Antiretroviral Therapy

Why is rapid initiation of ART important?

The Ending the HIV Epidemic (EHE) initiative aims to achieve reductions in new HIV infections in the US of 75% by 2025 and at least 90% by 2030. Globally, the Joint United Nations Program on HIV/AIDS has set a goal of 95-95-95: 95% of PWH to know their HIV status, 95% of people with diagnosed HIV infection to receive ART, and 95% of all people receiving ART to have viral suppression by 2025.4,5 Based on the goals of these initiatives, decreasing new HIV infections and increasing the uptake of test-and-treat strategies have been prioritized. Additionally, results of the START and TEMPRANO trials support expanded HIV guideline recommendations to initiate ART in all PWH, regardless of CD4+ count.6,7 Rapid initiation of ART after diagnosis, defined as same day (immediate start) or at least within a week, reduces the incidence of both AIDS- and nonAIDS–related events through faster and improved rates of virologic suppression.6 By achieving an earlier undetectable viral load (VL), rapid ART can decrease HIV transmission rates (eg, U=U). Additionally, there are some data suggesting that rapid ART improves linkage to care (Table 1).8

The RapIT trial was the first study to evaluate rapid ART initiation compared with standard management and demonstrated that significantly more patients in the rapid arm achieved virologic suppression compared with patients in the standard of care arm.9 In the CASCADE trial, same-day home-based ART initiation after new HIV diagnosis increased rates of linkage to care within 3 months and virologic suppression at 12 months compared with standard of care management.10 The RAPID trial evaluated rapid ART initiation in a high-risk population of patients where 51% had substance use disorder, 48% had a major mental health disorder, and 31% were unstably housed. With more patients in the early referral group achieving virologic suppression than the delayed referral group, this model demonstrated that rapid initiation of ART was not only beneficial, but that it could be achieved even in the presence of barriers.11 The DIAMOND trial evaluated rapid ART initiation with darunavir (DRV)/cobicistat (COBI)/emtricitabine (FTC)/tenofovir alafenamide (TAF) in a patient population that was 75% young MSM, which is similar to the current US population with the highest incidence of new HIV diagnoses. Virologic suppression (<50 copies [c]/mL) was achieved in 84% of patients at week 48 and there were no DRV or TAF resistance–associated mutations (RAMs) observed.12 These published studies demonstrate the benefits of rapid ART in multiple patient populations in terms of increased virologic suppression and linkage to care. It is important to note that all of these studies used different definitions of rapid ART.