title: Antiretroviral therapy initiation in an Australian cohort: implications for increased use of antiretroviral therapy.
abstract: Human immunodeficiency virus (HIV) management is entering a "universal test and treat" phase, although the benefits from this approach in developed world scenarios are uncertain. We analyzed 79 combination anti-retroviral therapy (cART)-naïve HIV-positive individuals who were intensively prospectively followed from 2004 to 2013. We studied HIV-related illnesses, potential HIV transmissions, impact on sexual behavior, and factors impeding earlier cART initiation. Sixty-eight (86 %) subjects commenced cART at a mean of 6.0 years after diagnosis: 71 % with a CD4 T-cell count <350 cells/μl. A significant minority of subjects (29 %) resisted initiation of cART despite physician recommendation for a mean of 18 months. Only one HIV-related illness occurred in a patient who had not previously recorded a CD4 T-cell count <500 cell/μl, totaling 195 person-years of observation. A 40 % increase in sexually transmitted infections (STIs) occurred after commencing cART. We detected six HIV transmissions in our cohort, all of which were before initiating cART and 5 of them had a prior CD4 T-cell count <500 cells/μl. Illnesses related to cART deferral were rare and most HIV transmissions we detected occurred in people with a prior CD4 T-cell count <500 cells/μl. Our study raises concerns about increasing STI rates after cART initiation. Focusing resources on cART initiation among patients with CD4 T-cell counts <500 cells/μl and enhancing safe sexual practices should remain a priority.
authors.affiliation: Department of Microbiology and Immunology, Peter Doherty Institute, 792 Elizabeth St., Parkville, VIC, 3010, Australia, stratovi@unimelb.edu.au.
authors.forename: I
authors.initials: I
authors.lastname: Stratov
authors.forename: S J
authors.initials: SJ
authors.lastname: Kent
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects*; D001315:Australia / Q000453:epidemiology; D018791:CD4 Lymphocyte Count; D015496:CD4-Positive T-Lymphocytes; D015331:Cohort Studies; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000635:transmission; D006801:Humans; D008297:Male; D008875:Middle Aged; D012749:Sexually Transmitted Diseases / Q000453:epidemiology* / Q000517:prevention & control; D055815:Young Adult