ABSTRACT & COMMENTARY
ART for Life's Sake: The Profound affect of Antiretroviral Therapy on HIV in Africa
Antiretroviral therapy could save 28 million life-years by 2030
By Dean L. Winslow, MD, FACP, FIDSA
Clinical Professor of Medicine and Pediatrics Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Associate Editor of Infectious Disease Alert
Dr. Winslow is a consultant for Siemens Diagnostic.
SYNOPSIS: Modeling was used to estimate the survival benefits of antiretroviral therapy in patients in South Africa initiating antiretroviral therapy in 2004-2011. Survival benefits ranged from 9.3 to 10.2 life-years across 8 cohorts with a total population lifetime benefit of survival being 21.7 million life-years.
Sources:April MD, et al. The survival benefits of antiretroviral therapy in South Africa. J Infect Dis 2013;(published online Dec 34): 1-9.
Survival benefits in adults attributable to antiretroviral therapy (ART) initiated in South Africa since 2004 were quantified using the Cost-Effectiveness of Preventing AIDS Complications-International model (CEPAC) simulating 8 cohorts of HIV-infected patients initiating therapy each year 2004-2011. Model inputs included cohort-specific CD4+ count at ART initiation, 24 week ART suppressive efficacy (78%), limited second-line ART availability, 36 month retention in care (55%-71%). Lifetime per capita survival benefits ranged from 9.3-10.2 years across the 8 cohorts. Total population estimated lifetime survival benefit was 21.7 million life-years, of which 2.8 million life-years had been realized by December 2012. By 2030 with increased linkage to care and universal second-line ART 28.0 million life-years could be realized.
COMMENTARY
As many as 5.6 million patients in South Africa are estimated to be infected with HIV using UN Programme on HIV/AIDS (UNAIDS) data. AIDS-related deaths exceeded 200,000 per year since 2001, reflecting a huge burden of human suffering. Beginning in about 2004 programs such as the US President's Emergency Plan for AIDS Relief (PEPFAR), other multilateral funding, and philanthropic funding (Bill and Melinda Gates Foundation) began making ART a reality for patients throughout many countries in sub-Saharan Africa, including South Africa. The particular modeling used in this study likely results in conservative estimates of survival benefits of ART. The profound survival benefits become even more impressive over the next 16 years if expanded linkage to care and treatment and universal second-line ART is provided. The model does not take into consideration the benefits of ART on prevention of secondary transmission ("treatment as prevention"), the benefits of prevention of mother-to-child transmission, nor the benefits of ART in children. If these were considered, the survival benefit of ART would be even larger.
In a related paper1, 12 focus countries in Africa (countries receiving the greatest US investments) were compared to 29 nonfocus countries. Tuberculosis incidence, prevalence, and mortality rates were estimated before and after PEPFAR's inception. The relative risk for developing TB, comparing those with and without HIV, was 22.5 for control and 20.0 for focus countries, showing that PEPFAR had a consistent and substantial effect on HIV and TB incidence in focus countries. This highlights the likely link between high levels of investment in HIV care and the effects on diseases such as TB.
Reference
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Lima VD, et al. Potential impact of the US President's Emergency Plan for AIDS Relief on the tuberculosis/HIV coepidemic in selected sub-Saharan African countries. J Infect Dis 2013; 208: 2075-84.
