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Montaner JS, Lima VD, Harrigan PR, Lourenço L, Yip B, Nosyk B, Wood E, Kerr T, Shannon K, Moore D, Hogg RS, Barrios R, Gilbert M, Krajden M, Gustafson R, Daly P, Kendall P. Expansion of HAART coverage is associated with sustained decreases in HIV/AIDS morbidity, mortality and HIV transmission: the "HIV Treatment as Prevention" experience in a Canadian setting. PLoS One 2014; 9:e87872. [PMID: 24533061 PMCID: PMC3922718 DOI: 10.1371/journal.pone.0087872] [Citation(s) in RCA: 243] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 12/30/2013] [Indexed: 12/26/2022] Open
Abstract
Background There has been renewed call for the global expansion of highly active antiretroviral therapy (HAART) under the framework of HIV treatment as prevention (TasP). However, population-level sustainability of this strategy has not been characterized. Methods We used population-level longitudinal data from province-wide registries including plasma viral load, CD4 count, drug resistance, HAART use, HIV diagnoses, AIDS incidence, and HIV-related mortality. We fitted two Poisson regression models over the study period, to relate estimated HIV incidence and the number of individuals on HAART and the percentage of virologically suppressed individuals. Results HAART coverage, median pre-HAART CD4 count, and HAART adherence increased over time and were associated with increasing virological suppression and decreasing drug resistance. AIDS incidence decreased from 6.9 to 1.4 per 100,000 population (80% decrease, p = 0.0330) and HIV-related mortality decreased from 6.5 to 1.3 per 100,000 population (80% decrease, p = 0.0115). New HIV diagnoses declined from 702 to 238 cases (66% decrease; p = 0.0004) with a consequent estimated decline in HIV incident cases from 632 to 368 cases per year (42% decrease; p = 0.0003). Finally, our models suggested that for each increase of 100 individuals on HAART, the estimated HIV incidence decreased 1.2% and for every 1% increase in the number of individuals suppressed on HAART, the estimated HIV incidence also decreased by 1%. Conclusions Our results show that HAART expansion between 1996 and 2012 in BC was associated with a sustained and profound population-level decrease in morbidity, mortality and HIV transmission. Our findings support the long-term effectiveness and sustainability of HIV treatment as prevention within an adequately resourced environment with no financial barriers to diagnosis, medical care or antiretroviral drugs. The 2013 Consolidated World Health Organization Antiretroviral Therapy Guidelines offer a unique opportunity to further evaluate TasP in other settings, particularly within generalized epidemics, and resource-limited setting, as advocated by UNAIDS.
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Affiliation(s)
- Julio S.G. Montaner
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
| | - Viviane D. Lima
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - P. Richard Harrigan
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lillian Lourenço
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
| | - Benita Yip
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Evan Wood
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas Kerr
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kate Shannon
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Moore
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert S. Hogg
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Rolando Barrios
- BC Centre for Excellence in HIV/AIDS, Providence Health Care, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Mark Gilbert
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mel Krajden
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Reka Gustafson
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Patricia Daly
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Perry Kendall
- Ministry of Health, Province of British Columbia, Victoria, British Columbia, Canada
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Raffi F, Reynes J. Antiretroviral treatment French guidelines 2013: economics influencing science. J Antimicrob Chemother 2014; 69:1158-61. [PMID: 24443513 DOI: 10.1093/jac/dkt533] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Guidelines for the preferred choice of initial combination antiretroviral therapy in those living with HIV are provided by several national and international committees. Following the recent presentation of the 2013 French guidelines on antiretroviral therapy, there has been a debate regarding whether and/or how economics should influence guideline decisions and to what extent this should counterbalance valid scientific evidence. We discuss here the reasons for the unique nature of some of the proposals made by the French guidelines panel. Indeed, some recommendations are debatable. In the new French guidelines, economic considerations significantly influence and, in some instances, take precedence over the scientific evidence, leading to guidelines that are significantly different from those of other national and international committees.
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Affiliation(s)
- F Raffi
- Infectious Diseases, University Hospital, Nantes, France
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105
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Cambiano V, O'Connor J, Phillips AN, Rodger A, Lodwick R, Pharris A, Lampe F, Nakagawa F, Smith C, van de Laar MJ. Antiretroviral therapy for prevention of HIV transmission: implications for Europe. ACTA ACUST UNITED AC 2013; 18:20647. [PMID: 24308982 DOI: 10.2807/1560-7917.es2013.18.48.20647] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The aim of this review is to summarise the evidence on the population-level effect of antiretroviral therapy (ART) in preventing HIV infections, and to discuss potential implications in the European context of recommending starting ART when the CD4 count is above 350 cells/mm3. The ability of ART to reduce the risk of HIV transmission has been reported in observational studies and in a randomised controlled trial (HPTN 052), in which ART initiation reduced HIV transmission by 96% within serodiscordant couples. As yet, there is no direct evidence for such an effect among men having sex with men or people who inject drugs. HPTN 052 led international organisations to develop recommendations with a higher CD4 threshold for ART initiation. However, there remains a lack of strong evidence of clinical benefit for HIV-positive individuals starting ART with CD4 count above 350 cells/mm3. The main goal of ART provision should be to increase ART coverage for all those in need, based on the current guidelines, and the offer of ART to those who wish to reduce infectivity; increased HIV testing is therefore a key requirement. Other proven prevention means such as condom use and harm reduction for people who inject drugs remain critical.
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Affiliation(s)
- V Cambiano
- Research Department of Infection and Population Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
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