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Updated - Guidelines for the Use of Antiretroviral
Agents in Adults and Adolescents Living with HIV - Oct 17 2017
  Guidelines format restructured - see Tables 6 & 7 below; Dual ART regimens discussed below


Most recently, the published START and TEMPRANO trials provide the evidence for the Panel's recommendation to initiate ART in all patients regardless of CD4 cell count (AI). The results of these two studies are summarized below.
Theoretical Continued Benefit of Early Antiretroviral Therapy Initiation Long After Viral Suppression is Achieved
While the START and TEMPRANO studies demonstrated a clear benefit of immediate ART initiation in individuals with CD4 cell counts >500 cells/mm3, it is plausible that the benefits of early ART initiation continue long after viral suppression is achieved. As detailed in the Poor CD4 Cell Recovery and Persistent Inflammation section, persistently low CD4 counts and abnormally high levels of immune activation and inflammation despite suppressive ART predict an increased risk of not only AIDS events, but also non-AIDS events including kidney disease, liver disease, cardiovascular disease, neurologic complications, and malignancies. Earlier ART initiation appears to increase the probability of restoring normal CD4 counts, a normal CD4/CD8 ratio, and lower levels of immune activation and inflammation.34-39 Individuals initiating ART very early (i.e., during the first 6 months after infection) also appear to achieve lower immune activation levels and better immune function (as assessed by vaccine responsiveness) during ART-mediated viral suppression than those who delay therapy for a few years or more.40-42 Thus, while these questions have yet to be addressed in definitive randomized controlled trials, earlier ART initiation may result in less residual immune dysfunction during treatment, which theoretically may result in reduced risk of disease for decades to come.




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