Adults and children with HIV who start antiretroviral therapy (ART) as early as possible reduce their risk of developing serious HIV-related infections, according to new findings published in the journal Clinical Infectious Diseases on 15 June 2016.
Two studies in adults and children, supported by the World Health Organization (WHO) and conducted in collaboration with Columbia University, the London School of Hygiene & Tropical Medicine and McGill University, are the first global systematic and comprehensive analyses of data on HIV-related opportunistic infections over a 20-year period in 3 global regions: Africa, Asia and Latin America. The 2 reviews compared the risk of serious HIV-related infections before and after starting ART, then estimated the global number of cases of infection that would have been prevented (using data from 2013), and the costs saved, if ART had been started earlier.
"Opportunistic and other infections are the major cause of death in adults and children with HIV," said Dr. Philippa Easterbrook from WHO's Department of HIV. "There have been previous estimates on the impact of ART in reducing deaths and new HIV infections, but not on its impact on each of the serious infections to which people with HIV are vulnerable, especially in low-income settings. Knowing how common these infections are is really important for planning HIV health services in these countries, including procuring drugs and diagnostic tests."
In 126 different studies based on almost half a million adult HIV patients, the most common infections were oral thrush, tuberculosis, shingles and bacterial pneumonia -- each of which occurred in more than 5% of adults before ART. There was a major reduction in the risk of development of all infections for those on ART, by 57% to 91%, and this was greatest in the first year of treatment. It was estimated that earlier ART would have prevented at least 900 000 cases of life-threatening infections and saved around US$ 50 million in 2013.
In the second review -- 88 studies based on 55 679 HIV-infected children -- bacterial pneumonia and tuberculosis were the most common infections, each occurring in around 25% of children before ART. As with the adult studies, there was a reduction in risk for all infections for those on ART, but this was greatest (by more than 80%) for HIV-related diarrhoea, cerebral toxoplasmosis and tuberculosis, with a smaller impact on bacterial septicemia and pneumonia. It was estimated that earlier access to ART could have prevented at least 161 000 cases of serious infections in children, with a saving of around US$ 17 million in 2013.
"Compared to adults, there is always a relative lack of data on HIV-infected children to inform guidelines and practice, and the scale-up of ART in children has been much less successful," said coauthor Dr. Marie-Renée B-Lajoie from McGill University. "But our study shows that the effect of ART in reducing HIV-related infections in children is as dramatic as that seen in adults."
Dr. Andrea Low, coauthor from ICAP, Columbia University, commented that "the level of effect of ART on serious infections in adults in these low-income settings was even more striking than that observed in high-income countries". However, she also noted that interpretation of regional variation in incidence and the effect of ART is limited, as there were significant gaps in data from some regions, such as Latin America.
Dr. Gottfried Hirnschall, Director of WHO's HIV Department, concluded: "We know that ART has a dramatic effect in reducing death rates as well as new HIV infections. These findings demonstrate that ART has the same effect in reducing the risk of serious HIV-relatedI nfections in adults and children -- thus, further explaining the reduction in death rates. This reinforces the need to continually prioritize the expansion of access to ART. The new WHO guidelines recommend starting ART in all HIV-infected persons as soon as possible, regardless of the stage of infection."