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China reported 60% decrease in HIV-related mortality, yet far from overall goal
Zhang F. Lancet Infect Dis. 2011;doi:10.1016/S1473-3099(11)70097-4.
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Officials from the Chinese CDC reported a 60% reduction in HIV-related mortality from 2002 to 2009 and a 63.4% increase in antiretroviral therapy use. Yet, officials said there is still an urgent need for earlier HIV diagnosis and better access to treatment for injection drug users and those infected sexually, according to new findings published in The Lancet Infectious Diseases.
“The recorded HIV treatment coverage is remarkable, considering the size of the country and geographical spread of the individuals with HIV, but is far from the goal of complete coverage of people who meet treatment criteria,” the researchers wrote. “IV drug users, those infected sexually, men, and those who are underserved by the public health system, such as the elderly and minority groups, are at greater risk for not receiving treatment.”
The China National Free Antiretroviral Treatment Program, piloted in 2002, has broadened HIV treatment coverage across the country during the past several years. However, the program did not account for treatment coverage of the entire population. “Understanding national mortality rates and treatment coverage in patients with HIV is essential for assessment of the national HIV program, to identify its strengths and weaknesses and the areas in which additional effort and focus is needed,” the researchers wrote.
For this reason, Fujie Zhang, MD, of the division of treatment and care at China’s National Center for AIDS/STD Control and Prevention, and colleagues conducted a national observational cohort study to assess the overall mortality and identify risk factors in treatment-eligible HIV-infected individuals.
Data were pooled from the national HIV epidemiology and treatment databases on 145,484 ART treatment-eligible patients aged 15 years and older with HIV between 1985 and 2009. At HIV diagnosis, median CD4 count was 201 cells/mcL, and it was 194 cells/mcL when eligible for treatment.
Zhang and colleagues observed a decrease in overall mortality from 39.3 per 100 person-years in 2002 to 14.2 per 100 person-years in 2009 — treatment coverage increased from almost zero to 63.4%.
Conversely, treatment coverage was lower and mortality rates were higher among IV drug users (15.9 deaths per 100 person-years; 42.7% coverage) and those infected sexually (17.5 deaths per 100 person-years; 61.7% coverage) vs. those infected via plasma donation or blood transfusion (6.7 deaths per 100 person-years; 80.2% coverage).
Risk factors associated with HIV-related mortality included not receiving ART (HR=4.35; 95% CI, 4.10-4.62) and having a CD4 count of less than 50 cells/mcL when eligible for treatment (HR=7.92; 95% CI, 7.33-8.57).
“Treatment coverage among those infected sexually and through IV drugs is still low, likely for multiple reasons, including programmatic factors, such as insufficient treatment personnel and the large geographic region that needs to be covered; risk population factors, such as fear of governmental organizations, not being able to be located after testing due to providing false names or addresses, and having poor medication adherence; and societal factors, such as stigma,” Zhang told Infectious Disease News. “Much work to coordinate the efforts of multiple governmental ministries is needed to develop an effective treatment response among these groups.”
In an accompanying editorial, Ka-Hing Wong and Kenny Chi-Wai Chan, of the Department of Health in the Hong Kong Special Administrative Region of China, wrote: “This program was one of the first to scale up HIV treatment access in a developing country. The investigators rightly draw attention to the importance of improving treatment coverage with HAART and ensuring treatment initiation before a patient becomes severely immunosuppressed, especially before their CD4 count falls to less than 50 cells/mcL. The data are strong and the message is clear on how the mortality outcomes of HAART can be improved. The study also provided evidence for the feasibility of a public health approach to generate continued positive outcomes in a large population of patients.”
Disclosure: The researchers report no relevant financial disclosures.
The study published in Lancet Infectious Diseases by Zhang et al. is impressive for several reasons. First, it is the first large scale description of the effects of HAART in China. Starting in 2002, the China National Free Antiretroviral Treatment Programme initially and successfully targeted individuals who were infected by plasma donation practices. In 2003, the program greatly expanded to cover all those infected with HIV and a CD4 T-cell count less than 350 per µl. While it may be argued that China is no longer a developing country, the breadth of the data are reassuring that the program is effective and the data will help the program determine if it has any weaknesses. Second, the growth of the program from 2003 to 2009 was dramatic, as the percent of eligible patients on HAART increased from ,5% to 63%. Third, this success suggests China has the potential to do much more. China plans to identify HIV positive people earlier and offer HAART to more patients. Since HIV treatment is a large part of prevention, the continuation and expansion of the program will not only improve mortality rates, but reduce the incidence of HIV in China. These data are reminiscent of the data from Western Europe, Canada and the USA in the late 1990’s. As did these countries, China’s program will have to embrace new technologies and therapies to continue to be effective in the long run.
– Stephen M. Smith, MD
Infectious Disease News Editorial Board member
Disclosure: Dr. Smith reports no relevant financial disclosures
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