New cases of HIV in India could fall by 38% with early ART and better retention, finds studyBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5684 (Published 23 October 2015) Cite this as: BMJ 2015;351:h5684
Starting antiretroviral therapy (ART) early in India could reduce new infections by 18% and AIDS mortality by 9%, a study has found. Better retention in care could reduce new cases by 38% over the next 20 years.
The study used dynamic compartmental modelling to compare early ART initiation (at CD4 counts of ≤500 cells/mm3) with delayed ART initiation (CD4 count ≤350 cells/mm3), under both ideal and realistic conditions of care.1
In 2011 over two million Indian people were estimated to have HIV/AIDS.2 Current practice in India is to initiate ART when CD4 counts drop to 350 cells/mm3 or below. But in 2013 the World Health Organization recommended that ART be initiated earlier (CD4 ≤500 cells/mm3) to reduce transmission and improve survival. However, earlier initiation could also mean a higher possibility of disruption of care as well as the development of resistance to ART.
Under ideal conditions (that is, higher rates of screening, linkage to care, treatment changes, adherence, and retention) the study estimated a 38% reduction in new HIV infections with early treatment initiation (517 000 new infections; 95% uncertainty range 330 000 to 896 000) compared with delayed initiation (831 000; 561 000 to 1 447 000) over the next 20 years. This could reduce new HIV infections to less than 15 000 a year. However, when current rates of attrition and gaps in care were taken into account early ART initiation reduced new HIV infections by only 18% in the next 20 years (1 050 000 new infections (706 000 to 1 729 000) compared with 1 285 000 (876 000 to 2 114 000) for delayed initiation).
The study estimated a 15% reduction in HIV associated deaths under ideal conditions over the same period, with 411 000 deaths (341 000 to 652 000) estimated for early ART initiation compared with 482 000 (427 000 to 821 000) for delayed initiation. This benefit fell to only a 9% reduction under more realistic conditions (883 000 (610 000 to 1 300 000) versus 973 000 (679 000 to 1 412 000)).
Even with the current HIV care continuum, the researchers found that early ART initiation was cost effective ($530 (£344; €470) per quality adjusted life year (QALY) gained) based on WHO definitions. Early initiation would mean 20 year incremental costs of $517m (undiscounted), which is only an approximate 4% increase in the $13bn that India would spend on HIV healthcare in that time.
In June 2014 about 60% of the 58 HIV focus countries were using the higher threshold (CD4 count ≤500 cells/mm3) to begin ART.3 Maunank Shah and Manoj Maddali, two of the study authors, told The BMJ that two years after the guidelines for early ART initiation were released India still had a policy of delayed ART initiation. India needed to prioritise early ART initiation, they said. But to maximise benefits the entire continuum of HIV care—particularly long term retention—had to improve, they added.
In September 2015 WHO strongly recommended that ART be initiated in adults (above 19 years) with HIV “at any CD4 cell count.”3
Cite this as: BMJ 2015;351:h5684