ART in Africa bridges health gap between those with, without HIV

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The expansion of ART for HIV infection has helped reduce disparities in health-related quality of life between HIV-positive and HIV-negative individuals in Zambia and South Africa, Healio reports according to study findings.

“Little evidence exists about the (health-related quality of life (HRQoL)) of HIV-positive people at various stages of engagement in HIV care, when benchmarked against the attainable HRQoL of the HIV-negative population,” Dr Ranjeeta Thomas, research associate in the Centre for Health Policy at Imperial College London School of Public Health, and colleagues wrote. “Evidence about the effectiveness of ART in reducing the extreme inequalities in population health caused by HIV in high-burden settings is a crucial piece of evidence missing from the current debate. Such evidence would garner support for reducing the funding gap required to achieve the UNAIDS 2020 Fast-Track 90-90-90 targets.”

The report says to compare the HRQoL of HIV-positive people with that of HIV-negative people in Zambia and South Africa – two countries where the prevalence of HIV infection exceeds 20% – researchers analysed data from a sample of the population that was included in the HPTN 071 study, an ongoing randomised trial measuring the effect of a prevention intervention on HIV incidence. Their analysis included 19,750 adults aged 18 to 44 years in Zambia and 18,941 adults in South Africa between Nov. 28, 2013 and March 31, 2015.

They assessed differences in HRQoL scores between HIV-negative and HIV-positive individuals who were: unaware of their infection status; aware but not in HIV care; in HIV care but who had not initiated ART; on ART for less than 5 years; and on ART for 5 years or more.

In total, HIV status was available for 19,330 participants in Zambia and 18,004 participants in South Africa; 4,128 (21%) of those in Zambia and 4,012 (22%) of those in South Africa were HIV positive. According to the researchers, HRQoL scores were not significantly different in individuals who had started ART more than 5 years ago and HIV-negative individuals, neither in Zambia (change in mean score, 0.002; 95% CI, 0.01 to 0.001; P = .219) nor in South Africa (change in mean score, 0.000; 95% CI, 0.002 to 0.003; P = .939). In contrast, scores differed between HIV-positive participants who had been on ART less than 5 years and HIV-negative individuals in Zambia (change in mean score, 0.006; 95% CI, 0.008 to 0.003; P < .0001).

Notably, 1,768 of 4,128 (43%) of HIV-positive people in Zambia and 2,026 of 4,012 (50%) HIV-positive people in South Africa were unaware of their HIV status and reported good HRQoL, with no significant differences from that of HIV-negative people.

HRQoL scores were slightly lower among HIV-positive people who were aware of their status but not enrolled in HIV care (change in mean score, 0.004; 95% CI, 0.01 to 0.001; P = .01) and those in HIV care but not on ART (change in mean score, 0.008; 95% CI, 0.01 to 0.004; P = .001) than among HIV-negative people in South Africa.

“The unique design of our study allowed us to identify the success of ART in reducing inequalities between the HRQoL of HIV-infected individuals and the HIV-negative population. But our findings are also a call to step up efforts to extend these benefits to the millions of people not yet on ART,” Thomas and colleagues wrote. “Improved access to ART is considered the main reason for the marked increase in overall life expectancy in sub-Saharan Africa over the last decade. Policy makers should remember the purpose of medical treatment is to add years to life, and life to years.”

In an accompanying editorial, Dr Kristen A Donald, from the division of developmental paediatrics and the department of paediatrics and child care at the University of Cape Town, South Africa, wrote that the findings of Thomas and colleagues will help in the management of HIV in a population where the disease remains prevalent.

“The authors provide a strong argument for getting individuals diagnosed with HIV onto treatment rapidly, not only in order to preserve and optimize their physical health, but also to give people hope for their future,” the report says Donald wrote.

Summary
Background: The life expectancy of HIV-positive individuals receiving antiretroviral therapy (ART) is approaching that of HIV-negative people. However, little is known about how these populations compare in terms of health-related quality of life (HRQoL). We aimed to compare HRQoL between HIV-positive and HIV-negative people in Zambia and South Africa.
Methods: As part of the HPTN 071 (PopART) study, data from adults aged 18–44 years were gathered between Nov 28, 2013, and March 31, 2015, in large cross-sectional surveys of random samples of the general population in 21 communities in Zambia and South Africa. HRQoL data were collected with a standardised generic measure of health across five domains. We used β-distributed multivariable models to analyse differences in HRQoL scores between HIV-negative and HIV-positive individuals who were unaware of their status; aware, but not in HIV care; in HIV care, but who had not initiated ART; on ART for less than 5 years; and on ART for 5 years or more. We included controls for sociodemographic variables, herpes simplex virus type-2 status, and recreational drug use.
Findings: We obtained data for 19 750 respondents in Zambia and 18 941 respondents in South Africa. Laboratory-confirmed HIV status was available for 19 330 respondents in Zambia and 18 004 respondents in South Africa; 4128 (21%) of these 19 330 respondents in Zambia and 4012 (22%) of 18 004 respondents in South Africa had laboratory-confirmed HIV. We obtained complete HRQoL information for 19 637 respondents in Zambia and 18 429 respondents in South Africa. HRQoL scores did not differ significantly between individuals who had initiated ART more than 5 years previously and HIV-negative individuals, neither in Zambia (change in mean score −0·002, 95% CI −0·01 to 0·001; p=0·219) nor in South Africa (0·000, −0·002 to 0·003; p=0·939). However, scores did differ between HIV-positive individuals who had initiated ART less than 5 years previously and HIV-negative individuals in Zambia (−0·006, 95% CI −0·008 to −0·003; p<0·0001). A large proportion of people with clinically confirmed HIV were unaware of being HIV-positive (1768 [43%] of 4128 people in Zambia and 2026 [50%] of 4012 people in South Africa) and reported good HRQoL, with no significant differences from that of HIV-negative people (change in mean HRQoL score −0·001, 95% CI −0·003 to 0·001, p=0·216; and 0·001, −0·001 to 0·001, p=0·997, respectively). In South Africa, HRQoL scores were lower in HIV-positive individuals who were aware of their status but not enrolled in HIV care (change in mean HRQoL −0·004, 95% CI −0·01 to −0·001; p=0·010) and those in HIV care but not on ART (−0·008, −0·01 to −0·004; p=0·001) than in HIV-negative people, but the magnitudes of difference were small.
Interpretation: ART is successful in helping to reduce inequalities in HRQoL between HIV-positive and HIV-negative individuals in this general population sample. These findings highlight the importance of improving awareness of HIV status and expanding ART to prevent losses in HRQoL that occur with untreated HIV progression. The gains in HRQoL after individuals initiate ART could be substantial when scaled up to the population level.

Authors
Ranjeeta Thomas, Ronelle Burger, Abigail Harper, Sarah Kanema, Lawrence Mwenge, Nosivuyile Vanqa, Nomtha Bell-Mandla, Peter C Smith, Sian Floyd, Peter Bock, Helen Ayles, Nulda Beyers, Deborah Donnell, Sarah Fidler, Richard Hayes, Katharina Hauck

Healio material
The Lancet Global Health article summary
The Lancet Global Health comment


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