Real-world clinical and economic outcomes from rapid start antiretroviral therapy in HIV: systematic review and meta-analysis.

OBJECTIVE

We aimed to synthesize clinical and economic outcomes of rapid start versus nonrapid antiretroviral therapy (ART) in people with HIV (PWH) in real-world settings.

METHODS

A search was conducted in PubMed, Embase, Web of Science, and ProQuest from January 2017 to January 2023, supplementing a previous search by Ford et al . in 2018. Observational studies investigating clinical or economic outcomes of rapid start ART versus nonrapid ART in PWH were included. Clinical outcomes were mortality, loss-to-follow-up (LTFU), and viral suppression. Economic outcomes were incremental cost-effectiveness ratio (ICER) values and per patient per month (PPPM) costs. Meta-analyses using random-effects models were performed for clinical outcomes, whereas qualitative syntheses were conducted for economic outcomes. The quality of clinical and economic studies was assessed.

RESULTS

Sixty-two studies were included. The pooled adjusted risk ratio (aRR) for mortality demonstrated a significant reduction in risk of mortality among participants who received rapid start ART compared with nonrapid ART [0.80, 95% confidence interval (CI), 0.65-0.98]. For LTFU at 6 and 12 months, the pooled aRR showed increased LTFU for rapid start ART (1.33, 95% CI, 1.15-1.55 and 1.18, 95% CI, 0.74-1.89 respectively). All cost-effectiveness studies reported cost-saving or cost-effective findings. The PPPM costs of rapid start ART across the first 36 months of treatment were consistently lower than nonrapid ART.

CONCLUSION

Rapid ART is associated with reduced mortality and is cost-effective compared with nonrapid ART in real-world settings. Clinicians and policymakers should consider these findings to facilitate rapid start of ART in PWH. Further research on LTFU in PWH is needed.