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TheBodyPRO.com Covers IAS 2015

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The Day the HIV Treatment Pendulum Stopped Swinging

July 21, 2015

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More sessions trail off the screen to the right, if one has the energy to keep scrolling.

More sessions trail off the screen to the right, if one has the energy to keep scrolling.

People expected the results to be good. But they never expected them to be this good.

An IAS 2015 session entirely devoted to the START study -- the HIV research community's most comprehensive effort yet to determine the value of starting a patient immediately on antiretroviral therapy upon a positive HIV diagnosis, regardless of CD4 count -- was given top billing by the conference organizers. It took place at 11 a.m. on the first full day of the conference, and although it technically competed with six other sessions on the schedule, the layout of the online conference program ensured that the START session would be seen first by anyone browsing the morning's options.

Fortunately, the session didn't disappoint.

It began with a sweeping, 30-minute presentation in which nearly four dozen slides were presented -- and we saw hints of at least a dozen more "backup" slides kept in the wings in case of emergency, or perhaps a particularly challenging follow-up question from the packed audience of more than 1,000 conference delegates. During those 30 minutes, we learned that:

  • At study initiation, the average CD4 count was almost identical between people who were randomized to start HIV treatment immediately and those who deferred.
  • Those numbers quickly separated. After as many as 60 months of follow-up, the immediate-therapy arm had an estimated mean CD4 count 194 cells/mm3 higher than the deferred-therapy arm.
  • People in the immediate-therapy arm had a 57% reduction in their risk of experiencing a serious AIDS-related event, serious non-AIDS event or death relative to people in the deferred-therapy arm.
  • Fifty serious AIDS events (mostly tuberculosis, lymphoma and Kaposi's sarcoma) occurred within the deferred-therapy arm, compared to 14 among the immediate-therapy arm.
  • Forty-seven serious non-AIDS events (usually a cancer diagnosis, onset of cardiovascular disease or death from some other cause) occurred within the deferred-therapy arm, compared to 29 among the immediate-therapy arm.
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  • Twelve people died in the immediate-therapy arm; 21 people died in the deferred-therapy arm.
  • The benefits of immediate therapy were similar regardless of baseline CD4 count or HIV viral load.
  • The benefits of immediate therapy were similar whether people were above or below the age of 35.
  • The benefits of immediate therapy were similar whether people were male or female.
  • The benefits of immediate therapy were similar whether people were black, white or another race.
  • The benefits of immediate therapy were similar whether people were living in a high-income region or not.
  • The benefits of immediate therapy were similar whether people were cigarette smokers or not, and regardless of their Framingham cardiovascular risk score.
  • That said, cardiovascular events in particular occurred at a nearly identical rate regardless of study arm.

Taken as a whole, the results -- which you can read about in considerably more detail in Simon Collins' recap, or by reading the published results for free in the New England Journal of Medicine -- are stunning. Not because they show early HIV treatment works; that was fully expected. Because they show early HIV treatment works so demonstrably well in almost every conceivable way, across ages, sexes, races and risk groups.

During the 90-minute session, one individual did most of the talking. That was Jens Lundgren, M.D., perennial HIV research luminary; you may remember him from another landmark study, D:A:D, which quantified the relative toxicity risks of long-term antiretroviral use. He guided us through the study construction and its results, which ended with about as firm a conclusion as we're ever likely to see in a presentation by a researcher, where findings are typically accompanied by a litany of caveats and limitations. "Combination antiretroviral therapy should be recommended for all HIV-positive persons, regardless of CD4 count," he said. Period. End of story.

When he was done, Lundgren yielded the stage to an all-star lineup of half a dozen high-profile HIV researchers and prominent clinicians, all of whom had spent the past 35 minutes quietly sitting at tables to either side of him as he spoke.

Jens Lundgren, M.D., starts speaking about START, as his top fellow investigators look on.

Jens Lundgren, M.D., starts speaking about START, as his top fellow investigators look on.


Expert Reaction: Silver Linings, With a Hint of Cloud

Onstage research analysis: This kind of thing doesn't happen very often at HIV science meetings. Normally, even when study findings are considered to be major, a single researcher stands at a podium for 10 or 15 minutes, takes the audience on a guided PowerPoint tour of charts, graphs and acknowledgements, receives a round of polite (perhaps even slightly energetic!) applause, and fields a few questions. Then she or he demurely sits down, and the session moves on to its next topic. Any ripples created by the dropping of a single presentation into the HIV research pond are left for the community to discern. There is no special panel of experts sitting on stage to discuss its importance.

For START, however, the conference organizers wanted to make sure the impact of the findings was as direct and profound as possible.

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This article was provided by TheBodyPRO.com. It is a part of the publication The 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention.
 


 

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Please note: Knowledge about HIV changes rapidly. Note the date of this summary's publication, and before treating patients or employing any therapies described in these materials, verify all information independently. If you are a patient, please consult a doctor or other medical professional before acting on any of the information presented in this summary. For a complete listing of our most recent conference coverage, click here.

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