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Higher antiretroviral treatment coverage is associated with lower HIV infection rates: analysis of 51 low and middle-income countries. Andrew Hill, Liverpool University, UK Anton Pozniak, Chelsea and Westminster Hospital, London Alice Raymond, Imperial College, London

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Andrew hill liverpool university uk anton pozniak chelsea and westminster hospital london

Higher antiretroviral treatment coverage is associated with lower HIV infection rates: analysis of 51 low and middle-income countries

Andrew Hill, Liverpool University, UK

Anton Pozniak, Chelsea and Westminster Hospital, London

Alice Raymond, Imperial College, London

Katherine Heath, Imperial College, London

Nathan Ford, World Health Organisation, Geneva

World AIDS Conference, July 2014, Melbourne, Australia [LBPE29]


Background

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

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]


Methods1

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

Countries with over 45% HIV-infected people on antiretroviral treatment

_____________________________________________________

Country Infected Treated %

_____________________________________________________

Andrew Hill et al. World AIDS Conference 2014 [LBPE29]


Andrew hill liverpool university uk anton pozniak chelsea and westminster hospital london

The percentage of all HIV-infected people on antiretroviral treatment, by country

UK:

67%

USA:

33%

Thailand:

54%

Brazil:

53%

Argentina:

52%

Botswana:

62%

Andrew Hill et al. World AIDS Conference 2014 [LBPE29]


Countries with 20 hiv infected people on antiretroviral treatment

Countries with <20% HIV-infected people on antiretroviral treatment

_____________________________________________________

Country Infected Treated %

Andrew Hill et al. World AIDS Conference 2014 [LBPE29]


Andrew hill liverpool university uk anton pozniak chelsea and westminster hospital london

Countries with less than 15% of HIV-infected people on antiretroviral treatment, by country

Somalia:

5%

Indonesia:

5%

Madagascar:

0.6%

Andrew Hill et al. World AIDS Conference 2014 [LBPE29]


Andrew hill liverpool university uk anton pozniak chelsea and westminster hospital london

Cascade of HIV care – UK

98400

Breakpoint in cascade:

not diagnosed HIV positive

77610

69198

65928

57072

Reference: Public Health England 2013 Report p.22 - Brown AE et al., 2014


Andrew hill liverpool university uk anton pozniak chelsea and westminster hospital london

Cascade of HIV care – Georgia

6600

3432

2904

2508

1716

1320

Reference: UNAIDS database (2012) – Chkhartishvili et al., 2013


Andrew hill liverpool university uk anton pozniak chelsea and westminster hospital london

Cascade of HIV care – United States

1148200

940376

Breakpoint in cascade:

diagnosed HIV positive

but not treated

755516

424834

375461

290495

Reference: CDC Fact sheet December 2013 p.2 - Halls et al., 2013


Andrew hill liverpool university uk anton pozniak chelsea and westminster hospital london

Results

  • 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


New hiv infections percentage growth versus art coverage in 51 countries

New HIV infections (percentage growth) versus ART coverage in 51 countries.

Andrew Hill et al. World AIDS Conference 2014 [LBPE29]

Figure 1. The percentage of all HIV-infected people taking antiretrovirals, by country


Death rates from hiv infection versus art coverage in 51 countries

Death rates from HIV infectionversus ART coverage in 51 countries.

Andrew Hill et al. World AIDS Conference 2014 [LBPE29]

Figure 1. The percentage of all HIV-infected people taking antiretrovirals, by country


Andrew hill liverpool university uk anton pozniak chelsea and westminster hospital london

Results

  • 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.


Andrew hill liverpool university uk anton pozniak chelsea and westminster hospital london

Limitations

  • 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


Conclusions

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]


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