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Impact of early antiretroviral therapy eligibility on HIV acquisition: household-level evidence from rural South Africa.

ABSTRACT: OBJECTIVES:We investigate the effect of immediate antiretroviral therapy (ART) eligibility on HIV incidence among HIV-uninfected household members. DESIGN:Regression discontinuity study arising from a population-based cohort. METHODS:Household members of patients seeking care at the Hlabisa HIV Treatment and Care Programme in rural KwaZulu-Natal South Africa between January 2007 and August 2011 with CD4 cell counts up to 350 cells/μl were eligible for inclusion if they had at least two HIV tests and were HIV-uninfected at the time the index patient linked to care (N = 4115). Regression discontinuity was used to assess the intention-to-treat effect of immediate versus delayed ART eligibility on HIV incidence among household members. Exploiting the CD4 cell count-based threshold rule for ART initiation (CD4 < 200 cells/μl until August 2011), we used Cox proportional hazards models to compare outcomes for household members of patients who presented for care with CD4 cell counts just above versus just below the ART initiation threshold. RESULTS:Characteristics of household members of index patients initiating HIV care were balanced between those with an index patient immediately eligible for ART (N = 2489) versus delayed for ART (N = 1626). There were 337 incident HIV infections among household members, corresponding to an HIV incidence of 2.4 infections per 100 person-years (95% confidence interval 2.5-3.1). Immediate eligibility for treatment reduced HIV incidence in households by 47% in our optimal estimate (hazard ratio = 0.53, 95% confidence interval 0.30-0.96), and by 32-60% in alternate specifications of the model. CONCLUSION:Immediate eligibility of ART led to substantial reductions in household-level HIV incidence.

SUBMITTER: Oldenburg CE

PROVIDER: S-EPMC5832606 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundAntiretroviral therapy (ART) was highly efficacious in preventing human immunodeficiency virus (HIV) transmission in stable serodiscordant couples in the HPTN-052 study, a resource-intensive randomized controlled trial with near-perfect ART adherence and mutual HIV status disclosure among all participating couples. However, minimal evidence exists of the effectiveness of ART in preventing HIV acquisition in stable serodiscordant couples in "real-life" population-based settings in hyperendemic communities of sub-Saharan Africa, where health systems are typically resource-poor and overburdened, adherence to ART is often low, and partners commonly do not disclose their HIV status to each other.MethodsData arose from a population-based open cohort in KwaZulu-Natal, South Africa. A total of 17 016 HIV-uninfected individuals present between January 2005 and December 2013 were included. Interval-censored time-updated proportional hazards regression was used to assess how the ART status affected HIV transmission risk in stable serodiscordant relationships.ResultsWe observed 1619 HIV seroconversions in 17 016 individuals, over 60 349 person-years follow-up time. During the follow-up period, 1846 individuals had an HIV-uninfected and 196 had an HIV-infected stable partner HIV incidence was 3.8/100 person-years (PY) among individuals with an HIV-infected partner (95% confidence interval [CI], 2.3-5.6), 1.4/100 PY (.4-3.5) among those with HIV-infected partners receiving ART, and 5.6/100 PY (3.5-8.4) among those with HIV-infected partners not receiving ART. Use of ART was associated with a 77% decrease in HIV acquisition risk among serodiscordant couples (adjusted hazard ratio, 0.23; 95% CI, .07-.80).ConclusionsART initiation was associated with a very large reduction in HIV acquisition in serodiscordant couples in rural KwaZulu-Natal. However, this "real-life" effect was substantially lower than the effect observed in the HPTN-052 trial. To eliminate HIV transmission in serodiscordant couples, additional prevention interventions are probably needed.

Project description:BackgroundStudies of HIV-serodiscordant couples in stable sexual relationships have provided convincing evidence that antiretroviral therapy can prevent the transmission of HIV. We aimed to quantify the preventive effect of a public-sector HIV treatment and care programme based in a community with poor knowledge and disclosure of HIV status, frequent migration, late marriage, and multiple partnerships. Specifically, we assessed whether an individual's hazard of HIV acquisition was associated with antiretroviral therapy coverage among household members of the opposite sex.MethodsIn this prospective cohort study, we linked patients' records from a public-sector HIV treatment programme in rural KwaZulu-Natal, South Africa, with population-based HIV surveillance data collected between 2004 and 2012. We used information about coresidence to construct estimates of HIV prevalence and antiretroviral therapy coverage for each household. We then regressed the time to HIV seroconversion for 14,505 individuals, who were HIV-uninfected at baseline and individually followed up over time regarding their HIV status, on opposite-sex household antiretroviral therapy coverage, controlling for household HIV prevalence and a range of other potential confounders.Findings2037 individual HIV seroconversions were recorded during 54,845 person-years of follow-up. For each increase of ten percentage points in opposite-sex household antiretroviral therapy coverage, the HIV acquisition hazard was reduced by 6% (95% CI 2–9), after controlling for other factors. This effect size translates into large reductions in HIV acquisition hazards when household antiretroviral therapy coverage is substantially increased. For example, an increase of 50 percentage points in household antiretroviral therapy coverage (eg, from 20% to 70%) reduced the hazard of HIV acquisition by 26% (95% CI 9–39).InterpretationOur findings provide further evidence that antiretroviral therapy significantly reduces the risk of onward transmission of HIV in a real-world setting in sub-Saharan Africa. Awareness that antiretroviral therapy can prevent transmission to coresident sexual partners could be a powerful motivator for HIV testing and antiretroviral treatment uptake, retention, and adherence.FundingWellcome Trust and National Institute of Child Health and Human Development (US National Institutes of Health).

Project description:Background and objectivesAlcohol causes more than 3 million deaths a year globally and contributes to over 5% of global disease and injury. Heavy drinking and alcohol use disorders among older adults have increased in the last 10-15 years. For individuals living in low-income countries, where wages are low and unemployment is high, old age pensions may provide a significant increase in household income. In turn, the receipt of supplementary income may increase spending on alcohol. Earlier life factors and socioeconomic status may affect alcohol consumption, making it difficult to directly assess the impact of income on alcohol consumption. This study reduces the potential for endogeneity with other life factors by exploiting an exogenous increase in income from old age pensions to isolate the impact of extra income on alcohol consumption for older adults.Research design and methodsWe used a regression discontinuity design to assess changes in drinking patterns among rural, low-income adults who were 3 years below and 3 years above South Africa's Old Age Pension Grant eligibility threshold (age 60). We assessed this relationship separately by gender and for employed and unemployed individuals.ResultsWe observed a significantly increased alcohol use associated with the Old Age Pension Grant eligibility for employed men (β = 4.57, 95% confidence interval: 1.72-12.14). We did not observe this same trend for unemployed men or for women.Discussion and implicationsThe analysis in this study indicates that increased income from reaching the pension eligibility age may contribute to an increase in alcohol consumption for employed men. Interventions, such as informational campaigns on the risks of alcohol consumption for older adults or age-appropriate health interventions to help individuals reduce alcohol consumption, targeted around the time of pension eligibility age for employed men may help to reduce alcohol-related harms in low-income, rural sub-Saharan African settings.

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Impact of early antiretroviral therapy eligibility on HIV acquisition: household-level evidence from rural South Africa.

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