ASHM Report Back
Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.
I've just attended the presentation of the findings from the START trial (the Strategic Timing of Antiretroviral Treatment), presented by the principal investigator Dr Jens Lundgren from Denmark.
The message conveyed was that the evidence is now clear that commencing treatment at diagnosis of HIV confers definite advantages to the individual regardless of their CD4 count.
The study randomized 4685 people to go onto immediate ART or to delay treatment until CD4 was below 350.
The primary endpoint was serious AIDS and non-AIDS events or death.
It was a multi-centre trial, with 35% of participants from Europe, 25% from Latin America, 21% from Africa, 11% from North America, 8% from Asia and 2% from Australia. Of the participants 27% were female, 30% were black, 55% acquired HIV through MSM, 38% heterosexual transmission, and 32% were smokers. The median time since diagnosis was 1 year, the median CD4 was 650 and median viral load 12,000.
The trial was terminated early due to a clear advantage in the early treatment arm.
It was interesting to see that there was no difference in reported treatment-related adverse events in the two groups; in other words it did not appear that starting treatment earlier resulted in extra adverse events for those patients.
There was a sub analysis of the outcomes at different CD4 counts, and it showed that there was still an advantage to starting treatment early even if CD4 counts were above 800. I would have liked to see more discussion about this, as the key question for many of our patients is about starting therapy with high CD4 counts, and the slides presenting this data were rather difficult to interpret for a non-statistician like me.
The room was abuzz with excitement when panel member Gottfried Hirnschall from WHO announced that the new guidelines being released by WHO in September will be recommending treatment for all people with HIV at all ages regardless of CD4 count.
The ensuing panel discussion was less of a discussion and more of a series of statements, mostly focusing on what the implications are for the future, and what the impediments are to global implementation of early treatment.