Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection: Results from the phase 3 HPTN 052 randomised controlled trial

Beatriz Grinsztejn, Mina C. Hosseinipour, Heather J. Ribaudo, Susan Swindells, Joseph Eron, Ying Q. Chen, Lei Wang, San San Ou, Maija Anderson, Marybeth McCauley, Theresa Gamble, Nagalingeshwaran Kumarasamy, James G. Hakim, Johnstone Kumwenda, Jose H S Pilotto, Sheela V. Godbole, Suwat Chariyalertsak, Marineide Gonçalves De Melo, Kenneth H. Mayer, Susan H. EshlemanEstelle Piwowar-Manning, Joseph Makhema, Lisa A. Mills, Ravindre Panchia, Ian Sanne, Joel Gallant, Irving Hoffman, Taha E. Taha, Karin Nielsen-Saines, David Celentano, Max Essex, Diane Havlir, Myron S. Cohen

Research output: Contribution to journalArticle

259 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)281-290
Number of pages10
JournalThe Lancet Infectious Diseases
Volume14
Issue number4
DOIs
StatePublished - Apr 2014

Fingerprint

HIV Infections
HIV-1
Randomized Controlled Trials
Therapeutics
Acquired Immunodeficiency Syndrome
CD4 Lymphocyte Count
Random Allocation
Tuberculosis
National Institute of Allergy and Infectious Diseases (U.S.)
Intention to Treat Analysis
Incidence
Vascular Diseases
Bacterial Infections

ASJC Scopus subject areas

  • Infectious Diseases

Cite this

Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection : Results from the phase 3 HPTN 052 randomised controlled trial. / Grinsztejn, Beatriz; Hosseinipour, Mina C.; Ribaudo, Heather J.; Swindells, Susan; Eron, Joseph; Chen, Ying Q.; Wang, Lei; Ou, San San; Anderson, Maija; McCauley, Marybeth; Gamble, Theresa; Kumarasamy, Nagalingeshwaran; Hakim, James G.; Kumwenda, Johnstone; Pilotto, Jose H S; Godbole, Sheela V.; Chariyalertsak, Suwat; De Melo, Marineide Gonçalves; Mayer, Kenneth H.; Eshleman, Susan H.; Piwowar-Manning, Estelle; Makhema, Joseph; Mills, Lisa A.; Panchia, Ravindre; Sanne, Ian; Gallant, Joel; Hoffman, Irving; Taha, Taha E.; Nielsen-Saines, Karin; Celentano, David; Essex, Max; Havlir, Diane; Cohen, Myron S.

In: The Lancet Infectious Diseases, Vol. 14, No. 4, 04.2014, p. 281-290.

Research output: Contribution to journalArticle

Grinsztejn, B, Hosseinipour, MC, Ribaudo, HJ, Swindells, S, Eron, J, Chen, YQ, Wang, L, Ou, SS, Anderson, M, McCauley, M, Gamble, T, Kumarasamy, N, Hakim, JG, Kumwenda, J, Pilotto, JHS, Godbole, SV, Chariyalertsak, S, De Melo, MG, Mayer, KH, Eshleman, SH, Piwowar-Manning, E, Makhema, J, Mills, LA, Panchia, R, Sanne, I, Gallant, J, Hoffman, I, Taha, TE, Nielsen-Saines, K, Celentano, D, Essex, M, Havlir, D & Cohen, MS 2014, 'Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection: Results from the phase 3 HPTN 052 randomised controlled trial', The Lancet Infectious Diseases, vol. 14, no. 4, pp. 281-290. https://doi.org/10.1016/S1473-3099(13)70692-3
Grinsztejn, Beatriz ; Hosseinipour, Mina C. ; Ribaudo, Heather J. ; Swindells, Susan ; Eron, Joseph ; Chen, Ying Q. ; Wang, Lei ; Ou, San San ; Anderson, Maija ; McCauley, Marybeth ; Gamble, Theresa ; Kumarasamy, Nagalingeshwaran ; Hakim, James G. ; Kumwenda, Johnstone ; Pilotto, Jose H S ; Godbole, Sheela V. ; Chariyalertsak, Suwat ; De Melo, Marineide Gonçalves ; Mayer, Kenneth H. ; Eshleman, Susan H. ; Piwowar-Manning, Estelle ; Makhema, Joseph ; Mills, Lisa A. ; Panchia, Ravindre ; Sanne, Ian ; Gallant, Joel ; Hoffman, Irving ; Taha, Taha E. ; Nielsen-Saines, Karin ; Celentano, David ; Essex, Max ; Havlir, Diane ; Cohen, Myron S. / Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection : Results from the phase 3 HPTN 052 randomised controlled trial. In: The Lancet Infectious Diseases. 2014 ; Vol. 14, No. 4. pp. 281-290.
@article{18e91d17739449768d78901ae79bbbc7,
title = "Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection: Results from the phase 3 HPTN 052 randomised controlled trial",
abstract = "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.",
author = "Beatriz Grinsztejn and Hosseinipour, {Mina C.} and Ribaudo, {Heather J.} and Susan Swindells and Joseph Eron and Chen, {Ying Q.} and Lei Wang and Ou, {San San} and Maija Anderson and Marybeth McCauley and Theresa Gamble and Nagalingeshwaran Kumarasamy and Hakim, {James G.} and Johnstone Kumwenda and Pilotto, {Jose H S} and Godbole, {Sheela V.} and Suwat Chariyalertsak and {De Melo}, {Marineide Gon{\cc}alves} and Mayer, {Kenneth H.} and Eshleman, {Susan H.} and Estelle Piwowar-Manning and Joseph Makhema and Mills, {Lisa A.} and Ravindre Panchia and Ian Sanne and Joel Gallant and Irving Hoffman and Taha, {Taha E.} and Karin Nielsen-Saines and David Celentano and Max Essex and Diane Havlir and Cohen, {Myron S.}",
year = "2014",
month = "4",
doi = "10.1016/S1473-3099(13)70692-3",
language = "English (US)",
volume = "14",
pages = "281--290",
journal = "The Lancet Infectious Diseases",
issn = "1473-3099",
publisher = "Lancet Publishing Group",
number = "4",

}

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.

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.

UR - http://www.scopus.com/inward/record.url?scp=84896493594&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84896493594&partnerID=8YFLogxK

U2 - 10.1016/S1473-3099(13)70692-3

DO - 10.1016/S1473-3099(13)70692-3

M3 - Article

C2 - 24602844

AN - SCOPUS:84896493594

VL - 14

SP - 281

EP - 290

JO - The Lancet Infectious Diseases

JF - The Lancet Infectious Diseases

SN - 1473-3099

IS - 4

ER -