Is expanded HIV treatment preventing new infections? Impact of antiretroviral therapy on sexual risk behaviors in the developing world

Venkatesh, Kartik K.; Flanigan, Timothy P.; Mayer, Kenneth H.

doi:10.1097/qad.0b013e32834b4ced

Cited by 51 publications

(66 citation statements)

References 112 publications

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“…This finding might challenge the results of several literature reviews, which pointed out decreased sexual risk behaviours associated with ART initiation [11, 29–31]. However, previous studies relied on comparisons between ART-treated versus untreated patients in a context where routine contacts with the care system are generally infrequent for patients not yet ART-eligible [32].…”

Section: Discussionmentioning

confidence: 94%

Decrease in sexual risk behaviours after early initiation of antiretroviral therapy: a 24‐month prospective study in Côte d'Ivoire

Jean

Gabillard

Moh

et al. 2014

Journal of the International AIDS Society

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IntroductionWhether early antiretroviral therapy (ART) initiation could impact sexual risk behaviours remains to be documented. We aimed to investigate changes in sexual behaviours within the 24 months following an early versus standard ART initiation in HIV-positive adults with high CD4 counts.MethodsWe used data from a prospective behavioural study nested in a randomized controlled trial of early ART (Temprano-ANRS12136). Time trends in sexual behaviours from enrolment in the trial (M0) to 12-month (M12) and 24-month (M24) visits were measured and compared, using Generalized Estimating Equations models, between participants randomly assigned either to initiate ART immediately (early ART) or to defer ART initiation until on-going WHO starting criteria are met (standard ART). Indicators of sexual behaviours included 1) sexual activity in the past year, 2) multiple partnership in the past year, 3) unprotected sex at last intercourse and 4) risky sex (i.e. unprotected sex with a partner of HIV negative/unknown status) at last intercourse.ResultsAnalyses included 1952 participants (975 with early ART and 977 with standard ART; overall median baseline CD4 count: 469/mm3). Among participants with early ART, significant decreases were found between M0 and M24 in sexual activity (Odds Ratio [OR] 0.72, 95% Confidence Interval [95% CI] 0.57–0.92), multiple partnership (OR 0.57, 95% CI 0.41–0.79), unprotected sex (OR 0.59, 95% CI 0.47–0.75) and risky sex (OR 0.58, 95% CI 0.45–0.76). Among participants with standard ART, sexual behaviours showed similar trends over time. These decreases mostly occurred within the 12 months following enrolment in the trial in both groups and prior to ART initiation in participants with standard ART. For unprotected sex and risky sex, decreases were or tended to be more pronounced among patients reporting that their last sexual partner was non-cohabiting.ConclusionsIn these sub-Saharan adults with high CD4 counts, entry into HIV care, rather than ART initiation, resulted in decreased sexual activity and risky sexual behaviours. We did not observe any evidence of a risk compensation phenomenon associated with early ART initiation. These results illustrate the potential behavioural preventive effect of early entry into care, which goes hand in hand with early ART initiation.

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Section: Discussionmentioning

confidence: 94%

Decrease in sexual risk behaviours after early initiation of antiretroviral therapy: a 24‐month prospective study in Côte d'Ivoire

Jean

Gabillard

Moh

et al. 2014

Journal of the International AIDS Society

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“…It is useful to compare model predictions with observational data. The epidemiologic consequences of high ART coverage in high-income country settings have seemingly been mixed, 24–29 but one observational study in rural South Africa has found the risk of HIV infection to be lower for individuals living in areas with higher ART coverage, 30 and studies have not found increases in sexual risk behaviour amongst persons initiating early ART 31,32 or the general population. 33 As in all scientific endeavours, the conclusions of this analysis should be re-evaluated in the light of new data as they become available.…”

