Mortality in well controlled HIV in the continuous antiretroviral therapy arms of the SMART and ESPRIT trials compared with the general population

Rodger, Alison; Lodwick, R; Schechter, Mauro; Deeks, Steven G.; Amin, Janaki; Gilson, Richard; Paredes, Roger; Bąkowska, Elżbieta; Engsig, Frederik Neess; Phillips, Andrew

doi:10.1097/qad.0b013e32835cae9c

Cited by 323 publications

(238 citation statements)

References 18 publications

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“…However, after the introduction of effective ART, the model suggests that there was an increase in CLS, associated with a rise in HIV infection incidence. Our analysis suggested that use of treatment, even under a policy of ART initiation only when the CD4 cell count was < 350 cells/µl 3 , and in the context of a relatively low rate of HIV diagnosis, has had an appreciable impact on HIV infection incidence in the UK, resulting in most (82%) new infections being from people who are yet to be diagnosed. We estimated that incidence would have been 68% higher than that actually observed had ART not been introduced (but sexual risk behaviour changes remaining unchanged) and more than five times higher than the observed had condom use ceased.…”

Section: The Partners Of People On Art: a New Evaluation Of The Risksmentioning

confidence: 84%

“…2 Antiretroviral therapy (ART) is now highly successful in reversing the effects of HIV and has led to death rates in successfully treated people that are not much greater than those of the general population. 3,4 Given that there are reductions in infectivity of people on ART, 5 there is widespread interest in the potential effect of ART in controlling the HIV epidemic, 6 but there are a number of areas, including the UK, in which ART use is high among MSM, and yet incidence has not declined [7][8][9][10] and its potential impact in epidemics in MSM has been questioned. 9,11 In the Comprehensive Assessment of the Prevention Role of Antiretroviral therapy (CAPRA) programme of research that started in 2010 we set out to address what would be the population-level clinical effectiveness, and cost-effectiveness, of introduction of a policy of initiating ART in all people with a diagnosed HIV infection.…”

Section: Synopsismentioning

confidence: 99%

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Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Miltz

