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Previous Volume 360:1815-1826 April 30, 2009 Number 18 Next

	Full Text PDF PDA Full Text PowerPoint Slide Set Supplementary Material Perspective by Ford, N. Editorial by Sax, P. E. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background The optimal time for the initiation of antiretroviral therapy for asymptomatic patients with human immunodeficiency virus (HIV) infection is uncertain.

Methods We conducted two parallel analyses involving a total of 17,517 asymptomatic patients with HIV infection in the United States and Canada who received medical care during the period from 1996 through 2005. None of the patients had undergone previous antiretroviral therapy. In each group, we stratified the patients according to the CD4+ count (351 to 500 cells per cubic millimeter or >500 cells per cubic millimeter) at the initiation of antiretroviral therapy. In each group, we compared the relative risk of death for patients who initiated therapy when the CD4+ count was above each of the two thresholds of interest (early-therapy group) with that of patients who deferred therapy until the CD4+ count fell below these thresholds (deferred-therapy group).

Results In the first analysis, which involved 8362 patients, 2084 (25%) initiated therapy at a CD4+ count of 351 to 500 cells per cubic millimeter, and 6278 (75%) deferred therapy. After adjustment for calendar year, cohort of patients, and demographic and clinical characteristics, among patients in the deferred-therapy group there was an increase in the risk of death of 69%, as compared with that in the early-therapy group (relative risk in the deferred-therapy group, 1.69; 95% confidence interval [CI], 1.26 to 2.26; P<0.001). In the second analysis involving 9155 patients, 2220 (24%) initiated therapy at a CD4+ count of more than 500 cells per cubic millimeter and 6935 (76%) deferred therapy. Among patients in the deferred-therapy group, there was an increase in the risk of death of 94% (relative risk, 1.94; 95% CI, 1.37 to 2.79; P<0.001).

Conclusions The early initiation of antiretroviral therapy before the CD4+ count fell below two prespecified thresholds significantly improved survival, as compared with deferred therapy.

Source Information

The authors' affiliations are listed in the Appendix.

This article (10.1056/NEJMoa0807252) was published at NEJM.org on April 1, 2009.

Address reprint requests to Dr. Kitahata at the University of Washington, Harborview Medical Center, 325 Ninth Ave., Box 359931, Seattle, WA 98104, or at kitahata{at}u.washington.edu.

Full Text of this Article

Related Letters:

Early versus Deferred Antiretroviral Therapy for HIV
Buchbinder S. P., Jain V., Hernán M. A., Robins J. M., Gelinck L. B., van der Ende M. E., Arribas J. R., Mora M., Pascual-Pareja J. F., Kitahata M. M., Gange S. J., Moore R. D.
Extract | Full Text | PDF  
N Engl J Med 2009; 361:822-824, Aug 20, 2009. Correspondence

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