OBJECTIVES: Rapid initiation of antiretroviral therapy (rART) has improved clinical outcomes among persons with HIV (PWH) in clinical trials. This study aims to comprehensively identify and synthesize clinical outcomes of rART vs. non-rapid ART (nrART) in the real world.

METHODS: We performed a systematic literature search in PubMed, Embase, Web of Science, and ProQuest from January 2017 to January 2023. Comparative observational studies investigating the clinical outcomes of rART in PWH were included. The of rART was restricted to ART initiation within 7 days of HIV diagnosis. Quality of studies was assessed using Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I). Meta-analyses were performed using a random-effects model for adjusted risk ratios (aRRs) of studies that reported adjusted effects. Heterogeneity was assessed using I²-statistic and Cochran’s Q test.

RESULTS: A total of 28 studies were included. Seventeen (61%) included data from 2018 or later and 9 (32%) were conducted in the US. We found a significant reduction in risk of mortality among patients who received rART compared to nrART (aRR [ 0.80 [95% CI 0.65, 0.98], 3 studies, I²= 0%, p= 0.74). Regarding LTFU at 6 and 12 months, the pooled estimates indicated increased LTFU for rART (aRR 1.33 [1.15, 1.55], 3 studies, I²= 34%, p= 0.22 and 1.18 [0.74, 1.89], 3 studies, I²= 87%, p< 0.001), respectively. None of the included studies in meta-analyses of LTFU outcomes were conducted in the US. Given insufficient studies, meta-analyses of viral suppression not performed.

CONCLUSIONS: Our study found that rART was associated with a significant decrease in mortality among PWH compared with nrART. Clinicians and policy-makers may consider these findings to facilitate rART in patients with HIV infection.