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Journal ArticleDOI

HIV Treatment as Prevention: Optimising the Impact of Expanded HIV Treatment Programmes

TL;DR: In re-evaluating the allocation of ART in light of the new data about ART preventing transmission, the goal should be to create policies that maximise epidemiological and clinical benefit while still being feasible, affordable, acceptable, and equitable.
Abstract: Until now, decisions about how to allocate ART have largely been based on maximising the therapeutic benefit of ART for patients. Since the results of the HPTN 052 study showed efficacy of antiretroviral therapy (ART) in preventing HIV transmission, there has been increased interest in the benefits of ART not only as treatment, but also in prevention. Resources for expanding ART in the short term may be limited, so the question is how to generate the most prevention benefit from realistic potential increases in the availability of ART. Although not a formal systematic review, here we review different ways in which access to ART could be expanded by prioritising access to particular groups based on clinical or behavioural factors. For each group we consider (i) the clinical and epidemiological benefits, (ii) the potential feasibility, acceptability, and equity, and (iii) the affordability and cost-effectiveness of prioritising ART access for that group. In re-evaluating the allocation of ART in light of the new data about ART preventing transmission, the goal should be to create policies that maximise epidemiological and clinical benefit while still being feasible, affordable, acceptable, and equitable.

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Citations
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Journal ArticleDOI
01 Dec 2015-PLOS ONE
TL;DR: Activity limitations are potentially experienced by a large portion of people on ART in southern Africa which impacts health and ART adherence negatively, and the importance of better understanding the new health-related needs of people who are on long term ART, as well as the nuances of the disability they experience is highlighted.
Abstract: BACKGROUND: Through access to life saving antiretroviral treatment (ART) in southern Africa HIV has been reconceptualised as a chronic disease. This comes with new challenges of HIV-related co-morbidities and disabilities. We still lack an understanding of the types and scope of disabilities experienced by people on long term ART and how this impacts health adherence and livelihood. This paper describes the results of a cohort study examining the new health- and disability-related needs of the millions of people on ART in the region. METHODS: Data was collected from a cohort of people who had been on ART for six months or longer in a semi-urban public health care setting in South Africa. 1042 adults (18 and older) participated in the cross-sectional study which investigated disabilities/activity limitations health ART adherence depression symptoms and livelihood. We analysed the associations between these constructs using descriptive statistics and bivariate and multivariate analyses. RESULTS: A large number of participants (35.5%) obtained a weighted score of two or more on the WHODAS 2.0 indicating possible activity limitations. A positive relationship was found between activity limitations and depression symptoms adherence and worse health outcomes while none was found for BMI or CD4 count. These associations varied by type of activity limitations and in some cases by gender. CONCLUSION: Activity limitations are potentially experienced by a large portion of people on ART in southern Africa which impacts health and ART adherence negatively. These results highlight the importance of better understanding the new health-related needs of people who are on long term ART as well as the nuances of the disability they experience. This is urgently needed in order to enable HIV-endemic countries to better prepare for the new health-related needs of the millions of people on ART in southern Africa.

63 citations


Cites methods from "HIV Treatment as Prevention: Optimi..."

  • ...We currently promote ART both in order to achieve maximum therapeutic benefits and for treatment as prevention [13]....

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Journal ArticleDOI
01 Jan 2014-AIDS
TL;DR: A deterministic model is developed to simulate births, breastfeeding, and HIV infection in women in four countries, Kenya, Zambia, South Africa, and Vietnam that differ in fertility rate, birth interval, age at first birth, and breastfeeding patterns, but have similar age at HIV infection.
Abstract: OBJECTIVE: Most countries follow WHO 2010 guidelines for the prevention of mother-to-child transmission (PMTCT) of HIV using either Option A or B for women not yet eligible for antiretroviral therapy (ART). Both of these approaches involve the use of antiretrovirals during pregnancy and breastfeeding. Some countries have adopted a new strategy Option B+ in which HIV-positive pregnant women are started immediately on ART and continued for life. Option B+ is more costly than Options A or B but provides additional health benefits. In this article we estimate the additional costs and effectiveness of Option B+. METHODS: We developed a deterministic model to simulate births breastfeeding and HIV infection in women in four countries Kenya Zambia South Africa and Vietnam that differ in fertility rate birth interval age at first birth and breastfeeding patterns but have similar age at HIV infection. We estimated the total PMTCT costs and new child infections under Options A B and B+ and measured cost-effectiveness as the incremental PMTCT-related costs per child infection averted. We included adult sexual transmissions averted from ART the corresponding costs saved and estimated the total incremental cost per transmission (child and adult) averted. RESULTS: When considering PMTCT-related costs and child infections Option B+ was the most cost-effective strategy costing between $6000 and $23 000 per infection averted compared with Option A. Option B+ averted more child infections compared with Option B in all four countries and cost less than Option B in Kenya and Zambia. When including adult sexual transmissions averted Option B+ cost less and averted more infections than Options A and B.

