Initiatives for early ART

Early antiretroviral therapy (ART) for HIV-positive people improves the prognosis and reduces the risk of transmission to others. Overseas guidelines recommend early ART, and in fact, many treatments are being offered. Japanese guidelines also state that 'initiation of ART is recommended for all HIV-infected patients', but the time taken to start treatment after a positive test is still far from being early. In light of this, Dr Toshifumi Taniguchi, Lecturer, Department of Infection Control and Infectious Diseases, Chiba University Hospital, who has clinical experience in the USA, gave a lecture entitled 'Challenges in initiating early ART'.

Early detection and treatment of HIV infection is important too!

Infectious disease specialist Dr. Toshifumi Taniguchi (Lecturer, Division of Infection Control and Infectious Diseases, Chiba University Hospital) first introduced an initiative at San Francisco General Hospital in the USA. People who test positive for HIV in a screening test are given a 'starter pack' containing a five-day supply of treatment drugs, which they are asked to take before the results of the confirmation test are available. Instead of waiting for the final test results, starting treatment immediately not only reduces the amount of virus in the body faster, but also lowers the risk of transmitting HIV to others.

Global guidelines recommend starting ART regardless of CD4-positive lymphocyte counts, and indeed, even if CD4 counts are not below 500, ART has reduced the incidence of AIDS and non-AIDS-related diseases and reduced the mortality. Some studies have found that starting ART within a week of diagnosis results in increased patient attendance retention (fewer drop-outs), shorter time to viral suppression, lower viral suppression rates and lower mortality rates among HIV-infected people.

Dr. Taniguchi noted that "the earlier treatment is started, the better the clinical course of the HIV-infected person himself/herself, the less anxiety, and the better continuity of care". In Japan, an estimated 25,500 people will be treated with ART in 2020, which is 71% of the infected population. On the other hand, there are approximately 5,000 people who are diagnosed but not have been treated, 5,400 people are diagnosed but not treated. This causes new HIV infections for approximately other 10,000 people.

Although there are some concerns about adopting early ART for some individuals, such as the risk of comorbidities and opportunistic infections, Taniguchi identifies the following four benefits of starting treatment early.
・Good clinical outcomes due to reduced time not treated with ART.
・Greater chances to increase retention in care
・Shorter treatment duration reduces anxiety and increases trust
・Public health benefits: reduced risk of infection.

Early ART was also discussed in a later panel discussion on 'Expanding HIV testing opportunities and early ART in Japan. The panellists were Dr. Toshifumi Taniguchi, Dr. Mayumi Imahashi (NHO Sendai Medical Centre), Dr. Mihoko Yotsumoto (Tokyo Medical University Hospital), Dr. Toshihide Kidokoro (Shinjuku East Exit Testing and Consultation Office, Tokyo) and Dr. Teiichiro Shino (Clinical Research Centre, National Center for Global Health).

With regard to the early introduction of ART, there were comments that review of existing support system is necessary, such as of 'criteria for recognition of immune dysfunction, 'disability certificates' and 'medical care for services and supports for persons with disabilities'. To initiate early ART, discussion of social concerns is important and must be expanded.