The effect of adherence to guidelines for initial antiretroviral therapy on 1-year outcomes: a French cohort study

Background: Guidelines for antiretroviral treatment (cART) are published regularly, but there is little information regarding the effect of adherence to guidelines on patient outcomes. We assessed the effect of following the "when-to-start" and "what-to-start" guidelines, on treatment modifications, and on immunological and virological outcome at 12 months in a cohort of HIV-1 infected patients initiating cART from 2000 to 2010. Methods: Consecutive HIV-1 infected patients, antiretroviral naive, initiating cART from 2000 to 2010 at a University Hospital were enrolled. HIV-2 infection, cART for prevention of mother-to-child transmission or during primary HIV-infection and unlicensed drugs were excluded. The respect or not of the "when-to-start" and "what-to-start" guidelines was based on French guidelines published from 2000 to 2010. Factors associated with cART modifications at 12 months and factors associated with an HIV viral load of <50 copies/mL at 12 months were assessed by univariate and multivariate logistic regression modeling. Variations in CD4 counts from baseline were assessed by univariate and multivariate linear regression. Results: Of 1365 patients starting cART, 151 were treated outside "when-to-start" guidelines and 150 were treated outside "what-to-start" guidelines. Not using "when-to-start" guidelines was mainly related to early initiation in young men having sex with men, and was not associated with a significantly different outcome at 12 months. Treatments that did not follow "what-to-start" guidelines were not observed in any specific population and were associated with more treatment modifications and a poorer virological outcome at 12 months. Conclusions: Adherence to "what-to-start" guidelines is associated with a better outcome at 12 months in HIV-infected patients initiating antiretroviral therapy. Efforts should be made to promote adherence to these guidelines.