Abstract
In this issue of the Journal, Delva et al. discuss in a Viewpoint our Perspective article published in the New England Journal of Medicine in which we argue for the urgent need for a clinical trial on when to initiate antiretroviral therapy (ART) in HIV-infected patients in sub-Saharan Africa. The authors posit that there is currently sufficient evidence to make informed decisions regarding this issue and consequently individual patients’ autonomy should be the key factor in determining the timing for ART initiation. (Published: 19 August 2013) Citation: De Cock KM and El-Sadr WM. Journal of the International AIDS Society 2013, 16 :18811 http://www.jiasociety.org/index.php/jias/article/view/18811 | http://dx.doi.org/10.7448/IAS.16.1.18811
Highlights
As readers can review our Perspective article, we will not repeat arguments concerning the lack of definitive evidence to guide antiretroviral therapy (ART) initiation, the limited evidence from observational studies nor the limitations of ongoing studies assessing timing for initiation of ART for African settings
Sabin et al carefully reviewed the available observational studies related to early versus deferred ART initiation and highlighted the inconsistent estimates of benefit with regard to mortality, the modest effect size noted with early ART use and the risk of confounding inherent to observational studies [6]
HPTN 052, the sole randomized study included in the former meta-analysis with relevant patient population, did not demonstrate a statistically significant reduction in the incidence of pulmonary tuberculosis, even though the control group initiated ART well below the advised CD4' cell count threshold of 350 cell/mm3 [9]
Summary
As readers can review our Perspective article, we will not repeat arguments concerning the lack of definitive evidence to guide ART initiation, the limited evidence from observational studies nor the limitations of ongoing studies assessing timing for initiation of ART for African settings. With regard to the observational studies the authors cite as evidence in support of early initiation of ART, two of the articles do not provide relevant information to the question of early versus deferred ART [2,3] and the other two are focused on the use of ART in individuals with early or acute HIV infection [4,5].
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