48 citations


Cites background from "HIV Treatment as Prevention: Optimi..."

  • ...have been proposals to increase ART eligibility, and, because limited resources constrain universal expansion, there have been suggestions for incremental expansion of eligibility, such as all pregnant women and discordant couples irrespective of CD4þ cell count, raising the CD4þ cell eligibility threshold to less than 500 cells/ml, or all persons with increased risk of HIV infection [6]....

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Journal ArticleDOI
25 Jan 2016-PLOS ONE
TL;DR: Only half of HIV-infected FSW reported current ART use, but the majority of those on ART were virally suppressed, and transmission risk behaviors were not associated with continuum outcomes.
Abstract: OBJECTIVE: The HIV care continuum among female sex workers (FSW) a key population has not been well characterized especially within the generalized epidemics of sub-Saharan Africa. This was the first study to characterize the HIV care continuum among FSW in Lilongwe Malawi. METHODS: From July through September 2014 we used venue-based sampling to enroll 200 adult FSW in Lilongwe Malawi into a cross-sectional evaluation assessing HIV care continuum outcomes. Seropositive FSW identified using HIV rapid testing received rapid CD4 counts in addition to viral loads using dried blood spots. We calculated proportions of HIV-infected FSW who had history of care were on ART and had suppressed viral load and we used Poisson regression to estimate the associations of demographic characteristics and transmission risk behaviors with each outcome. RESULTS: HIV seroprevalence was 69% (n = 138). Among all FSW the median age was 24 years (IQR: 22-28). Among the 20% who were newly diagnosed and reported previously testing negative the median time since last HIV test was 11 months (interquartile range: 3-17). The majority (69%) of HIV-infected FSW had a history of HIV care 52% reported current ART use and 45% were virally suppressed. Of the FSW who reported current ART use 86% were virally suppressed. Transmission risk behaviors were not associated with continuum outcomes. CONCLUSIONS: FSW in Lilongwe were predominately young and have a high HIV prevalence. Only half of HIV-infected FSW reported current ART use but the majority of those on ART were virally suppressed. To reduce ongoing transmission and improve health outcomes increased HIV testing care engagement and ART coverage is urgently needed among FSW. Universal testing and treatment strategies for all FSW in Malawi must be strongly considered.

45 citations

Journal ArticleDOI
TL;DR: Early ART decreased the estimated risk of HIV transmission by 90%, suggesting a major prevention benefit among seronegative sex partners in stable or casual relationships with seropositive individuals.
Abstract: Background. The effect of early antiretroviral therapy (ART) on sexual behaviors and HIV-1 transmission risk has not been documented beyond the specific population of stable serodiscordant couples.Methods. Based on a behavioral study nested in a randomized controlled trial (Temprano-ANRS12136) of early ART, we compared proportions of risky sex (unprotected sex with a partner of negative/unknown HIV status) reported 12 months after inclusion between participants randomized to initiate ART immediately ('early ART') or according to WHO criteria ('standard ART'). Group-specific HIV-transmission rates were estimated based on sexual behaviors and viral load-specific per-act HIV-1 transmission probabilities. Their ratio was computed to estimate the protective effect of early ART.Results. Among 957 participants (baseline CD4: 478/mm(3)), 46.0% reported sexual activity in the past month, 41.5% of them with non-cohabiting partners. Proportion of risky sex was 10.0% vs. 12.8%, respectively, in participants on early vs. standard ART (p=0.17). Accounting for sexual behaviors and viral load, the estimated protective effect of early ART was 90% (95%CI 81-95%).Conclusion. Twelve months after inclusion, patients on early and standard ART reported similar sexual behaviors. Early ART decreased the estimated risk of HIV transmission by 90%, suggesting a major prevention benefit among both stable and casual partners.

43 citations


Cites background from "HIV Treatment as Prevention: Optimi..."

