Rapid Initiation of HIV Treatment With ART

Segment Description: Allison Agwu, MD, ScM, provides an overview on the goals of antiretroviral therapy (ART) and the relevance of rapid initiation of therapy.

Interview Transcript (modified slightly for readability):

Joseph Eron, MD: Let’s switch gears a little and talk about antiretroviral therapy. And the first thing is very generally; discuss the goals of antiretroviral therapy. What are we trying to do, Allison?

Allison Agwu, MD, ScM: I think the goals of therapy are first, for the individual, right? And then in that individual, what you’re trying to do is to take the virus that’s in their system and get that to the lowest level that it can be. For what our test can measure, that’s undetectable, which is less than 20 copies per mL. At that level, the virus is not going to “beat up” the person’s immune system, decrease their T-cell count, and then have them progress to more immune suppression and have them have sequelae. That’s the goal. First individually, live long and prosper, for that individual.

What this also does, getting that viral load to minimal level, it decreases the risk of transmission to other individuals, for a pregnant mom to her baby, to the partners, and for someone who’s injecting drugs, to people they’re sharing needles with. There’s a public health benefit in terms of getting that viral load undetectable.

I would also emphasize that there’s an importance psychologically of getting people on therapy as well. Oftentimes we think: viral load, CD4, get that to a good place. But people most likely feel better that they’re doing something to actually take control of their health, that undetectable equals untransmittable. It’s really a powerful message for themselves and empowering for individuals. I think it should be part of the equation when we think about what the benefits are in getting people started as soon as possible.

Joseph Eron, MD: U=U, tell people what this means.

Colleen Kelley, MD, MPH: U=U, as Dr. Agwu said it, undetectable equals untransmittable. I think it’s really been life changing. We’ve all seen it be life changing for people who have HIV to not have concerns about whether they’re going transmit HIV to their partners. And so it’s really been one of the greatest things to watch over the last decade of that transition to understanding that stigma is such an important part of HIV prevention and care, and this is one thing that is slowly chipping away.

Joseph Eron, MD: Yes, it can be de-stigmatizing to really feel that way. I agree, that’s an incredibly important part of it. And sometimes I think as doctors we focus maybe a little bit too much on numbers. I have had, Allison, your experience, when patients see their viral load decreasing, they feel empowered, “I did that.” “You did that, you’re the one who did that. We prescribed the pills, but you took them and you did it.”

Allison Agwu, MD, ScM: Right.

Joseph Eron, MD: It makes a difference I think.

Allison Agwu, MD, ScM: It does. Particularly when we think about a lot of the communities that we work with, they’re so unempowered in so many ways. We talked about social determinants earlier. There are so many things that feel out of their control. “And here is this one thing that I was able to take control of and I did this. And therefore, I don’t have to put up with that person who treats me bad, because I’m actually good, and I am not a bad person.” And we have to really emphasize that. I think that’s why people have really hung on to that U=U message. People have gotten tattoos; it’s really been empowering.

Joseph Eron, MD: Colleen, one of the things that there’s a lot of discussion about is this rapid initiation of therapy. Not only should we get people on therapy, but maybe we should do it really quickly. Can you talk about that?

Colleen Kelley, MD, MPH: Yes. There are a few reasons why we think about getting people on antiretroviral therapy as soon as possible. First, it’s for their own health benefit, like we talked about. As soon as someone is identified HIV-positive, particularly if they’re in that acute seroconversion period, we can preserve the immune system better the earlier we start.

The other reason is so that we can reduce their viral load so that they’re not transmitting on to other partners. And then the third reason that has recently come to light is, it looks like people who receive antiretroviral therapy as soon as they are diagnosed are able to stay on antiretroviral therapy and adhere to the regimen a little bit better than folks who are told, “Oh, come back in 2 weeks, and we’re going to start your medicines in 2 weeks.

It makes a lot of sense, and a lot of places have tried to implement rapid starts, and some places have done it very successfully.

I will say that in our practice in the Southeastern United States, in Atlanta, we’ve found it to be extremely resource-intensive. Because we don’t have necessarily the financial support to get the medications, we oftentimes have folks who are dealing with many other hardships in their lives, like housing and substance use, and childcare and jobs, and lack thereof. Having to deal with that whole person before they’re even ready to get on this new medication and deal with this new diagnosis is challenging. And so I think the jury is still out as to how we can implement rapid start most successfully. But I think most people think it’s a good idea.

Joseph Eron, MD: Biologically it makes a lot of sense with the transmission. Ian, what’s your experience with rapid start?

Ian Frank, MD: Well, I think it’s been what’s been said. I think it’s great to get people on therapy as soon as possible. It’s great to convey a positive message that people can live with this disease. It’s not hard to treat people with HIV. People will survive. They can maintain whatever goals they have in their life. They’re not likely to die of HIV-related complications. And from a public health perspective, the fact that we can tell our patients that, “If your viral load is undetectable, you will not transmit your infection to your sexual partners.” That is very compelling. People don’t want to transmit their infection to anybody else.

That is a really important message. But I agree with Colleen that I don’t think it’s imperative that we start every patient as soon as they’re diagnosed, or at their first visit. There are some people who are not quite ready, and we don’t want people to start and stop. So we’ve got to convey the message that once they start, they’ve got to continue, and they’ve got to be ready for that. Sometimes because of the complexities of the lives of people living with HIV infection, sometimes their priority is not their disease, it’s their partners, it’s their housing stability, it’s their kids, it’s other factors that are higher priorities, and we’ve got to respect that.