Changes in inflammatory and coagulation biomarkers: a randomized comparison of immediate versus deferred antiretroviral therapy in patients with HIV infection

Abstract

Objectives: Among a subgroup of participants in the Strategies for Management of Antiretroviral Therapy (SMART) Trial that were naïve to antiretroviral therapy (ART) or off ART (6 months or longer) at study entry, risk of AIDS and serious non-AIDS events were increased for participants who deferred ART compared with those randomized to (re)initiate ART immediately. Our objective was to determine whether ART initiation in this group reduced markers of inflammation and coagulation that have been associated with increased mortality risk in SMART. Changes in these biomarkers have been described after stopping ART, but not after starting ART in SMART.

Methods: Stored specimens for 254 participants (126 drug conservation [DC] and 128 viral suppression [VS]) who were naïve to ART or off ART (6 months or longer) were analyzed for interleukin-6, high sensitivity C-reactive protein, and D-dimer at baseline and Months 2 and 6.

Results: At Month 6, 62% of the VS group had HIV RNA less than 400 copies/mL and median CD4 count was 190 cells/mm3 higher than for the DC group (590 versus 400 cells/mm3). Compared with DC, the VS group had 32% (95% confidence interval, 19%-43%) lower D-dimer levels at Month 6 (P < 0.001); differences were not significant for high sensitivity C-reactive protein or interleukin-6 levels.

Conclusions: In this randomized comparison of immediate versus delayed ART initiation, D-dimer, but not interleukin-6 and high sensitivity C-reactive protein, declined significantly after starting ART. Further studies are needed to determine whether improvements in D-dimer are associated with reduced risk of clinical disease and whether adjunct treatments used in combination with ART can reduce inflammation among individuals with HIV infection.

FIGURE 1. Design And Study Population of No-ART Subgroup in SMART

FIGURE 2. Biomarker Levels with Immediate (VS) versus Deferred (DC) ART

*p-values represent the difference between treatment groups in the change from baseline (on log_e scale) and are adjusted for baseline biomarker level Median levels of hsCRP (A), IL-6 (B) and D-dimer (C) are presented for VS and DC groups at each visit. Error bars represent the inter-quartile range (IQR). The reduction in D-dimer levels was greater after 2 and 6 months of ART (VS) when compared to participants randomized to defer ART (DC). The change in inflammatory biomarkers (hsCRP and IL-6) was not significantly different between treatment groups at the 2 follow-up visits.

FIGURE 3. Biomarker Change Stratified by HIV RNA Level at Month 6 after Starting ART (VS Group)

The 6 month change in biomarker levels (after natural log transformation) for participants randomized to start ART (VS group) are presented for hsCRP (A), IL-6 (B), and D-dimer (C). The mean change (error bars representing 95% CI) in biomarkers at month 6 are shown, stratified by HIV RNA level at month 6. The p-values reported for the association between 6-month biomarker change and HIV RNA level as a continuous variable. The figure demonstrates that significant biomarker changes at month 6 are only apparent for those participants who achieve HIV RNA levels <400 copies/mL.