Effect of Early versus Deferred Antiretroviral Therapy for HIV on Survival

被引：860

作者：

Kitahata, Mari M. ^{[1
]}

Gange, Stephen J. ^{[2
]}

Abraham, Alison G. ^{[2
]}

Merriman, Barry ^{[2
]}

Saag, Michael S. ^{[3
]}

Justice, Amy C. ^{[4
,5
]}

Hogg, Robert S. ^{[6
,7
]}

Deeks, Steven G. ^{[8
]}

Eron, Joseph J. ^{[9
]}

Brooks, John T. ^{[10
]}

Rourke, Sean B. ^{[11
]}

Gill, M. John ^{[12
]}

Bosch, Ronald J. ^{[13
]}

Martin, Jeffrey N. ^{[8
]}

Klein, Marina B. ^{[14
]}

Jacobson, Lisa P. ^{[2
]}

Rodriguez, Benigno ^{[15
]}

Sterling, Timothy R. ^{[16
]}

Kirk, Gregory D. ^{[2
]}

Napravnik, Sonia ^{[9
]}

Rachlis, Anita R. ^{[11
]}

Calzavara, Liviana M. ^{[11
]}

Horberg, Michael A. ^{[17
]}

Silverberg, Michael J. ^{[17
]}

Gebo, Kelly A. ^{[2
]}

Goedert, James J. ^{[18
]}

Benson, Constance A. ^{[19
]}

Collier, Ann C.

Van Rompaey, Stephen E.

Crane, Heidi M.

McKaig, Rosemary G. ^{[18
]}

Lau, Bryan ^{[2
]}

Freeman, Aimee M. ^{[2
]}

Moore, Richard D. ^{[2
]}

机构：

[1] Univ Washington, Harborview Med Ctr, Seattle, WA 98104 USA

[2] Johns Hopkins Univ, Baltimore, MD USA

[3] Univ Alabama Birmingham, Birmingham, AL USA

[4] Yale Univ, New Haven, CT USA

[5] Vet Affairs Connecticut Healthcare Syst, New Haven, CT USA

[6] British Columbia Ctr Excellence & HIV AIDS, Vancouver, BC, Canada

[7] Simon Fraser Univ, Vancouver, BC, Canada

[8] Univ Calif San Francisco, San Francisco, CA 94143 USA

[9] Univ N Carolina, Chapel Hill, NC USA

[10] Ctr Dis Control & Prevent, Atlanta, GA USA

[11] Univ Toronto, Toronto, ON, Canada

[12] Univ Calgary, Calgary, AB, Canada

[13] Harvard Univ, Sch Med, Boston, MA USA

[14] McGill Univ, Montreal, PQ, Canada

[15] Case Western Reserve Univ, Cleveland, OH 44106 USA

[16] Vanderbilt Univ, Nashville, TN USA

[17] Kaiser Permanente No Calif, Oakland, CA USA

[18] NIH, Bethesda, MD 20892 USA

[19] Univ Calif San Diego, San Diego, CA 92103 USA

来源：

NEW ENGLAND JOURNAL OF MEDICINE | 2009年 / 360卷 / 18期

基金：

美国国家卫生研究院; 美国医疗保健研究与质量局;

关键词：

HUMAN-IMMUNODEFICIENCY-VIRUS; CD4 CELL COUNT; DISEASE PROGRESSION; INFECTED PATIENTS; BASE-LINE; HIV-1-INFECTED PATIENTS; COLLABORATIVE ANALYSIS; LYMPHOCYTE COUNTS; VIRAL LOAD; AIDS;

D O I：

10.1056/NEJMoa0807252

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

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.

引用

页码：1815 / 1826

页数：12

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