  • ...The social acceptability and equity of prioritizing access to early ART to this population is questionable, though [37]....

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Journal ArticleDOI
TL;DR: An alternative approach is proposed that provides a better evidence base and outlines a fair policy process to improvepriority setting in HIV treatment in South Africa and holds large potential to improve HIV priority setting in the country.
Abstract: South Africa, the country with the largest HIV epidemic worldwide, has been scaling up treatment since 2003 and is rapidly expanding its eligibility criteria. The HIV treatment programme has achieved significant results, and had 1.8 million people on treatment per 2011. Despite these achievements, it is now facing major concerns regarding (i) efficiency: alternative treatment policies may save more lives for the same budget; (ii) equity: there are large inequalities in who receives treatment; (iii) feasibility: still only 52% of the eligible population receives treatment. Hence, decisions on the design of the present HIV treatment programme in South Africa can be considered suboptimal. We argue there are two fundamental reasons to this. First, while there is a rapidly growing evidence-base to guide priority setting decisions on HIV treatment, its included studies typically consider only one criterion at a time and thus fail to capture the broad range of values that stakeholders have. Second, priority setting on HIV treatment is a highly political process but it seems no adequate participatory processes are in place to incorporate stakeholders’ views and evidences of all sorts. We propose an alternative approach that provides a better evidence base and outlines a fair policy process to improve priority setting in HIV treatment. The approach integrates two increasingly important frameworks on health care priority setting: accountability for reasonableness (A4R) to foster procedural fairness, and multi-criteria decision analysis (MCDA) to construct an evidence-base on the feasibility, efficiency, and equity of programme options including trade-offs. The approach provides programmatic guidance on the choice of treatment strategies at various decisions levels based on a sound conceptual framework, and holds large potential to improve HIV priority setting in South Africa.

39 citations


Cites background from "HIV Treatment as Prevention: Optimi..."

  • ...Research suggests that alternative policies such as universal testing and immediate treatment of all HIV-infected patients (UTT) [9] and targeting specific risk groups [10,11], would be more efficient than the present programme....

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  • ...In addition, there is a growing interest in tailoring HIV treatment guidelines to most efficiently target programmes [10,11]....

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References
More filters
Journal ArticleDOI
TL;DR: In this article, Antiretroviral therapy that reduces viral replication could limit the transmission of human immunodeficiency virus type 1 (HIV-1) in serodiscordant couples.
Abstract: Background Antiretroviral therapy that reduces viral replication could limit the transmission of human immunodeficiency virus type 1 (HIV-1) in serodiscordant couples. Methods In nine countries, we...

5,871 citations

Journal ArticleDOI
TL;DR: These Guidelines were developed by the Panel* on Clinical Practices for Treatment of HIV Infection convened by the Department of Health and Human Services and the Henry J. Kaiser Family Foundation.
Abstract: SUMMARY The availability of an increasing number of antiretroviral agents and the rapid evolution of new information has introduced extraordinary complexity into the treatment of HIV-infected persons. In 1996, the Department of Health and Human Services and the Henry J. Kaiser Family Foundation convened the Panel on Clinical Practices for the Treatment of HIV to develop guidelines for the clinical management of HIV-infected adults and adolescents. This report recommends that care should be supervised by an expert, and makes recommendations for laboratory monitoring including plasma HIV RNA, CD4 cell counts and HIV drug resistance testing. The report also provides guidelines for antiretroviral therapy, including when to start treatment, what drugs to initiate, when to change therapy, and therapeutic options when changing therapy. Special considerations are provided for adolescents and pregnant women. As with treatment of other chronic conditions, therapeutic decisions require a mutual understanding between the patient and the health care provider regarding the benefits and risks of treatment. Antiretroviral regimens are complex, have major side effects, pose difficulty with adherence, and carry serious potential consequences from the development of viral resistance due to non-adherence to the drug regimen or suboptimal levels of antiretroviral agents. Patient education and involvement in therapeutic