Section: Discussionmentioning

confidence: 99%

Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models

Eaton

Menzies²,

Stover

et al. 2014

The Lancet Global Health

196

163

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Background New WHO guidelines recommend ART initiation for HIV-positive persons with CD4 cell counts ≤500 cells/µL, a higher threshold than was previously recommended. Country decision makers must consider whether to further expand ART eligibility accordingly. Methods We used multiple independent mathematical models in four settings—South Africa, Zambia, India, and Vietnam—to evaluate the potential health impact, costs, and cost-effectiveness of different adult ART eligibility criteria under scenarios of current and expanded treatment coverage, with results projected over 20 years. Analyses considered extending eligibility to include individuals with CD4 ≤500 cells/µL or all HIV-positive adults, compared to the previous recommendation of initiation with CD4 ≤350 cells/µL. We assessed costs from a health system perspective, and calculated the incremental cost per DALY averted ($/DALY) to compare competing strategies. Strategies were considered ‘very cost-effective’ if the $/DALY was less than the country’s per capita gross domestic product (GDP; South Africa: $8040, Zambia: $1425, India: $1489, Vietnam: $1407) and ‘cost-effective’ if $/DALY was less than three times per capita GDP. Findings In South Africa, the cost per DALY averted of extending ART eligibility to CD4 ≤500 cells/µL ranged from $237 to $1691/DALY compared to 2010 guidelines; in Zambia, expanded eligibility ranged from improving health outcomes while reducing costs (i.e. dominating current guidelines) to $749/DALY. Results were similar in scenarios with substantially expanded treatment access and for expanding eligibility to all HIV-positive adults. Expanding treatment coverage in the general population was therefore found to be cost-effective. In India, eligibility for all HIV-positive persons ranged from $131 to $241/DALY and in Vietnam eligibility for CD4 ≤500 cells/µL cost $290/DALY. In concentrated epidemics, expanded access among key populations was also cost-effective. Interpretation Earlier ART eligibility is estimated to be very cost-effective in low- and middle-income settings, although these questions should be revisited as further information becomes available. Scaling-up ART should be considered among other high-priority health interventions competing for health budgets. Funding The Bill and Melinda Gates Foundation and World Health Organization

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“…Sexual transmission risk behavior in resource limited settings has been generally observed to decline after initiation of ART [11], and studies of HIV sexual transmission risk between discordant couples in Uganda have shown impressive declines in transmission [2, 12]. However, sexual transmission risk behavior has remained elevated in some populations during treatment, including those aware of its efficacy to prevent transmission [13–15].…”

Section: Discussionmentioning

confidence: 99%

Treatment as long-term prevention

Siedner¹,

Musinguzi²,

Tsai³

et al. 2014

Aids

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Objectives Suppressive anti-retroviral therapy (ART) substantially decreases HIV transmission in clinical research settings. We sought to measure the frequency and correlates of periods of transmission risk among individuals taking ART during multiple years of observation in rural, southwestern Uganda. Design Observational cohort study Methods We collected sexual behavior and viral load data in a Ugandan cohort of people living with HIV/AIDS from the time of ART initiation. We defined each 90-day visit as a potential transmission period if HIV-1 RNA was > 400 copies/mL and the participant reported sexual transmission risk behavior, defined as unprotected sexual contact with ≥1 HIV-uninfected partners or partners of unknown serostatus in the prior 90 days. Results We evaluated data from 463 individuals on ART over a median 3.5 years of observation and 5,293 total study visits. During that time, over half (259, 56%) had detectable viremia or reported sexual transmission risk behavior at least once. However only 23 (5%) had both simultaneously, at 28 (<1%) of all visits. Transmission sexual behavior was reported at 6% of visits with detectable viremia. In multivariable regression modeling, correlates of transmission risk periods included younger age, lower CD4 count, low household asset ownership and increased internalized stigma. Conclusions Although detectable viremia and/or sexual transmission risk behavior occurred in over half of individuals, ART reduced periods of HIV transmission risk by over 90% during up to six years of observation time. These findings provide further support for provision of ART, along with interventions to promote long-term adherence, to reduce HIV transmission in HIV-endemic settings.

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Is expanded HIV treatment preventing new infections? Impact of antiretroviral therapy on sexual risk behaviors in the developing world

Cited by 51 publications

References 112 publications

Decrease in sexual risk behaviours after early initiation of antiretroviral therapy: a 24‐month prospective study in Côte d'Ivoire

Decrease in sexual risk behaviours after early initiation of antiretroviral therapy: a 24‐month prospective study in Côte d'Ivoire

Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models

Treatment as long-term prevention

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