Phillips

Speakman

et al. 2017

Programme Grants Appl Res

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BackgroundMore than 100,000 people in the UK are living with a human immunodeficiency virus (HIV) infection. There are currently estimated to be around 4000 people newly infected in the UK per year, mostly men who have sex with men (MSM). It has become increasingly clear that antiretroviral therapy (ART) used to treat people infected with HIV also has a profound effect on infectivity. At the initiation of the programme, it was the policy in the UK to initiate ART in people when their cluster of differentiation 4 (CD4) count was approaching 350/µl.ObjectivesTo assess what would be the effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis among MSM, taking into account the potential reductions in new infections.DesignWe calibrated an individual-based model of HIV transmission, progression and the effect of ART in MSM, informed by a series of studies on sexual behaviour in relation to ART use and the transmission risk in people with viral suppression on ART, and by surveillance data collected by Public Health England.Setting, participants and interventionsThe series of studies used to inform the model included (1) the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study, a cross-sectional self-administered questionnaire study of people diagnosed with HIV attending eight HIV outpatient clinics in the UK (2011–12); (2) the Cognitive Impairment in People with HIV in the European Region (CIPHER) study, a study of levels of neurocognitive impairment in HIV-positive ASTRA participants and people from HIV clinics in Rome, Copenhagen and Minsk; (3) the Attitudes to, and Understanding of, Risk of Acquisition of HIV (AURAH) study, a cross-sectional self-administered questionnaire study of individuals who have not been diagnosed as HIV-positive attending 20 genitourinary medicine clinics across the UK (2013–14); (4) a substudy of sexual behaviour among individuals enrolled in an open-label multicentre international randomised trial (from 2013) of immediate versus deferred ART (to CD4 cell counts of 350/µl) in people with CD4 cell counts of > 500/µl [the Strategic Timing of Antiretroviral Therapy (START) trial]; and (5) Partners of People on ART: a new Evaluation of the Risks (PARTNER), an observational multicentre longitudinal study of HIV serodifferent heterosexual and MSM couples, in which the HIV-positive partner is on ART (2010–14).Main outcome measuresThe main outcome measures were the clinical effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis.ResultsBased on data from studies (i)–(v), we estimated from our modelling work that increases in condomless sex (CLS) among MSM as a whole may explain the increase in HIV infection incidence in MSM epidemics over a time when ART coverage and viral suppression increased, demonstrating the limiting effects of non-condom use on the HIV epidemic among MSM. Accordingly, an increase in the overall proportion of MSM living with HIV who are virally suppressed on ART from the current level of < 60% to 90% without increases in CLS was required to achieve a reduction in the incidence of HIV among MSM to < 1 per 1000 person-years. The incremental cost-effectiveness ratio associated with the fourfold increase in levels of HIV testing and ART at diagnosis required to provide this increase from < 60% to 90% was £20,000 if we assumed continuation of current ART prices. However, this value falls to £3500 if we assume that ART prices will fall to 20% of their current cost as a result of the introduction of generic drugs. Therefore, our evaluation suggests that ART initiation at diagnosis is likely to be highly cost-effective in MSM at a population level, particularly accounting for future lower ART costs as generic drugs are used. The impact will be much greater if levels of HIV testing can be enhanced.LimitationsIt was necessary to make some assumptions beyond the available data in order to extrapolate cost-effectiveness through modelling.ConclusionsOur findings suggest that ART initiation at diagnosis is likely to be cost-effective in MSM. Of note, after this programme of work was completed, results from the main START trial demonstrated benefit in ART initiation even in people with CD4 cell counts of > 500/µl, supporting ART initiation in people diagnosed with a HIV infection.Future workThere is a need for future research into the means of increasing the frequency with which MSM test for HIV.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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Section: The Partners Of People On Art: a New Evaluation Of The Risksmentioning

confidence: 84%

Section: Synopsismentioning

confidence: 99%

Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Miltz

Phillips

Speakman

et al. 2017

Programme Grants Appl Res

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show abstract

“…[2] Human Immunodeficiency Virus (HIV) is currently a manageable chronic illness [3] and the life expectancy of infected people in developed countries is comparable to those without HIV. [4] While HIV/AIDS is widely recognised as a chronic illness, it is often excluded from wider chronic disease management, focusing on conditions like diabetes and COPD etc. ; however the integrated principles of self-care are also applicable to HIV/AIDS, similar to other chronic illnesses.…”

Section: Introductionmentioning

confidence: 99%

Beliefs and practices of complementary and alternative medicine (CAM) among HIV/AIDS patients: A qualitative exploration

Ahmed

Sulaiman

Thiruchelvam

et al. 2016

European Journal of Integrative Medicine

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“…1,9 HIV testing benefits individuals by increasing the likelihood of early identification of the disease, linkage to care, and prescription of life-saving HIV therapies. [10][11][12] In addition, testing benefits the general population by decreasing the risk of HIV transmission, since individuals aware of their HIV infection are less likely to engage in high-risk behaviors and those in care and on treatment are more likely to achieve viral suppression. [13][14][15][16][17] HIV screening may be additionally important for individuals with mental illness, as testing facilities and providers can enable access to mental health services.…”

mentioning

confidence: 99%

HIV Testing Among Adults with Mental Illness in the United States

Yehia

Cui

Thompson

et al. 2014

AIDS Patient Care and STDs

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Mortality in well controlled HIV in the continuous antiretroviral therapy arms of the SMART and ESPRIT trials compared with the general population

Abstract: In HIV-infected individuals on ART, with a recent undetectable viral load, who maintained or had recovery of CD4(+) cell counts to at least 500 cells/μl, we identified no evidence for a raised risk of death compared with the general population.

Cited by 323 publications

References 18 publications

Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Beliefs and practices of complementary and alternative medicine (CAM) among HIV/AIDS patients: A qualitative exploration

HIV Testing Among Adults with Mental Illness in the United States

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