Rapid Initiation of Antiretroviral Therapy

William Short, MD, MPH, AAHIVS: When you talk about rapid initiation of antiretrovirals, it’s a hard term to define. Some people define it as: I get an HIV test, I’m diagnosed today. You know, in San Francisco they do wonderful work. A patient gets a diagnosis of HIV, and they’re sent right over to the clinic to start on antiretrovirals right away. That’s not done all over the place. What we typically see is what we call early initiation of antiretrovirals. So those people will get diagnosed and, then, within a week or two, get started on antiretrovirals. So we sort of use both rapid and early to mean the same thing. But if you’re talking truly about rapid, it’s, “I’m diagnosed today. I am brought right to the clinic. I have labs drawn, and then I’m starting on antiretrovirals.” And there are a couple of datasets out there looking at that, and really a couple of different benefits that you see from that. As one, patients are able to get to undetectable in a shorter amount of time, which you would expect because you’re starting on day 1. And then, also, they’re able to remain in care. This is one of our goals when we sort of look at the cascade of care for HIV. How do we keep and retain patients in care? And from some of the studies that are out there now, getting someone to get rapid initiation really does help them stay in care.

So I think the thought process for me is anyone that’s there and is newly diagnosed is a candidate. We know that treatment is for everyone, and the question is, do you start today or do you start a week from now? And I feel there’s no reason to wait a week from now. There’s nothing that I would see on physical examination. There is nothing in labs that would hold me back from starting. I think the one thing where I would be hesitant is if the person had an opportunistic infection. So if I’m meeting the person in the hospital on day 1, and it depends on the opportunistic infection, if someone had a central nervous system process, such as toxoplasmosis or cryptococcal meningitis, I wouldn’t start it right away because they run the risk of immune reconstitution, inflammatory signal. But for the most part, there’s really not a reason not to start.

We have access to drugs. We have access to programs that patients can get drugs right away. So there really is no reason not to start. One reason: Unless the patient is not ready to start. And I think that’s an important message. If the patient is unwilling to start and the provider wants to start, listen to the patient because the patient will not start if they’re not ready.