Advanced HIV disease at ART initiation declines in low-, middle-income countries

The prevalence of advanced HIV disease at ART initiation declined in eight of 10 low- and middle-income countries that participated in a recent CDC analysis.

According to Andrew F. Auld, MBChB, of CDC’s Division of Global HIV & TB and Center for Global Health, and colleagues, the findings reflect an increase in HIV testing and treatment services in low- and middle-income countries (LMICs) since 2004. Despite this progress, however, the researchers estimated that one-third of patients living with HIV in these countries still initiated treatment late, underscoring the need to continue increasing interventions for earlier testing and treatment. In particular, the researchers stressed the importance of adopting WHO’s “treat-all” guidelines, which recommend that all patients diagnosed with HIV become eligible for ART, regardless of CD4 count.

“In the Strategic Timing of Antiretroviral Therapy (START) trial, initiating ART for patients with CD4 greater than 500/L rather than deferring ART initiation until more advanced disease stages was shown to reduce risk for a composite endpoint of any serious acquired AIDS–related event, non-AIDS–related event or death by 57%,” they wrote. “In addition, early rather than deferred ART for HIV–positive persons in a serodiscordant relationship was found to reduce HIV transmission to the HIV–negative partner by approximately 96%.”

The researchers noted that most countries included in the analysis (Haiti, Mozambique, Namibia, Nigeria, Swaziland, Vietnam, Zimbabwe, Tanzania, Uganda and Zambia) have implemented WHO’s “treat-all” guidelines. Vietnam — the only country that did not yet fully implement the guidelines — is in the process of phasing them in. The country plans on nationwide adoption by 2020.

For the analysis, Auld and colleagues examined information on 694,138 patients treated at 797 ART facilities. According to the researchers, the prevalence of advanced disease at ART initiation significantly declined from:

73% to 37% in Mozambique (2004-2014);
80% to 41% in Namibia (2004-2012);
75% to 34% in Haiti (2004-2015);
72% to 54% in Swaziland (2004-2010);
84% to 75% in Zimbabwe (2007-2009);
89% to 60% in Uganda (2004-2009);
68% to 53% in Nigeria (2004-2011); and
91% to 80% in Vietnam (2005-2009).

Over the same periods, the researchers observed significant increases in median baseline CD4 counts in Mozambique (from 128/L to 261/L; P < .001), Nambia (from 125/L to 230/L; P <.001), Haiti (from 103/L to 297/L; P <.001), Swaziland (from 143/L to 184/L; P < .001), Uganda (from 89/L to 170/L; P <.001) and Vietnam (from 22/L to 92/L; P = .014).

“Given the low median baseline CD4 from Vietnam in 2009 (92/L), much lower than Haiti’s median baseline CD4 the same year (219/L), evaluation of more recent trends in baseline CD4 is warranted,” the researchers wrote. “With Vietnam’s epidemic largely involving men who inject drugs, late presentation for ART might be partly explained by suboptimal health-seeking behavior in this population. In Vietnam and similar LMICs, continued monitoring of the prevalence of advanced HIV disease at ART initiation is necessary to inform understanding of ART program access, outcomes and prevention strategies.” – by Stephanie Viguers

Reference:

Auld AF, et al. MMWR Morb Mortal Wkly Rep. 2017;doi:10.15585/mmwr.mm6621a3.

Disclosure: The researchers report no relevant financial disclosures.