4,321 citations

Journal ArticleDOI
TL;DR: The exciting evidence generated by this paper – that antiretroviral treatment of HIV-1 infection definitively reduces the risk of onward transmission of the virus by 96% – was rightly dubbed Science magazine's ‘Breakthrough of the Year’ in 2011.
Abstract: MS Cohen, YQ Chen, M McCauley N Engl J Med 2011 365:493–505. The exciting evidence generated by this paper – that antiretroviral treatment of HIV-1 infection definitively reduces the risk of onward transmission of the virus by 96% – was rightly dubbed Science magazine's ‘Breakthrough of the Year’ in 2011.1 ,2 It has long been known that the probability of sexual transmission of HIV is strongly correlated with concentrations of HIV in blood and genital fluids.3 ,4 Effective antiretroviral therapy (ART) produces prolonged and sustained suppression of HIV replication in these compartments, reducing the amount of free virus.5 ,6 Thus, there has long been a …

4,259 citations


"HIV Treatment as Prevention: Optimi..." refers background or methods in this paper

  • ...The HPTN 052 study [4] demonstrated that earlier ART initiation can reduce heterosexual HIV transmission [5]....

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  • ...Observational and clinical trial data that link transmission events confirm that heterosexual transmissions occur from asymptomatically infected individuals with CD4 counts between 350 and 500 cells/ml [5,11], and the HPTN 052 study demonstrated a 96% reduction in transmission associated with treatment initiation at a CD4 cell count between 350 and 550 cells/ml compared to delaying treatment until CD4 count was below 250 cells/ml [5]....

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  • ...was associated with a 41% increased hazard of adverse clinical outcome [5]....

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  • ...Trial and observational data have demonstrated the efficacy of ART in preventing HIV transmission in stable serodiscordant heterosexual partnerships [5,11], and recent WHO guidelines for stable serodiscordant couples already include offering ART to the HIV-infected partner irrespective of CD4 cell count, in addition to behaviour change counselling [69]....

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  • ...7 per 100 person-years at risk ([5]; among those with CD4 counts of 350–500 cells/ml: [11])....

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Journal ArticleDOI
TL;DR: The viral load is the chief predictor of the risk of heterosexual transmission of HIV-1, and transmission is rare among persons with levels of less than 1500 copies of HIV -1 RNA per milliliter.
Abstract: Background and Methods We examined the influence of viral load in relation to other risk factors for the heterosexual transmission of human immunodeficiency virus type 1 (HIV-1). In a community-based study of 15,127 persons in a rural district of Uganda, we identified 415 couples in which one partner was HIV-1–positive and one was initially HIV-1–negative and followed them prospectively for up to 30 months. The incidence of HIV-1 infection per 100 person-years among the initially seronegative partners was examined in relation to behavioral and biologic variables. Results The male partner was HIV-1–positive in 228 couples, and the female partner was HIV-1–positive in 187 couples. Ninety of the 415 initially HIV-1–negative partners seroconverted (incidence, 11.8 per 100 person-years). The rate of male-to-female transmission was not significantly different from the rate of female-to-male transmission (12.0 per 100 person-years vs. 11.6 per 100 person-years). The incidence of seroconversion was highest among ...

2,897 citations

01 Jan 2006
TL;DR: These guidelines are primarily intended for use by national and regional HIV programme managers managers of nongovernmental organizations delivering HIV care services and other policy-makers who are involved in the scaling up of comprehensive HIV care and ART in resource-limited countries.
Abstract: This publication is intended to serve as a reference tool for countries with limited resources as they develop or revise national guidelines for the use of ART in adults and postpubertal adolescents (see Annex 9 for pubertal Tanner staging; prepubertal adolescents should follow the WHO paediatric guidelines). The material presented takes updated evidence into account including new ART treatment options and draws on the experience of established ART scale-up programmes. The simplified approach with evidence-based standards continues to be the basis of WHO recommendations for the initiation and monitoring of ART. The guidelines are primarily intended for use by national and regional HIV programme managers managers of nongovernmental organizations delivering HIV care services and other policy-makers who are involved in the scaling up of comprehensive HIV care and ART in resource-limited countries. The comprehensive up-to-date technical and clinical information on the use of ART however also makes these guidelines useful for clinicians in resource-limited settings. The recommendations contained in these guidelines are made on the basis of different levels of evidence from randomized clinical trials high-quality scientific studies observational cohort data and where insufficient evidence is available expert opinion. The strengths of the recommendations in Table 1 are intended to indicate the degrees to which the recommendations should be considered by regional and country programmes. Cost-effectiveness is not explicitly considered as part of the recommendations although the realities of human resources health system infrastructures and socioeconomic issues should be taken into account when the recommendations are being adapted to regional and country programmes. (excerpt)

1,454 citations

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