Rapid Antiretroviral Therapy: Time for a new Standard of Care.
Rapid Antiretroviral Therapy: Time for a new Standard of Care.
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快速抗逆转录病毒治疗：是时候制定新的护理标准了。
DOI：
10.1093/cid/ciaa1171
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发表时间：
2021
期刊：
影响因子：
--
通讯作者：
Colasanti,JonathanA
中科院分区：
文献类型：
--
作者：
Coffey,Susa;Halperin,Jason;Rana,AadiaI;Colasanti,JonathanA
快速抗逆转录病毒治疗 (ART) 是指在诊断出 HIV 后尽快开始 ART，最好是在诊断当天，如果没有，则在进入治疗当天开始（快速 ART 的研究通常使用诊断后≤ 7 天的衡量标准）。支持快速 ART 的证据不断增加，Martin 等人[1] 在本期《临床传染病》中撰写的研究将该证据扩展到急性 HIV 感染和早期 HIV 感染时期。从历史上看，HIV 医学界推迟开始 ART 的原因包括担心 ART 毒性、耐药性遗传屏障较低的药物、耐药性产生时的治疗选择有限、缺乏药物支付来源，以及认为只要 CD4 计数保持在一定阈值以上，未经控制的 HIV 病毒血症造成的伤害有限（现已被证明是错误的）。然而，现在我们对 ART 对 HIV 感染者 (PWH) 以及社区的益处已不再不确定——有效的 ART 既支持 HIV 感染者的健康，又预防 HIV 传播。对于大多数新的艾滋病毒诊断，没有理由推迟 ART。数据来自国际环境中的随机对照研究 [2-4] 和美国的队列研究 [5-8]。已显示出与护理和病毒抑制时间的更好联系，并且表现出令人鼓舞的保留和长期病毒抑制结果。因此，世界卫生组织自 2017 年起推荐快速 ART [9]，美国国际抗病毒协会自 2018 年起推荐[10]，美国卫生与公众服务部自 2019 年起推荐[11]。在大多数情况下，快速 ART 的主要障碍是临床医生缺乏对快速 ART 有效性和安全性的了解，以及快速加入保险计划和获得 ART 的系统级障碍。迄今为止，大多数快速 ART 文献都关注所有新诊断的 HIV 感染者或重新接受护理的患者 [2-8]。马丁等人。特别关注那些在急性和早期 HIV 感染期间被诊断出来的人，并招募参加 2014 年至 2018 年间在加利福尼亚州圣地亚哥进行的一项早期治疗研究。研究队列包括 84 名个体，其中 39.3% 患有急性 HIV 感染，60.7% 患有早期 HIV 感染。平均年龄为 30 岁，近三分之二是拉丁裔或黑人。与其他地方发表的许多研究一样，该群体中吸毒者 (46%) 和生活贫困者 (24%) 的比例很高。从诊断到开始 ART 的中位时间为 4 天（IQR 1-8），其中 69% 在诊断后 7 天内开始 ART。整个队列显示，从预计感染日期到病毒抑制 (VS)（< 50 拷贝/mL 或检测不到）的中位时间为 15.3 周，从 ART 开始到 VS 的中位时间为 7.5 周。自感染之日起第 12、24 和 48 周，分别有 58.3%、79.8% 和 88.1% 达到 VS。重要的是，在感染后 7 天内开始 ART 的 58 名参与者的 VS 率甚至更高：在 12 周、24 周和 48 周时分别为 67.3%、90.9% 和 98.1%。在 26 名急性感染参与者中也发现了类似的趋势，从开始 ART 起病毒抑制的中位时间仍仅为 8 周。模型各不相同，但大多数估计 25%–50% 的新 HIV 传播可能归因于急性 HIV 感染者 [12–14]。正如作者指出的，这可能对在个体病毒血症水平最高的时期中断传播产生巨大影响。快速 ART 队列的数据很明确。那些在 HIV 诊断后立即开始 ART 的人可以实现高 VS 率，并且可以很快实现。在那些患有以下疾病的人中，队列始终显示出长期的病毒抑制……
Rapid antiretroviral therapy (ART) means initiating ART as soon as possible after diagnosis of HIV, ideally on the day of diagnosis and, if not then, on the day of entry to care (studies of rapid ART often use a metric of≤ 7 days from diagnosis). The evidence supporting Rapid ART continues to build, and the study authored by Martin et al.[1], in this issue of Clinical Infectious Diseases extends that evidence to the periods of acute HIV infection and early HIV infection. Historically, the HIV medical community delayed initiation of ART for reasons that included concerns for ART toxicities, drugs with low genetic barrier to resistance, limited treatment options when resistance developed, lack of a payor source for medications, and beliefs (now disproved) that unchecked HIV viremia caused limited harm as long as the CD4 count remained above a certain threshold. Now, however, we have no uncertainties about the benefits of ART for persons with HIV (PWH) as well as for the community—effective ART both supports the health of those with HIV and prevents HIV transmission. There is no reason to delay ART for most new HIV diagnoses. Data from randomized controlled studies from international settings [2–4] and from cohort studies in the US [5–8]. have shown improved linkage to care and time to viral suppression, plus demonstrate encouraging retention and longer-term viral suppression outcomes. Thus, the WHO has recommended Rapid ART since 2017 [9], the International Antiviral Society-USA since 2018 [10], and the Department of Health and Human Services since 2019 [11]. The principle barriers to Rapid ART in most settings are lack of clinician understanding of the effectiveness and safety of Rapid ART and systems-level hurdles to quick enrollment in insurance programs and access to ART. The majority of the Rapid ART literature, to date, focuses on all newlydiagnosed persons with HIV or those re-entering care [2–8]. Martin et al. focus specifically on those diagnosed during acute and early HIV infection and recruited into an early treatment study in San Diego, California, between 2014 and 2018. The study cohort included 84 individuals, 39.3% with acute HIV infection, and 60.7% with early HIV infection. The median age was 30 years old and close to two-thirds were Latinx or Black. This cohort, like many published elsewhere, has a high proportion of individuals with substance use (46%) and living in poverty (24%). The median time from diagnosis to ART initiation was 4 days (IQR 1–8) with 69% initiating ART within 7 days of diagnosis. The overall cohort showed median time from estimated date of infection to viral suppression (VS)(< 50 copies/mL or undetectable) of 15.3 weeks and from ART initiation to VS of 7.5 weeks. At 12, 24, and 48 weeks from date of infection, 58.3%, 79.8%, and 88.1% achieved VS, respectively. Importantly, the 58 participants who initiated ART within 7 days of infection had even higher rates of VS: 67.3%, 90.9%, and 98.1% at 12, 24, and 48 weeks, respectively. Similar trends were found in the 26 participants with acute infection with median time to viral suppression still only 8 weeks from time of ART initiation. Models vary, but most estimate that between 25%–50% of new HIV transmissions may be attributable to people with acute HIV infection [12–14]. As the authors point out, this may have enormous implications for interrupting transmission during a time when individuals have their highest levels of viremia. The data from Rapid ART cohorts are clear. High rates of VS are achieved, and achieved quickly, by those who initiate ART soon after HIV diagnosis. Cohorts consistently show long-term viral suppression among those who …
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影响因子：
6.4
作者：
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通讯作者：
Paraskevis, Dimitrios
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作者：
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作者：
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通讯作者：
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影响因子：
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作者：
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通讯作者：
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