Higher antiretroviral treatment coverage is associated with lower HIV infection rates: analysis of 51 low and middle-income countries
Andrew Hill, Liverpool University, UKAnton Pozniak, Chelsea and Westminster Hospital, LondonAlice Raymond, Imperial College, LondonKatherine Heath, Imperial College, LondonNathan Ford, World Health Organisation, Geneva
World AIDS Conference, July 2014, Melbourne, Australia [LBPE29]
Background
Antiretroviral treatment lowers the risk of HIV transmission in sero-discordant couples (HPTN 052 trial)
Mathematical modelling studies suggest that HIV transmission could be significantly reduced if more than 80% of HIV infected people are treated with antiretrovirals
Research question
Do countries who treat more people with antiretrovirals have lower rates of new HIV infections, and lower rates of HIV-related death?
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
Methods
UNAIDS database. For each country, standardised estimates for 2012:
Total with HIV-infection
Receiving antiretroviral treatment
New HIV infections
HIV-related deaths
36 African countries were included, plus 15 non-African low and middle-income countries with at least 50,000 HIV-infected individuals.
Data from 7 high-income countries were extracted from published references, but were not included in the correlations of ART coverage versus incidence
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
Methods
Weighted least squares and linear regression methods were used to investigate the association between:
% Treated: percentage of all people with HIV who received ART in 2012
% Incidence: percentage increase in total HIV infections in 2012
% Deaths: percentage of people with HIV who died from HIV in 2012
This analysis looks at ART coverage of the whole population, not just from people eligible for treatment
Linear and non-linear regression models
Multivariate analysis: African / non-African, GDP per capita, PEPFAR inclusion
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
Countries with over 45% HIV-infected people on antiretroviral treatment
_____________________________________________________Country Infected Treated %_____________________________________________________
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
The percentage of all HIV-infected people on antiretroviral treatment, by country
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
USA: 33%
Brazil: 53%
Argentina: 52%
Thailand: 54%
UK: 67%
Botswana: 62%
Countries with <20% HIV-infected people on antiretroviral treatment_____________________________________________________Country Infected Treated %
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
Countries with less than 15% of HIV-infected people on antiretroviral treatment, by country
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
Indonesia: 5%
Madagascar: 0.6%
Somalia: 5%
Reference: Public Health England 2013 Report p.22 - Brown AE et al., 2014
Cascade of HIV care – UK
_x000f_Liv
ing with
HIV
Diagnose
d
_x000e_Li
nked to ca
re
_x0007_In
care
_x0007_O
n ART
_x000f_Adherent t
o ART
_x0018_V
irologica
lly su
ppressed
0%
20%
40%
60%
80%
100%
79%70% 67%
58%
98400
77610
6919865928
57072
Breakpoint in cascade: not diagnosed HIV positive
Living with HIV
Diagnosed Linked to care
In care On ART Adherent to ART
Virologically suppressed
0%
20%
40%
60%
80%
100%
52%44%
38%
26%20%
Breakpoint in cascade: not diagnosed HIV positive
Cascade of HIV care – Georgia
6600
3432
29042508
17161320
Reference: UNAIDS database (2012) – Chkhartishvili et al., 2013
Reference: CDC Fact sheet December 2013 p.2 - Halls et al., 2013
Cascade of HIV care – United States
Living with HIV
Diagnosed Linked to care
In care On ART Adherent to ART
Virologically suppressed
0%
20%
40%
60%
80%
100%
82%
66%
37%33%
25%
1148200
940376
755516
424834375461
290495
Breakpoint in cascade: diagnosed HIV positivebut not treated
• Weighted least squares regression analysis showed that countries with higher ARV coverage rates had
- lower rates of new HIV infections (p<0.0001)
- lower HIV-related death rates (p<0.0001)
• These were both linear correlations – the non-linear models did not improve the strength of the associations.
• In multivariate analyses, these correlations were independent from GDP per-capita, African / non-African regions and PEPFAR support
Results
New HIV infections (percentage growth) versus ART coverage in 51 countries.
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
Death rates from HIV infection versus ART coverage in 51 countries.
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
• According to these analyses, if all 51 low and middle income countries had had the same ART coverage as Botswana (62%), 1,243,647 of the 1,901,800 total HIV infections in 2012 (65%) could have been prevented.
• Under the same conditions, 998,732 of the total 1,427,200 deaths from HIV in 2012 in these 51 countries (70%) could have been avoided.
Results
• This is a cross-sectional analysis of a single year - 2012. However the analysis is being repeated using the new 2013 UNAIDS database, for validation
• There are many other differences between countries which might explain these associations. Countries with better treatment coverage might also have better HIV prevention programmes for example.
• There is variability around the association – some countries have high rates of new infections despite high ARV coverage (e.g. Uganda) or low infection rates despite lower ARV coverage (Niger).
• High income countries have not yet been included
Limitations
Conclusions
Countries with higher ART coverage rates had significantly lower rates of new HIV infection and HIV-related death.
According to this analysis, in 2012, if all 51 countries had antiretroviral coverage rates as high as Botswana (62%).
- 65% of the new HIV infections (1.2/1.9 million) could have been prevented
- 70% of the HIV-related deaths (1/1.4 million) could have been prevented
The results provide a compelling argument for continuing to improve antiretroviral treatment coverage worldwide
Andrew Hill et al. World AIDS Conference 2014 [LBPE29]
