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 non-rapid 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, 2018. Observational studies investigating clinical or economic outcomes of rapid start ART versus non-rapid 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, while 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 to non-rapid ART (0.80, 95%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 non-rapid ART.

Conclusions: Rapid ART is associated with reduced mortality and is cost-effective compared to non-rapid 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.