Early versus deferred antiretroviral therapy initiation and long-term cardiovascular disease outcomes in people with HIV: The START study - Scorecard - MDSpire
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Early versus deferred antiretroviral therapy initiation and long-term cardiovascular disease outcomes in people with HIV: The START study
Clinical Scorecard: Comparison of Immediate and Delayed Antiretroviral Therapy on Long-Term Cardiovascular Outcomes in HIV-Infected Individuals: Findings from the START Trial
At a Glance
Category
Detail
Condition
Cardiovascular disease (CVD) in people with HIV (PHIV)
Key Mechanisms
HIV viremia, chronic inflammation, immune activation, traditional cardiometabolic risk factors, and ART-related toxicities
Target Population
ART-naïve adult people with HIV with CD4+ counts > 500 cells/µL
Care Setting
HIV clinical care and research settings with long-term follow-up
Key Highlights
No difference in long-term CVD event rates between immediate and deferred ART initiation over median 9.3 years follow-up.
Possible cardiovascular benefit of immediate ART initiation observed in female participants but not males.
Traditional CVD risk factors and HIV-specific factors both contribute to increased CVD risk in PHIV.
Guideline-Based Recommendations
Diagnosis
Assess traditional CVD risk factors (hypertension, dyslipidemia, diabetes, smoking) in PHIV.
Monitor HIV-specific factors including viral load, immune activation, and inflammation markers.
Management
Initiate ART promptly to reduce HIV viremia and related inflammation.
Consider cardiovascular risk when selecting antiretroviral agents due to potential toxicities.
Manage traditional CVD risk factors aggressively in PHIV.
Monitoring & Follow-up
Regular follow-up of CD4+ count, viral load, and fasting lipids.
Monitor for development of CVD events including myocardial infarction, stroke, and coronary revascularization.
Long-term surveillance for ART-related metabolic side effects.
Risks
Delayed ART initiation does not reduce CVD events and may miss potential benefits, especially in females.
Certain antiretrovirals may increase risk of MI, dyslipidemia, insulin resistance, and weight gain.
Patient & Prescribing Data
ART-naïve adults with HIV and high CD4+ counts (>500 cells/µL)
Immediate ART initiation reduces overall morbidity and mortality but does not significantly reduce CVD events compared to deferred ART; potential sex-specific cardiovascular benefits warrant further study.
Clinical Best Practices
Evaluate and manage traditional and HIV-specific cardiovascular risk factors in all PHIV.
Start ART promptly regardless of CD4+ count to improve overall outcomes.
Tailor ART regimens considering individual cardiovascular risk profiles.
Maintain long-term follow-up for CVD event surveillance and metabolic monitoring.
Recognize potential sex differences in cardiovascular outcomes related to ART timing.
by Nila J Dharan, Shweta Sharma, Alejandro Arenas-Pinto, Daniel Duprez, Vicente Estrada, Karen Ha, Mariana Angelica Kundro, Rosie Mngqibisa, Henry Mugerwa, David Munroe, Rakan Nasreddine, Tess E Peterson, Irini Sereti, Janine M Trevillyan, Jason V Baker, Gail V Matthews, Andrew N Phillips, for the INSIGHT START Study Group
