Early ART can prevent millions of deaths

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Results from a new study indicate that millions of Aids-related deaths could be averted in high HIV burden countries – an estimated 3.4 million in the countries of Nigeria and South Africa alone – with improved and earlier access to antiretroviral therapy (ART).

The study’s authors said, “expanding access to earlier ART beyond the currently reported 14m people will have significant individual and public health impact. Additionally, the geographic disparity in mortality trends and rates illustrates the need for further focus and rapid action to reduce Aids-related deaths in those countries where the problem is most severe.”

A team led by the International Association of Providers of AIDS Care (IAPAC), used global surveillance data to examine the relationship between ART access and Aids-related deaths in the 30 highest HIV burden countries of the world. The team consisted of researchers from IAPAC, the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, BC, Canada; the Joint UN Programme on HIV/AIDS (UNAIDS) in Geneva, Switzerland; and University of the Witwatersrand in Johannesburg, South Africa.

“It is abundantly clear from the latest science that ART prevents Aids-related morbidity and mortality as well as HIV transmission, and that its early initiation nets greater benefit than waiting for now obsolete ART initiation thresholds based on CD4 cell counts,” said Dr Reuben Granich, the article’s lead author and IAPAC vice president/CTO. “Our analysis of the available global surveillance data demonstrates the importance of expanding earlier access to ART to both save millions of lives and as an integral part of global efforts to control the HIV epidemic.”

The study’s authors acknowledge that the estimated number of annual Aids-related deaths has decreased 38% from 2.4m (2.2m-2.6m) in 2005 to 1.5m (1.4m-1.7m) in 2013 – in some measure reflective of ART’s prevention impact on illness, death, transmission, and costs. However, although early ART can now provide a near normal lifespan, globally in 2013 there were still an estimated 1.5m ART-related deaths.

The study combined surveillance data with modelling projections to examine the impact of achieving the UNAIDS 90-90-90 Target for HIV testing and treatment on averting Aids-related deaths – 90% of people living with HIV diagnosed, 90% of those diagnosed on ART, and 90% of those on ART achieving viral suppression and thus triggering its therapeutic and preventative benefits. “Given the benefits of early ART initiation, it is an appalling human rights violation that far too many HIV-positive people are dying unnecessarily in so many countries around the globe,” said Dr José M. Zuniga, IAPAC president/CEO and article co-author. “IAPAC is mobilising its network of 20,000-plus clinical and lay providers to support the President’s Emergency Plan for AIDS Relief (PEPFAR); Global Fund to Fight AIDS, Tuberculosis & Malaria; governments of high HIV burden countries; and affected communities in their efforts to overcome barriers to HIV testing, ART initiation, and long-term viral suppression.”

Abstract
Background
Antiretroviral therapy (ART) prevents human immunodeficiency virus (HIV) disease progression, mortality and transmission. We assess the impact of expanded HIV treatment for the prevention of Acquired Immunodeficiency Syndrome (AIDS)-related deaths and simulate four treatment scenarios for Nigeria and South Africa.
Methods
For 1990–2013, we used the Joint United Nations Programme on HIV/AIDS (UNAIDS) database to examine trends in AIDS deaths, HIV incidence and prevalence, ART coverage, annual AIDS death rate, AIDS death-to-treatment and HIV infections to treatment ratios for the top 30 countries with the highest AIDS mortality burden and compare them with data from high-income countries. We projected the 1990–2020 AIDS deaths for Nigeria and South Africa using four treatment scenarios: 1) no ART; 2) maintaining current ART coverage; 3) 90% ART coverage based on 2013 World Health Organization (WHO) ART guidelines by 2020; and 4) reaching the United Nations 90-90-90 Target by 2020.
Findings
In 2013, there were 1.3 million (1.1 million–1.6 million) AIDS deaths in the top 30 countries representing 87% of global AIDS deaths. Eight countries accounted for 58% of the global AIDS deaths; Nigeria and South Africa accounted for 27% of global AIDS deaths. The highest death rates per 1000 people living with HIV were in Central African Republic (91), South Sudan (82), Côte d’Ivoire (75), Cameroon (72) and Chad (71), nearly 8–10 times higher than the high-income countries. ART access in 2013 has averted as estimated 1,051,354 and 422,448 deaths in South Africa and Nigeria, respectively. Increasing ART coverage in these two countries to meet the proposed UN 90-90-90 Target by 2020 could avert 2.2 and 1.2 million deaths, respectively.
Interpretation
Over the past decade the expansion of access to ART averted millions of deaths. Reaching the proposed UN 90-90-90 Target by 2020 will prevent additional morbidity, mortality and HIV transmission. Despite progress, high-burden countries will need to accelerate access to ART treatment to avert millions of premature AIDS deaths and new HIV infections.

IAPAC material
PLOS One abstract


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