnstone
AU - Pilotto, Jose H.S.
AU - Godbole, Sheela V.
AU - Chariyalertsak, Suwat
AU - De Melo, Marineide Gonçalves
AU - Mayer, Kenneth H.
AU - Eshleman, Susan H.
AU - Piwowar-Manning, Estelle
AU - Makhema, Joseph
AU - Mills, Lisa A.
AU - Panchia, Ravindre
AU - Sanne, Ian
AU - Gallant, Joel
AU - Hoffman, Irving
AU - Taha, Taha E.
AU - Nielsen-Saines, Karin
AU - Celentano, David
AU - Essex, Max
AU - Havlir, Diane
AU - Cohen, Myron S.
N1 - Funding Information:
This study was supported by the HIV Prevention Trials Network (HPTN) and by grants from the National Institute of Allergy and Infectious Diseases to the HPTN Network Laboratory ( UM1-AI068619, U01-AI068619, UM1-AI068613, and U01-AI068613 ), to the HPTN Statistical and Data Management Center ( UM1-AI068617 and U01-AI068617 ), and to DH, HJR, and SS (U01-AI068636). The National Institute of Allergy and Infectious Diseases assumes all sponsor responsibilities through an investigational new drug application with the US Food and Drug Administration. The antiretroviral drugs used in this study were donated by Abbott Laboratories, Boehringer Ingelheim Pharmaceuticals, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline/ViiV Healthcare, and Merck.
Funding Information:
JE is a consultant to Bristol-Myers Squibb, GlaxoSmithKline, Gilead Sciences, Janssen, Merck, and ViiV HealthCare, and has received research funding to the University of North Carolina (UNC) from GlaxoSmithKline, Abbvie, and Merck. JG has served on scientific advisory boards or has received consulting income from Bristol-Myers Squibb, Gilead Sciences, Janssen Therapeutics, and Merck; has served on a Data Safety Monitoring Board for Takara Bio; and has received research funding to his institution from Bristol-Myers Squibb, Merck, Sangama Bio Sciences, Vertex Pharmaceuticals, and ViiV Healthcare (to Southwest CARE Center) and Gilead Sciences (to Johns Hopkins University and Southwest CARE Center). JGH is on the board of Mylan Pharmaceuticals. DH is principal investigator on an NIH-funded study that receives drugs from Gilead for its participants. KHM has received unrestricted research grants from Merck, Gilead, and Bristol-Myers Squibb. All other authors declare that they have no competing interests.
PY - 2014/4
Y1 - 2014/4
N2 - 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 ClinicalTrials.gov, number NCT00074581. 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 μL in patients assigned to the early treatment group and 428 (357-522) cells per μL 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 μL. Primary clinical events were reported in 57 individuals assigned to early treatment initiation versus 77 people allocated to delayed antiretroviral treatment (hazard ratio 0·73, 95% CI 0·52-1·03; p=0·074). New-onset AIDS events were recorded in 40 participants assigned to early antiretroviral treatment versus 61 allocated delayed initiation (0·64, 0·43-0·96; p=0·031), tuberculosis developed in 17 versus 34 patients, respectively (0·49, 0·28-0·89, p=0·018), 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 24·9 per 100 person-years, 95% CI 22·5-27·5) versus 585 in the delayed treatment group (29·2 per 100 person-years, 26·5-32·1; p=0·025). 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.
AB - 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 ClinicalTrials.gov, number NCT00074581. 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 μL in patients assigned to the early treatment group and 428 (357-522) cells per μL 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 μL. Primary clinical events were reported in 57 individuals assigned to early treatment initiation versus 77 people allocated to delayed antiretroviral treatment (hazard ratio 0·73, 95% CI 0·52-1·03; p=0·074). New-onset AIDS events were recorded in 40 participants assigned to early antiretroviral treatment versus 61 allocated delayed initiation (0·64, 0·43-0·96; p=0·031), tuberculosis developed in 17 versus 34 patients, respectively (0·49, 0·28-0·89, p=0·018), 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 24·9 per 100 person-years, 95% CI 22·5-27·5) versus 585 in the delayed treatment group (29·2 per 100 person-years, 26·5-32·1; p=0·025). 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.
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U2 - 10.1016/S1473-3099(13)70692-3
DO - 10.1016/S1473-3099(13)70692-3
M3 - Article
C2 - 24602844
AN - SCOPUS:84896493594
SN - 1473-3099
VL - 14
SP - 281
EP - 290
JO - The Lancet Infectious Diseases
JF - The Lancet Infectious Diseases
IS - 4
ER -