Abstract
BackgroundThere 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.MethodsWe 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.ResultsHAART 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%.ConclusionsOur 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.
Highlights
After 30 years, controlling the HIV epidemic remains an extraordinary challenge. This is despite the availability of a number of proven prevention tools, including harm-reduction strategies and emerging biomedical interventions. [1,2,3,4,5,6,7] Recently, increasing attention has been focused on the potential role that the expansion of HIV treatment may offer to curb progression to AIDS and premature death among HIV infected individuals and secondarily reduce HIV transmission, commonly referred to as HIV treatment as prevention or TasP. [8,9,10,11] In brief, HIV-1 RNA concentration is a key determinant of the level of risk associated with sexual, vertical and needle sharing-related HIV transmission. [12,13,14,15,16,17,18,19,20,21] Appropriate use of highly active antiretroviral therapy (HAART) suppresses HIV replication on a sustained basis, leading typically to undetectable, viral load in plasma and halting disease progression to AIDS and premature death
We estimated that HAART coverage increased from 11% to 57% (p-value 0.0004) during this period
Statistical Models we developed two statistical models with the outcome being the estimated HIV incidence rate and the explanatory variables being the number of individuals actively on HAART and the percentage of individuals suppressed on HAART
Summary
After 30 years, controlling the HIV epidemic remains an extraordinary challenge. This is despite the availability of a number of proven prevention tools, including harm-reduction strategies and emerging biomedical interventions. [1,2,3,4,5,6,7] Recently, increasing attention has been focused on the potential role that the expansion of HIV treatment may offer to curb progression to AIDS and premature death among HIV infected individuals and secondarily reduce HIV transmission, commonly referred to as HIV treatment as prevention or TasP. [8,9,10,11] In brief, HIV-1 RNA concentration (hereafter referred to as viral load) is a key determinant of the level of risk associated with sexual, vertical and needle sharing-related HIV transmission. [12,13,14,15,16,17,18,19,20,21] Appropriate use of HAART suppresses HIV replication on a sustained basis, leading typically to undetectable, viral load in plasma and halting disease progression to AIDS and premature death. In addition, as viral load rapidly declines in plasma and subsequently in other biological fluids (including semen, vaginal fluids and rectal mucosa), the likelihood of HIV transmission per exposure event is markedly reduced. [12,13,14,15,16,17,18,19,20,21] The concept of scaling up highly active antiretroviral therapy (HAART), commonly referred to as TasP, has gained substantial momentum, as its efficacy and effectiveness have become increasingly apparent. [8,9,22,23,24] the real-world population-level effectiveness and sustainability of this strategy remains to be adequately characterized.British Columbia (BC), Canada, provides a unique environment to address this issue within a concentrated HIV epidemic. After 30 years, controlling the HIV epidemic remains an extraordinary challenge. This is despite the availability of a number of proven prevention tools, including harm-reduction strategies and emerging biomedical interventions. [12,13,14,15,16,17,18,19,20,21] Appropriate use of HAART suppresses HIV replication on a sustained basis, leading typically to undetectable, viral load in plasma and halting disease progression to AIDS and premature death.. [8,9,22,23,24] the real-world population-level effectiveness and sustainability of this strategy remains to be adequately characterized. Population-level sustainability of this strategy has not been characterized
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